254 JEFFERSON AVE - BUILDING INSPECTION ect- o l (e
C -- -- The Commonwealth of Massachusetts
' 13oard of 1uiIding Regulations and Standards CITY OF
Massachusetts State Building Code. 780 CNIR SALEAI
L, Hdri.veLllur_'ill/
Building Permit Applirttion TO Cunstnmct. Repair, Renovate Or Demolish a
One- or Tuw-Fumilt Dwelling
This Section For OtIricial Use Only
Building Permit Number: _ Date Applied: _
( LUT ,=(VVux V-1
Building 0117cial(Print Name) Signature We
SECTION I:SITE INFOR ATION
1.1 Proutirty Address: 1.2 Assessors blap& Parcel Numbers
ac 6- S EF;. ,o d 14-Af
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'rposed(Ise Lot Area(sq It) Promagc(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.l.c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munici al❑ W'On site disposal s stun ❑
Chock it' cs0 p >� '
SECTION I: PROPERTY OWNERSHIP'
1.1 Ownert of Recor
Ria1l /+uD bRWA kp51C 2 01s9 J�FFPZ�ou AYF SA��
N:une(Print) City.Statc.ZIP
, ,S-9 Z79- 7 95-95-
Nu.and Street f Telephone 6noit Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) Alterations) 0 Addition 0
Demolition 0 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': n ID P r;b F-- A-4 0 2t 72=-6 r-
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Co,,,:
Labor and\la
terials) Official Use Only
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S 0 Standard City/Town Application Fee
0 Total Project tostm(Item 6)x multiplier _,. x
i 7. Plumbing S 1.
- -----
_. Other Fees: S
J. Mcclmanic,d 111\'.1('1 S List:
i .\Icchanical IPin - ---- ------ -----
tiu,mrcssiunl S Total .\11 Fees: S —`— .--- —_-_. .
9
Cheek No. ('heck AmounAmount: l',uh \mount:
o. Total Project Cost: S — — - ----
❑Paid in Full ❑Outstanding Balance Due:
H
�? ags Ae 0 r'L
,
SECTION 5: CONSTRUCTION SF.RVI TS
5.1 C'unstructiots Supervisor License(CSL) 0,6 g Sa _,oh(1,3
License Nuulhcr Pyliralion U;ae
Name of(St. I Ioldef
_ foil l'SI. I)pe lse¢h¢lol�l.__.t'��"A/t"i1
I,v_,4r 5 �v_—yk�e
_. '1'IPC Dcscripliun
No. and Strcvt —7
/ I I n,ride 1 1 Fai ii gs li to 15,11110 eu. I11
_ Reitrietcd L@_ f:unill Daellin
l'it)i loon.Sl;It- / ---- ----_. . M1I NLuon
ry
ICC Roolin (L'overin
— --'.—. R'S Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
'1'c1c hone If mail address D 17enuJiliun
5.2 Registered Home Improvement Contractor(HIC)
b t�
rUO�Q � /� 5T IIIC'Itcgistration Numl+er Ifcpiration Date
IIIC C'ont) Nano or I IIC'Registrant Name Z �
A wrr� saw Ave 2 �Te��SFfo
Nu Id Stn• / (� _ Lmuil address
City/Town.State'ZIP Telc hone TKO
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.0 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance9ftht building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize PO
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Olwer's Name(Elcutrunic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in t is application is true and curate to the best of my knowledge and understanding.
Trim Ooner's or Au loriicd nt's Name(Flectrunic Sigmuure) Date
VOTES:
I. :kn Owner whu obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
Inut registered in the Hume improvement Contractor(HIC) Program).will nu have access to the arbitration
program or guaranty fund under.M.G.L.c. 142A. Other important information on the HIC Program can be found at
m t,, n ,`, I Information on the Construction Supervisor License can be found at 1,„ , nio,; �,I 1p,
�. When substantial work is planned,pruside the information below:
rota) flour area(sq. R.1 - (including garage. finished basement,auics,decks or porch)
Cross lining area uy. 11.1 __-_ _-_-- Habitable room count
\umber ul lircplaces,.-... \umber of he'drmUttt$
Number of bathromns _ Number of half huths
I')pe of heating s)item .. .. . _ Number of decks, porches _
I\lie of e0ohng "%stcin Fticloied _ _ . -_01'en _
i
1, "Loral Project Square Footage'im;p he substituted tier"fowl Project Cost"
CITY OF S:u.E,,t, NL1SSACHCSETTS
BUILDING❑EPA&TMENT
120 WASHINGTON STREET, 3'a FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KnmERLEY DRISCOLL
MAYOR Angus ST.PIE.RRB
DIRECTOR OF PL'8LIC PROPERTY/BUILDING CO.11�IISS ION EIt
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
APpllcant Information cy� Please Print Lepibly
VnInC(Ilusi'ixrys�Organi:atiuro'Individual): 1 6uJ 2 O ✓� - mo
Address:v4 3 6 1� 'A�c 2 i D2-.
City/State/Zip: 1 '�/P�/ilZ fl- 19013 Phone M: 61e)
Are You an employer?Check the appropriate boil. Type of project(required):
L L(d"I am a employer with /U 4. Q 1 am a general contractor and I 6, New construction
employees(full and/or pan-time).• have hired the sub-contractors
2.0 lama sole proprietor or partner. listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These sulrcontmctors have g. Demolition
working liar me in any capacity. workers'comp, insurance. 9. Building addition
(No workers'comp, insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(,No workers'sump. C. 152,§1(4),and we have no 12,0 Roof repairs
insurance required.) t employees.[No workers' l3 0 Other
comn.insumnce rcyuimJ.j
,Ally apphc:ue OW chucks box ill muse stills fall uut the section below showing their workers'compenattun policy imbrmation.
111 nvowaxns who ahmit this A lMvit indicating They ore doing all work and Ihm him outside contractors mint an unit a new amdaril indicting ruck:f-mtrwton that chuck this box must anach.xi an additiun l sheet showing the nwne of Iho au sc,ni ,an and Ihelr workers'wmp.policy informatioq,
f am an eorpluyer that is providing workers'cumpensatlon insurance for my emp/uyeex Below/s the policy and Job site
infonnadoo. r� '/
Insurance Company Name: Ql 5 ��/ /(�I"� Mqr-�I /F 1/ F O
Policy N or Sclf--inn. Lic. d: a a I - 1(5 7 "-6g_ pt.z) 7B WIC Expiration Date: 9/a a /I
—1-- A
Job Site Address: -Q � �\t�.G j.-P P/ �(o City/Blatt/Zip: -
Attach a copy of the workers' compensation pulley declaration page(showing the policy number and ex ration date). / V
Failure to secure coverage as required under Section 23A ot'%fGL c. 152 can lead to the imposition of criminal penalties of a
tincpp to S1,500.00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may bu forwarded to the 011ice of
Investigations ul'the DIA for insurance cnveragc verification.
f du hereby certify under the pahrs cud penalties flfperi4 that the information provided above i.r true filial correct
Fli
se only. Oa uofwfire fit this area,to be completed by city ur town )1jhiaL
uwn: Permitil.lccoseul Kurily(circle one):
u1 Ilcallh 2, Iluildimg Ilepurtutent .3.cilyi town Clerk 4. Electrical Inspector 5. Phunhing Inspectorc ruOf: .. _ _ _ phone It•
Information and Instructions
tlassachuscus General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL chapter 152, g25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally,MGL chapter 152, §25C(7)status"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)nume(s),address(es)and phone numbet(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to rill out in the event the Office of investigations has to contact you regarding the applicant
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"lob Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on rate for future permits or licenses. A new affidavit must be rnlled out each
year. Where a(tome owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Offico of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/dia
CITY OF S.UZNf, Akss:1Cf-i[,'SETTS
BLLLDLNG DEPAMIENT
120 WASHLNGTON STIM, YA Rccit
T)M (978) 745-9599
K .NimArSY DaMOLL FAX(978) 740.9946
,MAYOR TRam .t ST.PtEAU
D'"Cral,OP PLUIC P1t0PE)tTY/8LMD0 G COSQnSSIONEft
Construction Debris Disposal Attidavit
(required for all demolition and rcnovation work)
In accordance with the sixth edition of the State Building Code, 180 CMR section I I I.s
Debris, and the provisions of MGL c 40, S 54;
11 Building Permit p is issued with the condition that the dcbris resulting from
work shall be disposed of in a properly
1 11, S I SOA. licensed waste disposal facility as dcfincd by MGL c
The debris will be transported by;
(narO or hauler)
The debris will be disposed of in
— _j
(name of facdi�y)ilt')
o ST n3 v)Da J7
(iddress of ricilrty)
°1dn�nueafp rm113 Cant
Idle
i Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supcn'isor, t & 2 Fitmih
License:CSFA-066980
sa.rc
STEVEN NO.. lsT `•- ?�
3 WARSAW�iVE , r
DUpLEY Ng 015711
Expiration
Commissioner 1010412013
_ _ in
p smess ego ahoa
GfLoo yrA afire
Office of C CTOR Type,
HOMEIMPROVEMENTCONTRA
- - R25339
e9istration:'?'A'M2013 DBA
ExPI tion
REPAi
STE ` 'S HOME ,
�;rl
STEVEN NOROUIST�. �iu
"�. r'J
NUE 7
a WARSAW AVE
POWER-1 OP ID:EL
A✓ CERTIFICATE OF LIABILITY INSURANCE DAT 10r2 FP(T 1
o726n,
THIS CERTIFICATE 10 ISSUED AS A MATTER OF INFORMA'RON ONLY AND CONFERS NO RIG"I S UPON THE CE•RTIRCATE HOLDER.TMS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISMING INSUREP481 AUTHORNO
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER
1 POR I —the esn a It~la an ADDITIONAL INSURED,on polley)Ms)muM M m0orsed. R SU13ROGAYM 16 WAIVEDL subject to
the{Hats and conditions of the policy,caneln polielse may require an andoreamern. A statement on ltda esrfillmdo doss not center riphta to the
canmcab holder in lieu of sL=h andersomenttsl.
PRODUCER 216-'72343 Chad Lacher -.
Lecher i Assoclatea Im Agency 216-723 W4 L{{
Lachar Inalsarwe Group
$32 E Broad M P O BDI 61390
ydancom PA 10864 _ a1aDRagNKFOAONOCOy[wA6e IMCe
Clad Lacher _
ImmaNA Penneylvanls Manufacturers 41424
MBVIED Power Home Remodelling wwsreR a:Penn IYBnle Manufneww's 12262
Group,Inc. Nau+wcaronshore S le Ins.Co. 0440
2601 Seaport Drive Ste 8110 NxweAD
Chssteq PA 19019 ---- -----"
COVERAGES CERTIRCAT9 NUMBER: REVISION NUMBER:
H6 T IS TO CERTIFY THAT THE POLICIES OF BISURANCE LISTED BELON NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWrr113TANDNO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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C4NNSVAIE QGGCUR MED E'P fMY ww ONiMI i to,,
PEPSON/-I aADV N1Mr { 1•BDD
GENERAL Ati GREGM1IE i ;�•
GPM AOaREGATE LPAn A➢PLiE9 PER PRODUCi6-COA1PgP AGG { 2•DOOr
X MO ' ° LGC {
ArlTorosae Wsem E ¢aaaLC 1,000•
A X Ater wlo 61100.88.2&4WA OW 271 22M1 OB112 fit— NAIRr IPu OaTnRI f
�LOWv ED LEO� I eODxr NAIRr IPP tlwtlw+l {
NONOVINED {
HREDNJTOS Wt% '
i
VNWIaLLALMB X OCCVR E HGCCU Ewe ! g000,
000
x X fzCHp we GIAa,6a.•DE
t6B20D OW22111 QW=12 MCIREWE t 6,000.
X rt 10otq
MDerLws eOMPENeATR]I X YrC STAID OTH-
ANOBIFLPILTM'LIAeILITY 1000
A AM'pROgME1pnPARTNER£kCGTVE Y® NfA 011G0,6630• 11-7A I OW22111 OBFGli2 EL EKHACCmENT i
B tom' r���T 10748-Z4 4ENMASS) i OS127111 Op122112 tt DbE�E FAEMRLoree 1 1.00D
II rrraNAUMw !EL DNF -PomcruAR is. 1•�•
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pFagllnpry DP OF®MTICN/LOGIIDNa INEM0.at P•atlRr ACpO Nt.AadtlYral RYnRtltl aen.asw Hnen rpsY MnrMMI
E E 7T0
SALEM BIiDtILD AHY OF T1i ABOVB DBBCRM®P0.ICHIe WC'ANCBL®SVORB
THE WIRATION DATE TMIRIDP. NOTICE WILL Bi OM.NN® IN
Salem ACCORDAIRx YAM 111E POLICY PROMSIDM.
12O W001119t0n St
3rd Floor AunaRrs®sesRMeNrATNs
Salem,MA 0%970
®isBB-2010 ACORD CORPORATION. An"onto ras"M
ACORD 26120IDMI The ACORO name 900 logo Be rsplshrtd marks Of ACORD
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aag 88Q-REMODEL
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
a58<3 0acamber 1 s.xe++
BuyMe Inbrmetlon Prgecn NUmae/ r....
IUCtI Fo@er Ierel T0Sx,T(MCn'>t CeO)
Dswn Foster
250 Jetkvewl M
Sa -,MA.01970
County'.Evsto
Towashlp: _
Buyer(a)listed above hereby 101"and severally agrees to purchase the gouda arrdfor Servicesa
of Power Home,
Remodeling Group('Contractor')In accordancs with the Prices and terms described on the front and the following four
pages of this agreement and any S"Ci cstton sheets(collectively.this"Ag ment).This
Agree ant reclllad tleracash
ante of goods and services.Buyers)agrees to pay the cost of the good he
regardless of timing W approval of any financing Suyarts)may seek for(half purchase.
Purchase Price' $9,335,64 Pro installation Inspection Date($)7W ':
$0.00 Estimated Project start:
Down Payment', o m a woaXs
Balance Due on $9,335.54 Estimated PfOlocl Completion:
of Jae
Substantial
Camplal1. Dofman Fui:pWlum ante m nlN of afa 98aanN.Dn1aYs tnyO�n Crin cRiculekna Ines 11w 1 S.MLWIU,1WM)m,Cvm
Method of Peymanl Check
Buyats)hereby acknowledges receipt of a COPY of the PamPMet,'"The Lead-Safe Certified Guide to Renovate Right
Informing Buyer(,)of the potential risk of lead hasard*"SUM from renovation activity to be performed In BuyeYs home,at
the address written above.Buyer(a)received this Pamphlet On the date of this Agreement,before commencement of work.
(Buyses Inhlela).
IF is agreed and understood by and between the Parties that this Agreement constitute,the entire Understanding between
the pairs",and there ere no verbal understandings changing or modifying any of the lstms of this Agreement.Buyers)
hereby acknowledges that BUYar(s)i)boa read the entire Agreement and has received a wmpieted,signed.and dated copy
ellation tome.an the date fire(written abnm and 2)
*of ibis.ally Innfermad of Mreement adrrisr right Iuding Himo Ca es this tr ying rnsactioon.00 NOotice of T SIGNTHIS AGREEMENT IF THERE ARE ANY BLANK was
SPACES.
Future Promotions not applicable.
I have read end received eacn pogo of Ihie 5 page agreement
Home Ram ling Group Buyarls) Buyer($)
r
-.-/ ) ,
gri Sales Representative Signature Signature
Harris Zeltler Rlch Foster Dawn Foster
YOU,THE RUYERISI,MN'CANCEL THI$TRAN5AC1ION AI AN, I IAG PHIOR r,i MION!..HT 01 T11i'.11•IFID HU;INBii GAY
AFTER THE OAT E Or THIS TRANSf.CTiON, SEE 1 HE NOT!CG Oi G.WCELLA LION I-ORM FUR AN k.%Pt.ANATION Of IHIS RIGH r
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Project 30-35845
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NATIONAL IIE ADOUAR POWER .4
15015e.Pat Onve,Chester.PA 19 t9a13 l3
888-REMODEL;
Project SpecMcatlons
RPO FI ENTIRE HOUSE/ "ATc'ei o'
ROOFING:Coto,S GAF ood I ArLdl{te 131-atllIld S es types None Gon!ige Nate
OPTIONS:fqb!Shakew0otl I gomOve!Slamartl ShNgle f Instellanon Dafabs Norw
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OAF IAAn5%AI3
CORPORATION
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ROOFING;
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Rootlsg:PEAK 19a.0'Rt.e'
ROOFING;MIorSGAFSl AM90 IDVenl Typ�NorN NOnB GOn9gs NOne
OPTIONS'Cobr'JleMewOotl!fnstePBaOn Oeleils NOPB
GILF MAMMUS
CORPORATION
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12/21/2011 2:59 PM