106 LEACH ST - BUILDING INSPECTION (3) lZ<S• qL 1 ZZ2-D
„5 The Commonwealth oftYlassachusetts IRECEtYE
O / Board of Building Regulations and Standiu aPEC'TIONAL SE° Y IC&$Y OF
Massachusetts State Building Code, 780 CMR Sr1LEW1
11 np 4 V",Nar 2011
Building Permit Application To Construct,Repair, Renovat� �[ i�oNSlt n
O One-or71vo-FamilyDrvelling
This Section For Official Use Only'
Building Permit Number. Data plied � '
y Building OtTtcial(Front Name)
SECTION 1:SITE INFORMATION"
1.1 Property Addriess: /f ' pf 14 Assessors Map St Parcel Numbers
�mrn eGCh V 3
1.1 a Is this an accepted street?yes no M1lap Nwnber Parcel Numbef
N ,,, e
1.3 Zoning Information: 1.4 Property Dimensions:,., ,t r V
Zuntng Disuict -: Propose)Use - " - LorArea(sy ft) Fmotuge(it) -
1.5 Building Setbacks(R) .
Front Yard - -- Side Yards - Rear Yard - -
114hed - Provided Required -P.rovided.: . • Required:. .`. Provided.
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Informations 1.8 Sewage Disposal System: '
Zone: _ Outside Flood Zone?
Public O Private O.- . - Cheek ifycsC3 _ Municipal O On site disposolsystem O
SECTION 2...P ROPE[tTY.OWNERSHIP,
2.1 Own ofRecord: / /e al
.__ ^
Abraa7 / - `oetjef7 .S4CIr
RFC(Print) J - - _ City,Stnta,ZIP , - -
mC, L�ccl7 Sfi .� G n-3o/- a�3
No.and Street - Telephone T Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(ebeek all thatapply)`
New Construction 1] Existing Building O OwherrOccupkil O Repairs(s) O. cration(s) 17 Addition O
Demolition O Accessory Bldg.O, Number of Units_ Other Specify:
Brief Description of roposed war, zi
A10,vr✓ L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S cv; 1. Building Permit Fee:S- ._ Indicate how fee is determined:
2.Electrical - S D StandW Cilylrown Appticatton Fee-- '
D Total Project Cost!(item 6)x multiplier x
3. Plumbing S jb Qther Fires: .S
4.Mechanical (FIVAC) Is - List: C dr � •
5.,Nlechanical (Fire S
Su rcssiun) � Total All Fees:S
Check No.f 112o Check Amount: Cash Amount:
6.Total Project Cost:. S L12OV, ❑Paid in Full 0 Outstanding Balance Due:
SECTION5: CONSTRUCTION SERVICES
5.t Coils- ctiotr'Supe fsorLicense(CSL) B797-7
License Number Expiration Date
^ w
` Name of CSLHuIJei ElkW� List CSL'rype(see befow)_�_ _
3 11ifte ft-cet Types, - Description .
- No.and Street SEIeiD MA Oj JTO U - Unrestricted Buildin u to 35,000 cu.Il.
R Restricted 1&2 Family Dwelling
Eayamm,State,ZIP M Masomy
RC Roorm Covering'
WS Window and Eding
SF Solid Fuel Burning AppliancesInsulation
D Demolition'
Telephone
Email adJress
5.2 Reg(sterrg�, llome,(mprovement Contractor(HIC) l y Z p kid/. 3 L /b'i
At tic cdthctiL'aiwn, LLC HIC Registration Number Expiration Date
MCCOMPRYNAMA1%4lfa N C ,
c ler �n n t t ?9
No.and Street i Email address
ci frown State ZIP .-Telephone
SECTION 6 WORKERSr COMPENSATION INSURAI!iCE AFFIDAVIT cc I52.§25C(6W
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to,provide
this affidavit will result in the denial of the Is9uance f the building permit
Signed Affidavit Attached? Yes.......... No...........O
SECTION 7a:01MER AUTHORIZATION'TO BE.COMPLETEO.}VHENt'
OWNER'S AGENT OR CONTRACTOR APPI:IES FFOkBUIGDING.PERt1I1T'
1.as Owner of the subject property,hereby authorize 1Kt C ' '1//17
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Lill
Print Olmer's Nome(Electronic Signature) - Date
SECTION 7b:OWNEIe OR AUTHORIZED AGENT DECLARATION
- ,
By entering my name below.I hereby attest under the pains and penalties of pedury that all of the information -
contained in 1 ' appltcati true a�d rate to the best of my knowledge and understanding. .
Print Owner's or Authorized Agent's Name(Etcctromc Signature) Dme
NOTESr
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor '
(not registered in the Home. M rovement Contractor(HIC)Program);will Lid have access to the arbitration
program or guaranty fund under M.G.L.c. IQA.O—ht er important mformnfion on Ore HtCYrogra—m can be on"
www.rnass.eov.'oca Information on the Construction Supervisor License can be found at www.mas.•ovldns .
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) '_(including garage,finished basementlattics,decks or parch)
Gross living area(sq. ItJ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'type of healing system Number of Jcckst porches
Type of cooling system Enclosed Open
T "Total Project Square Footage"may be substituted rur"Total Project Cost" '
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Contractor Arbitration "
The Home Improvement Contractor law provides homeowners with t1t1'ight to initiate an arbi ration action(as an
alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a
contractor,however_ The contmcm would have to resolve any dispute he/she has with a homeowner in court unless
both parties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. i
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,the ;itaZs}lbrll ft-dispute to a private arbitration form which bas been approved by
tho:SecrataryofthelixcchdveO ceof o Affairs and Business Regulation and the caitsumer shall be required
to submit to such ar4osatipli:a6ipYal `; ' r'achusetts General Laws,cha er 142A.. .
a
Homern is Siguatum Contractor's Signature
NOTICE:The signatures of the parties above apply only to the agreement of the parties to altelmative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is notseparately signed by the parties
Homeowner's Rights
A homeowners rights under the Home Improvement Contractor law(MGL chapter 142A)an otter consumer
protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement However,homeowners
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a
timely and workmanlike manner- Homeowners may be entitled to other specific legal rights i the contractor
guarantees or provides an express warranty for workmanship or materials. In addition to g=2tees or warranties
provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merefoantability,and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be
added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have
questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy of all exhibit and referenced
documents have been attached. Parties are also advised not to sign the document until all blank sections have been
filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to
be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing
and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of
the contract,and the throe day rescission period has expirerL
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems bim/herself to be financially insecure. However,in instances where a contractor deems him/berself
to be financially insecure,the contractor may require that the balance of fords not yet due be placed in a joint escrow
` account as a prerequisite to continuing the contracted workk, withdrawal of finds from said accountwould require the
signatures of both parties. -
Additional Information
If you have general questions or treed additional information about the Home Improvement Contractor Law or other
consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide tp Home Improvement"
contact
Consumer Information Hotline
Office of Consumer Affair.and Business Regulation
10 ParkPlam.Room 5170,Boston,MA 02116
617-973-8787,888-293-3757 or visit the OCABR wvebsite at httm./linN�v.ma j eov/ocabr/
If you want to verify the registration of a contractor or if you have questions or need additional information specifically
about the contractor registration component of the Home Improvement ConimcturLawI cont!ct
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888 283-3757 or visit the HIC website at httw/Mmw.mass.^ov/ocabr/
Go online to view the status of a Home hnprovement Contmetor`s Registration:- i{I
httn9/db state ma ils/homeimorovement/licenseelist.mD ( _
For assistance with informal mediation of disputes or to register formal complains against a business,call:
onsuiher plaint Section
a �; fficef mey General
617-727-9400
AND/OR
Better Business Bureau -
508-652.4800,508-755-2548 or 413-734-3114
Vasion2l-IMM/'1110
The Commonwealth ofMassacliusetts
Deparinti0ft oflndustrialAccidents
Office oflnvestigadons
600 Washington Street
Boston, MA 02111
www.mass-gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Analicant Information Please Print L,e2jbly
Name (Business/Organization/Individual): Adak �o'�s[tiUtlfltlutt,LLL
6FRTe—norhop Avonue
Address: Sale?l Nil A 111 970
City/State/Zip: Phone#: ! 7k- 74��/-
Are yo n employer? Che��:
propriate box:
18.
ype of project(required):I. am aemployer with � 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors . New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. . Di Remodeling
ship and have no employees These sub-contractors have (� Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance? 9. d Building addition
required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their i I.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 Q;Roof r pairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13. I ther
comp insurance required.]
Any applicant that checks box 91 most also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submi�a new affidavit indicating such.
<Contractors that check this box must attached an additional sheet showing the name of the sub-cvntmctors and state whether or not those entities have
employees. If the sub�contrsctors have employees,they must provide their workers'comp.policy number-
I am an employer that is providing workers'compensation insurance for my employees. Belo 1 is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.M ::Cg a 7rrO /Z / Expiration Date 3/Zo�l -7
Job Site Address:_ /0�p Lear h 51L. City/State/Zip: 1 h°i>7 /M
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi under the pains and pena&ies of perjury that the information provided above is true and correct.
Si ature:
Phone#: 7Y/9- P/1-1 3
7Other ;
only. Do not write in this area,to be completed by city or town official
n: Permit/License#
ority(circle one):
Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing
,Inspector
,' Pson: Phone#
ACOR®® DATE(MMIDD/YYYY)�.� CER1,11-1CATE OF LIABILITY INSURANCE 3/9/2016
[:ER-nF'CA
HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
TE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTENDOR ALTER THE COVERAGE AFFORDED BY THE POLICIESELOW. THIS CERTIFICATE OF INSI�RANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: Ir the certificate holder i$an ADDITIONAL INSURED,the policy((es)must tTe endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions or the policy,certain policies may require an endorsement A statement on this certificate does not corder rights to the
certificate holder in lieu of such endoreemerrt(s). g
PRODUCER I CONTACT
Eastern Insurance Group LC NAME: Construction
233 West Central St PHONE
(B00)333-7234 FAX
-MAIL c o
Natick MIL 01760 INS U S AFFORDING COVERAGE NAICO
INSURED I INSURER AArbella Protection Ins, Co. 1360
Atlantic Weatherization INSURER 6 Nautilus Insurance CO
61 Rear Jefferson Avenue INSURERc:
INSURER D:
Salem MA 019j70 INSURER E:
COVERAGES CERTIFICATENUMBER:Mnster 2016 uRERF
THIS IS TO CERTIFY THAT THE POLICIES UI INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDEN REVISION
ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQIIIREMEp1T, 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.
INSR
L TYPE OF INSURANCE M LICY EFF MPOLICY QP
GENERAL LIABILITY POLICY NUMBER LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
A CLAIMS-MADE r—xl OCCUR 500042816 /20/2016 /20/2017 PREMIaES LIE- O n A S 50,000
X CONTRACTDML LIABILITY MEDEXP(ArryoneporsnnJ S 5,000
X C00001 10/01 FORM PERSONAL S ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICY X PRO- LOC PRODUCTS-COMplop AGO $ 2,000,000
AUTOMOBILE LIABILITY S
MEWED SINGLE LIMIT
p ANY Aurp E • pan S 1 000 000
ALL OWNED X SCHEDULED BODILY INJURY(Ferpaeon) S
AUTOS AUTOS 020015873 /20/2016 /20/2017
X HIRED AUTOS X NON-OWNED BODILY INJURY(pe ea end) S
AUTOS PO ERa Y DA AGE R S
X UMBRELLA LAB X OCCUR PIP-Bask $
A EXCESS UAB CLAIMS.MADE EACH OCCURRENCE $ 1,000,000
DIED RETENTIONS 10,00 600058654 AGGREGATE $ 1,000,000
WORKERS COMPENSATION /20/2016 /20/2017
AND EMPLOYERS-MIN ITV ,�/N S
OFF) EANY PROPR1 BEN PARTNER/IXE-CUTIVE WC STATU- OTH-
(MandaRIMEMBEREXCLUDEDT ❑ N/A E.LEACHACCIDEM
If -S a[ory in NH) S
DESCer
R PObe TION OF OPERATIONS W w EL DISEASE-EA EMPLOYE $
B POLLTITION S.L.DISEASE-PODGY UMR $
L200378614 0/1/2015 0/1/2016 EA POLLUTION CONDITION
$1,000,000
GENERAL AGGREGATE $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES(Aifaah ACORD 101,Addi0onal Remade S,n dule,it more apace M Mqutred)
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ADAIBOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF 3ALEM ER
ACCORDANCE JV17Ti THE POTHE EXPIRATION DATE LICY PROVISIONSE WILL BE DELIVERED IN
'ME EXPIRATION
93 WASHINGTON STREET
SALEM, MA 0197 0 AUTHORIZED REPRESENTATIVE
John Aoegel/SOII+
ACORD 25(2010/05) ^
INS025 nn,nrtsr m n.o�arnwn.+o...e g,,,r I..nn aro ronicfnrorH naae4o 8- pry,p�ORD CORPORATION_ All rights reserved.
rss-, YNVL 37 UU:s Fax server
CEI TIFICATE OF LIABILI TY INSURANCE DATE(MMI7nlg 1I
IFICATE IS ISSUED AS A MA17ER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DO"NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
O D C T CE TE I ER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the Policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
he terms and conditions Of the Policy,cehain Policies may require and endorsemenL A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorlemen s.
PRODUCER CONTACT
EASTERN INS GROUP LLC NAME:
233 W CENTRAL STREET PHONE FAX
(AIC,No,Ext): (A/C,No):
NATICK,MA 01760 E-MAIL
22MLW
ADDRESS:
INSURERS)AFFORDING COVERAGE NAICP
INSURED INSURER A: AMRRICANZURTCH INSURANCE COMPANY
ATLANTIC WEATHERIZATION LLC I INSURER 8:
INSURER C:
61 REAR JEFFERSON AVE INSURER 0:
SALEM,MA 01970 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:
TQCERTFYT TERMAT OR CON OF INSURANCERAT Be. W AYEB EN ISSUED TO THE a)SURED NAMED ABOVE FORTHE POLICYPREVISIERIOD 011 dMiga. NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION CONTRACTOROTHER DOCUMENT WITH RESPECT TO YAWN THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE PlSURANCE
AFFORDED eV THE POLICIES pESCR1eEp HEREN6SI)BJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LAMTS MGYM MqY HAVE BEENREUNSURM
DAO CLAIMS. '
INSR
CED BY
LTR TYPE OF INSURANCE ADD
IT POUCYNUMBER F(MIAMPPATE P(MLYEXPDA)
(WIVpD1YWY) (NMpD\WW1 LaDR9
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY CH OCCURRENCE $
CLAIMS MADE Ej OCCUR. DAMAGE TO RENTED $
PREMISES(Ea occurrence)
ED EXP(Any one person) $
GEN•L AGGREGATE LIMIT APPLIES PER: j PERSONAL A ADV INJURY $
POLICY r7 PROJECT r]LOC I ENERAL AGGREGATE $
AUTOMOBILE LIABILITYPRODUCTS-COMP/OP AGO $
ANY AUTO COMBINED SINGLE $
ALL OWNED AUTOS LIMIT(Ea accident)
SCHEDULEAUTOS BODILY INJURY $
(Per person)
HIRED AUTOS $
NON-OWNED AUTOS 80DILY INJURY(Per accident)
PROPERTYOAMAGE $
(Per accident)
UMBRELLA LIAR OCCUR
EXCESS UAS CLAIMS-MADE EACH OCCURRENCE $
DEDUCT18LE GGREGATE $
RETENTION$ $
WORKER'S COMPENSATION AND $
A EMPLOYER'S LIABILITY Y/N I UB-58270121-16 03202010 X WCSTATUTORY OTHER
ANY PROPERITORPARTNEWEXECUTIVE 0&202017 LIMITS
OFFICEPIMEMBER EXCLUDED? Q WA(MandaIwy in NN) E.L EACH ACCIDENT $ 500,000
Ij
It yes,describe enter I E.L.DISEASE-EA EMPLOYEE $ 500,000
OESCRIPnON OF OPERATIONS W w
E.L DISEASE-POLICY LIMIT $ 500000
DESCRIPTION OF OPERATIONS+LOCATIONSIVEHICLESIRESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED To THE CBRITFTCATB HOLDER AFFECTING WORKERS COMP COV13RAGE
CERTIFICATE HOLDER
CANCELLATION
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
93 W ASHINGTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
SALEM,MA 01970 AUTHORIZED REPR -
ACORD 25(2010i05) The ACORD name and logo are registered marks of ACORD 1954=2p10 ACORD CORPORATION. All rights reserved.
Massachusetts Department of Public Safety Construction Supervisor
"- Board of Building Regulations and Standards Restricted to:
License:CS-087977 Unrestricted-Buildings of any use group which contain
Construction supervisor less than 35,000 cubic feet(991 cubic meters)of -
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enclosed space.
ERIC W PALM
S HILTON ST - -
SALEM MA 01070 -
M..nn CA, expiration: failure to possess a current edition of the Massachusetts
Commissioner 04/23/2018 State Building Code is cause for revocation 011114111'license.
- OPS Licensing information visit:W W W.MASS-GOV/DPS
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License or registration valid for iadividol an only
Office of Consumer Affairs&Business Regulation - before the expiration date. If found return to:. .
C- ME IMPROVEMENT CONTRACTOR - Office of Consumer Affairs and Business Regulation -
V ,. e istration 142oa9 Type: •10 Park Plaza-Suite 5170
�, pird6on: 311212016� Ltd Liable Corpor Boston,MA 02116
ATLANTIC WEATHERIZA770N:L:LC_ /) -
ERIC PALM
61RJEFFERSONAVE
-SALEM,MA 01970 Undersecretary - Not valid without signature
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