16 LINDEN ST - BUILDING INSPECTION (2) The Commonwealth of MMassachuse `EG AL SE �C CITY OF
Board of Building Regulations- I I SALEM
4 � Massachusetts State Building Code, 780CpMR.qq � 4? RevisedS.far2011
Building Permit Application To Construct, Repoir?VMAAtM m oiish a
One-or Two-Family Dwelling
t
This Section For Oftictat Use Only
Building Permit Number: Date Ap�ed "i0 f"
Building OtlicialPont( Name) - _ .Sig�natum ,: D a
SECTION I:SITK INFOBAUTION'
1}-- i.l Pro erty Addres : 12 Assessors Map&Parcel Numbers
-
1.la is this an accepted street?yes no Map Number, ,ivu:r� - ;u:PawdAmf,
1 3Loning Information: TIA Property'd)1oCtdsldWi'`19�1..'d !r"Zoning District Proposed Use tArea(sit R) - Frontage(ft) ..
1.5 Building Setbacks(R) .
From Yard Side Ywih Rear Yurd
RequhcJ Provided Required Provided . - fteyuired Provided
1.6%Voter Supply:(M.G.L a 40,§54) 1.7 Flood Zone loforsentlow 1.8 Sewage DlsposaI system:
Zone: Outside Flood Zone?
Public O Private 0.- Municipal O On sfte disposolsystem O-
Checkif O_ -
SECTION2. PRO PER'-fVOWNERSH/Pk
kNew
Owner'of Record: �iY�e Z ��1vr /�"�✓
AVG hLi✓0.. .
(Print) Gty;Stue,ZiPdSuch Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED'WORKS(check all list apply)`
onstruction O 61sting Building O Owaer•Occupied O --Repairs(s) ❑ Alteration(s) O Addition O
Demolition O Accessory Bldg.t7 Number of Units_ Other pecify:
Brief Description of Proposed
�!/T7 .� C'e G -
6� 4 �-�--a�-
SECTION 4:ESTIAIATED CONSTRUCTION COSTS - -
Estimated Costs:
Rent - Official Use Only,,
Labor and Materials
I. Building $ CJ(�. 1. Building Permit Fee$ '� indicate how fee is determined:
❑Standard Cityadwa Application Fee
2. Electrical S
0 Total Project Cost'(Item 6)x multiplier s
3. Plumbing S '1:e Qther Fees: S
4.Mechanical (HVAC) S ' . List
5.h lcchanical (Fire Is -
Su ressiun) Total All Fees:S
Check No.1111U Check Amount: Cash Amount:
6. Total Project Cost: S 13 Paid in Full 0 Outstanding Balance Due:
j jV'SECTION 5: CONSTRUCTION SERVICES
5.1 Construction SuperviioF`Lieiilsi(CSL) 379-7-7 GJ1,Q,j I IS
License Number Expiration Date
Name ofCSLHolder ° b R.1. VfVf>)) yp ( _
Eric W.Palm List csL r e see below) /L
W Type - : . Description
No.and Street ��NU�➢�o, _ U Unrestricted DoiWbn a to 75 000 cu.fl.
R Restricted i&2 Fain D+vellin
Cityfrown.State,ZIP M Masomy
RC Roofm Coverin
WS Window and Sidin
� SF Solid Fuel Burning Appliances
O 1 Ireulation
Tcle Aone Email address D pemoliiwn -
5.2 Registered (Itmcoe eatCot Y� HIC)vL stpp
arVUAU+)t , HIC Registration
Number Expiration Date
IIIC Company Name 01151111110 a
l`w►rart tit A 11 1970
No.and Street (, Email address
Ci frown State ZIP Telephone
SECTION 6.WORKERS'.CO&IPENSATIONlNSUl2A1!NCEAFFIDAVIE(MG.G cc15;.§2SC(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 Isluan the building permit
i
Signed Affidavit Attached? Yes.......... No...........13
SECTION 7a:OWNER A" roRIZATIog-Tp BE.COMPLETED.W HEM -
OWNER'S AGENT OR CONTRACTOR APMES70a BUNING.PERMi
I,as Owner of the subject properly,hereby authorize 6 i c P�/"
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
�CridAh new i (IllS-
Print Owner's Name(Electronic S.rgn ore) Date
r
SECTION 7b:OWNERr OR AUTHORIZED AGENT DECLARATION
Dy entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of in knowledge and understanding.
+ 66
Print Owner's or Authorized Agent's Nume Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
_knot registered in the Home Improvement Contractor(HIC)Program);will nor have access to�e arbitration
program or guaranty fund under M.G.L.c. I42A.Other important mformation on the HIC Pro a—m can bel'o ndT
www.mnss.eov'oca information on the Construction Supervisor License can be found at w+vw•.mass.eow'Jus
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) N (including garage.finished basement/attics,decks or porch)
(;ross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
j. "Total Project square Footage"may be substituted for"Total Project Cost"
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Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an
alternative to court action)if they have a dispute with a contractor. The same right is mot anmniaticatty afforded to a
contracmy however- The contractarwould have to resolve any dispute he/she has with as 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 a$'aided to the homeowner by the Home Improvement Contractor Law. 1
The contractor and the homeowner hereby mutually agree in advance that in the event the contactor has a dispute
concerning this contract,the contra�to'�a5ay,.;s}lbroitdtite dispute to a private arbitration firm which has been approved by
c.-•
the Secretary of the ExecutiveO�ce of o Affairs and Business Regulation and the consumer shall be required
m submit to such arbigati A: sachusetts General Laws,chi 142A.
a
n i '"1 P i 4}
A `A� Connector's Signature
Homeowner's Signature go
NOTICE:The signatures of the parties above apply only to the agreement of the parties to allgmarive dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resoluti n even where this
section is not separately signed by the parties
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law(MI L chapter 142A)and other consumer
protection laws(i.e_MGL chapter 93A)may not be waived in any way,even by agreement. ifowever,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 Fond provisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the work as desmibed,in a
timely and workmanlike manner. Homeowners may be entitled to other specific legal rights iIthe contractor
guarantees or provides an express warranty for workmanship or materials. It addition to guarantees or warranties
provided by the contractor,a0 goods sold in Massachusetts carry an implied waaanty of memoantability and fitness for
a particular purpose. An anumeration of othermatters on which the homeowner and wroactoir lawfully agree may be
added to the terms ofthe contract as long as they do not restrict a homeowners basic consumer rights. If you have
questions about your cernsumer/hmmeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in dualicate and should not be signed until a copy of all exhibits and referenced
documents have been attached. Parties are also advised not to sign the document until all bleak sections have been
filled in or marked as void,deleted,or not applicable. One original signed copy of the con with attachments is to
be given to the owner and the other kept by the contractor. Any modificatian m the original contract must be in writing
and agreed to by both parties.Contracted work may not begin until both parties have receive a fully executed copy of
the contract,and the three day rescission period has expiredd
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
1 homeowner deems him/herself to be financially insecure. However,in instances where a coal motor deems him/berself
to be financially insecure,the contractormay require that the balance of fords not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted wink Withdrawal of funds from said account would require the
signatures of both parties.
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights,or ifyou wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement"
contact: !I
Consumer Information Hotline
Office of Consumer Affair and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCABR website at httn://w%w.ma aov/ocabr/
if you want to verify the registration of a contractor or if you have questions or need additionaal information specifically
about the contractor registration component of the Home Improvement Contractor Law,cwlct:
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 ht n:/htwiv.mass. v/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration
htto,//dbstatemans/b meimnrotiement/licenseelistasm .
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
�;�• onsuiner plaint Section
. "s mey General ,
�c 617-727-8400
AND/OR
Better Business Bureau
508-652-4800,508-755-2548 or 413-734-3114
Vasiav2l-11f'-1/°a110
The Coninwnwealtlt ofMassacl:nsetis
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Plectricians/Plumbers
Aoalicant Information - Please Print Leeibly
Name (Business/Organization/Individual): AdWic Wi�dticfiz atiuli,LLC
e crhoi venue
Address: &1[em »4 111 a70
City/State/Zip: Phone#: TF7.
Are yo n employer?Check the appropriate box: of project{required):
1. am a employer with Z � 4. I am a general contractor and IIemployees(full and/or part-time).* have hired the sub-contractors New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. Remodeling
ship and have no employees These sub-contractors haveDemolition
working for me in any capacity, employees and have workers'[No workers' comp. insurance comp. insurance.t Building addition
required.] 5. We are a corporation and its Electrical repairs or additions
3.❑ I am a homeowner doin all work officers have exercised theirg Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGLrt c. 152, Roof r pairs
insurance required.] §I(4), and we have noemployees. [No workers' . ther :2&S5 t/G
comp. insurance required.]
•Any applicant that checks box 91 must 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 hive outside contractors most submi}a new affidavit indicating such.
,Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation tusurance for my employees Belo i is the policy and job site
Information.
Insurance Company Name: 2Gl 1 r G 1
Policy#or Self-ins.Lic.#: 5�6,2 7 /O /Z /(� Expiration Datel Zo
Job Site Address: L th d//th S� City/State/Zip: 4l2/i dl'J9
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 a 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
I do hereby certi• under thepains andpenalties ofperjury that the information provided above is true and correct.
Siarrature a a
Date
Phone#: �7� 7G/(•/- g/ti 3 l
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitUcense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Phone
Contact Person- #•
ACCORHCERTIFICATE OF LIABILITY INSURANCE 3/9/2016 Dg/2016 "'
THIS CERTIFICATE IS ISSUED AS A MATTER 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 DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. H SUBROGATION IS WANED,subject to
the terns and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not Confer rights to the
certificate holder in lieu of such endomement(s).
PRODUCER CONTACT
N Construction
AME
Eastern Insurance Group LLC PHONE (800)333-7234 FAX(AJC lo.
233 West Central St E-MAIL
ADDRESS:Ban.
INSU S AFFORDING COVERAGE NAICN
Natick MA 01760 INsumRAArbella Protection Ins. Co. 41360
INSURED
WsuREReNautilus insurance Co
Atlantic Weatherization INSURERC:
61 Rear Jefferson Avenue INSURER D:
NSURER E:
OE MA 01970
COVERAGES
INSURER F:
CERR AGES CERTIFICATE NUMBERMaster 2016 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING 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.
WLJR ER I TYPE OF INSURANCE POLICY EFF MPO5LICY UP
UNSTS
POLICY NUMBER
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES a TREITFEIT—
E 50,000
A CLAIMSIAADE OCCUR 500042616 /20/2016 /20/2017 MED EXP(An one person) S 5,000
X CONTRACTUAL LIABILITY PERSONAL S ADV INJURY $ 1,000,000
X CG0001 10/01 FORM GENERAL AGGREGATE E 21000,000
GEN'L AGGREGATE UNIT APPLIES PER: PRODUCTS-COMP/OP AGG E 2,000,000
POLICY X PR0. LOC S
AUTOMOBILE LIABILITY COMBINED SINGLE UM
Ea acddaM E 1,000,000
A ANY AUTO BODILY INJURY(Per person) $
ALL
TOOS X AUTTOOSULED 020015871 /20/2016 /20/2017 BODILY INJURY(Peracatlem) E
X HIREDAUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS E
Per gad
PIP-Basic S
X UMBREEXCESS LAB X OCCUR EACH OCCURRENCE S 1,000,000
A EXCESS LVI6 CLAIMS-MADE
AGGREGATE E 1,000,000
DED RETENTIONS 10,000 600058654 /20/2016 /20/2017 1S
WORKERS COMPENSArON NC STATU- OTH-
AND EMPLOYERS,LIABILITY YIN
ANY PROPRIETOR/PARTNERIEXECUTNE
OFFICERIMEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT Is
(Mandatory in NN)
If yes,describe antler E.L DISEASE-EA EMPLOYE S
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY UNIT S
B FOLLDTION PL200378614 O/1/2015 0/1/2016
EA POLLUTION CONDITION $1,QQQ,QQQ
GENERAL AGGREGATE $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AddWaAal Remad¢Schedule,N more apace Is reputed)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF SALEM ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINGTON STREET
SALEM, MA 01970 AUTHORISED REPRESENTATWE
John ICoegel/SLR
ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved.
INSO25,?mnnsl n, Th¢ACflrn nn, and Inns Aro roni¢lnrod m>,W¢of arnion
nigntiax VJ—z z/l4/LU18 9:28 :45 AM PAGE 3/003 Fax Server
DATE(MM/DD/YYYYI
CERTIFICATE OF LIABILITY INSURANCE
T IFICATE IS ISSUED AS A MATTER 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 BYTHE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
OR PRODUCER. CERTIFICATE
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
he terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to
he certificate holder In lieu of such endorsements.
PRODUCER CONTACT
NAME:
EASTERN INS GROUP LLC PHONE FAX
233 W CENTRAL STREET (A/C,No,Ext): (A/C,No):
NATICK,MA 01760 EMAIL
ADDRESS:
22MLW INSURER(S)AFFORDING COVERAGE NAICa
INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY
ATLANTIC WEATHERIZATION LLC INSURER B:
INSURER C:
INSURER D:
61 REAR JEFFERSON AVE INSURER E:
SALEM,MA 01970
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISIONNUMBER:
THIS IS TO IFY THAT THE POLICIES OF INSIURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED. NOTWRHSTANONG
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE
AFFORDED BY THE POLICIES DESCRIBED HEREIN S SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAD CLAIMS.
Nan ADD sue POUCYEFFDATE POLICYEXPDATE
LTR TYPE OF INSURANCE L R POLX:YRUMBER IMYRDOIYYYY) tmiaomWW) Meta
GENERAL LIABILITY [ACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITYAGE TO RENTED $
CLAIMS MADE OCCUR. MISES(Ea occurrence)
EXP(Anyone person) $
SONAL B ADV INJURY $
GEML AGGREGATE LIMIT APPLIES PER: ERAL AGGREGATE $
POLICY [:]PROJECT[:]LOC RODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILYINJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKERS COMPENSATION AND WCSTATUTORY OTHER
EMPLOYER'S LIABILITY Y/N UB-5B27012/-16 03/202016 0312UM17 X LIMH$
ANY PROPERITOMPARTNER/EXECUTIVE El
E.L.EACH ACCIDENT $ 500,000
OFFICERIMEMBER EXCLUDED?
(Mendsmryln NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
11 yes,describe urger
DESCRIPTION OF OPERATIONS Wm E.L.DISEASE-POLICY LIMIT $ 500.000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLEWRESTRICTONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO TWE CERIIRCATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
93 WASHINGTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPR - A MYE
SALEM,MA 01970 _ _ ! "
ACORD 25(207D/D5) The ACORD name and logo are registered an of ACORD 19882010 ACORD CORPORATION. All rights reserved.
Massachusetts Department of Public safety
Board of Building Regulations and Standards Construction Supervisor
; i Restricted to-
Unrestricted S-087977 Unrestricted-Buildings of any use group which contain
License:
C Supervisor less than 35,000 cubic feet(991 cubic meters)of
r _ enclosed space.
ERIC W PALM
3 HILTON ST
SALEM MA 01070 _
M.�n Cjt✓,� expiration: Failure to possess a current ediion ofthe Massachusetts
Commissioner ON2312018 State Building Code is cause for revocation of this license.
OPS Licensing information visit VW W.MASS-GOV/DPS
License or registration valid for individal use only _
Office of Consumer Affairs&Business Regulation - _ before the expiration date. Iffound return to:
ME IMPROVEMENT CONTRACTOR _ Office of Consumer Affairs and Business Regulation -
d egistration: 142089 Type- -10 Park Plaza-Suite 5170
c piration: .311212U1a_' Ltd Liability Corpor _ Boston,MA 02116
ATLANTIC WEATHERIWq-N;L:tC.
ERIC PALM
61RJEFFERSONAVE
SALEM,MA 01970 Undersecretary - Not valid without signature