2 LOGAN ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
L• 1`� Department of Public Safety
•(�'!•tl� Massachusetts Slate Building Code(780 C\IR)Seventh Edition -
City of Salem
Building Permit Application for any 0,uilding other than a 1-or 2-Eamil Ili
(This Section For Official Use Only)
Building Permit Number. Date Applied: I O '0 I-I 3 Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot#forlocations for which a addres is not.av ' eY
a lOq rr vl f
No.and Street U Cite /Toren Zip Code - Name of Building(if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Cl Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other. pecify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
2 - C S
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Hazard
Index
Proposed Use Group(s): f
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1.2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 Cl R-3 ❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: A lunch will not be Licensed Disposal Site El
CICheck it outside Flund Gme❑ Indicate municipal ❑ required O or trench or Pccif,%:
['ricate❑ or indenlifc Zone: or on.oe scstem❑ permit is enclosed ❑
Railroad right-of-way: to Air.Navigation: \I:\ I lislorir c"�nnmi-imi 1(,•cu„ Pnvv..:
Nnl :\pphcablt•❑ F-Haxards
'4Iru,t ure, rthin.urpurtappnoch area' Is their re%ie,c cnnpletrd.'
• r l- m�cnl to lituld endo•ed ❑ 1'es❑ or No❑ I Yes❑ \o ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
lidilim of Code: - L,r Gruupl.l: rtpeof Gmstnidwn: Occupant Load per Fluor
I L,e,the building conl•un an Sprinkler';% lem?: Spraal Stipulations:
r '
SECTION 9: PROPERTY OWNER AUTHORIZATION
N im and Address of Prupert_v Owner
Q)"�n 1' refv Logav �f• �yr l)V} 0/
:Nome(Print) Nu.a d Slrrrt City/Town Zip
Propertv the ner Contact Information: 7� 33 / ?1-19 r
Title Telephone No. (business) Telephone No. (cell) a-mail address
If. plicable, the prupertc owner hereby authori es
r17 Qulh , 3 ff� SJ- -Iles a/9 70
Name Street Address City/Town State Zip
to act on the propem opener's behalf, in all matters relative to work authorized by this building permit a p lication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It building is less than 35,001.1 cu. it.of enclosed s ace and/ur nut under Construction Control then check here D and skip Sectiun 10.1)
10.1 Registered Professional Responsible for Construction Control
8/`13 -rP&,).,,1 oI %Y��if>
Name([Zgis`t�rant ^ Telrphunp Nu. e-mail adders ` Registration Number„ ' /
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Com any Name:
P, is Pa. I+'Y) i..�e
Name of Pertiuq gesponsible fur Construction License No. and Type if Applicable
3 1 �; IIr Sr
Street Address City/Town State Zip
7'0 - - /vim �bt� _ �2L^ _ /03l. -T P C i (�, IVC4
Tele hone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with thisapplication? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE.
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) =$
1. Building $ 02 16ey,6o Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact munici -lily)
6. MechTotal Cost
(Other) - $ Enclose check payable to (�
6.Total Cost -- $ r/U (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information cnntained in this
application is true and accurate to the best of my knowledge and understanding.
I'lea�e pr nt and sign name title Telephone.No. Dale
tiu-ret Address City/Town - State Zip
.Municipal Inspector to fill out this section upon application approval:
Name Date
AC 0 DATE(MODD/YYYY)
� CERTIFICATE OF LIABILITY INSURANCE 3/11/2013
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. If SUBROGATION IS WAIVED, subject to
the terms 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 endorsement(s).
PRODUCER NAME- UOnstruction
Eastern Insurance Group LLC PHONE (508) 651-7700 - FAX
233 West Central Street - a INC,Nok
INSURE S AFPORDINO COVERAGE NAIC#
Natick MA 01760 INSURERArbella Protection Ins. Co. 41360
INSURED :A
INSURER B Arbella Indeann-ity Ins Co. 10017
Atlantic Weatherization INSURER CNautilus Insurance Cc
61 Rear Jefferson Avenue INSURER D:
INSURER E:
Salem MA 01970 INSURER F:
COVERAGES CERTIFICATE NUMBER3'77+STER 2013 REVISION NUMBER: -
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED I V 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,
INTR TYPE OFINSURANCE POLICY NUMBER PWD EFF MOLICY EXPW
LIMITS
GENERAL LIABILITY
CE E 1,000,000
X COMMERCIAL GENERAL LIABILITY vrte E 50,000
ArrENL,A
CLAIMS-MADE X�OCCUR 500042816 /20/2013 /20/2014 arson E 5,000INJURY § 1,000,000GATE § 2,000,000
GREM TE LIMIT APPLIESPER: PRODUCTS-COMP/OP AGO E 2,000,000
ICY X PIFCT RO- LOC §
AUTOMOBILE LIABILItt COMBI DSIN LELIMI 11000,000
Ea ea dent
8HANY AUTO BODILY INJURY(Per Person) E
ALL OWNED BCMEDVLED /20/2013
AUTOS X AUTOS 020015871 /20/2014 BODILY INJURY(Per acddenl) E
HIRED AUrOS X NONOMED
AUTOS P PERTY DgMAGE E
P ee<Itlenl
PIP-Beslc E
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE E 1,000,000
A EXCESS LVtB CLAIMS-MADE AGGREGATE Is 1,000,000
DED RETENTION L0004782O /20/1.13 /20/2014 §
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY
ANY.PROPRIETOR/PARTNER/EXECUTIVE YIN
OFFICERAIEMBER EXCLUDED? NIA E.L.EACH ACCIDENT §
(Mantlatory In NN)
If yas,OesulCa antler E.L DISEASE-EA EMPLOYE E
DESCRIPTION OF OPERATIONS below C POLLUTION LIABILITY E.L.DISEASE-POLICY LIMIT §
PL2003786001 0/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000
EA POLLUTION CONDITION $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANaeh ACORD 101,Ad;monel Remarks Schedule,If more apace Is requlmd)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE Dtd
CITY OF RAT M ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINGTON STREET
SALEM, MA 01970 AUTHORIZED REPRESENTATIVE
Rosemary Fulham/PMA �5«"—�a`�✓ACORD 25(2010/
05) 01988-2010 ACORD CORPORATION. All rights reserved.
8 INS02S ronims,m Tbo ncnwn name end Innn v.n ronicb.nd ma.4a of ernwn
e
nisnziax U:J_z 3/11/2013 4 : 45 : 54 AM PAGE 2/002 Fax Server
y- CERTIFICATE OF LIABILITY INSURANCE DATeIMM/DD/YYYY)
T IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
CERTIFICATE DOES NOT AFFIRMATIVELY NO RIGHTS UPON THE RTIFIC)T HOLDER. THIS
N LY 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. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
EASTERN INS GROUP LLC PHONE FAX
233 WEST CENTRAL ST (A/C.No,Est): (A/C,No):
NATICK,MA 01760 E-MAIL
ADDRESS:
22MLW INSURER(S)AFFORDING COVERAGE
NAIC ft
INSURED INSURERA: AMERICAN ZURICH INSURANCE COMPANY
ATLANTIC WEATHERIZATION LLC INSURER B:
INSURER C:
D
61 REAR JEFFERSON AVE INSURER :
SILENT,MA 01970 INSURER E:
' INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
HIS ISTO CERTIFY EPD IESOFI 5 RAN LISTED BIELOWHAVEBEEN ISSUED TO THEINSURED NAMED ABOVE FOR THEPOLICY 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. LIMBS SHOWN MAY
HAVE BEEN REDUCED BY PAID CLAIMS.
UISR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDOwyYy) (MMNDDIYYYY) LIMITS
GENERAL LIABILITY ACH OCCURRENCE $
COPAMERCIAL GENERAL LIABILITY
CLAIMS MADE OCCUR. DAMAGE TO RENTED $
EMISES(Ea occurrence)
MED EXP(Arty one person) Is
GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL&ADV INJURY Is
ENERAL AGGREGATE $
POLICY �PROJECT 0 LOC RODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE $
LIMIT(Ea axident)
ALL OWNED AUTOS BODILY INJURY g
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY Ig
NON-OWNED AUTOS Per accident)
PROPERTY DAMAGE $
(Per accident)
UMHRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION S s
A WORKER'-COMPENSATION AND WC STAMORY OTH=R
EMPLOYER'S LIABILITY Y/N UB-5B270121.13 032020/3 03/20/2014 X LIMITS
ANY PROPERMCR/PARTNEWEXECUTNE N/A OFFICER/MEMBER EXCLUDED' E.L.EACH ACCIDENT I$ 500,000
(Mandelory In NH) E.L.DISEASE-EA EMPLOYEE S 500,000
tl yes,dewibe antler
DESCRIPTION OFDPERATIDNS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED
93 WASHINTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
SILENT,MA 01970
AUTHORIZED REPR " TA ° Ant—
CORD
'
ACORD 25(2010/05) The ACORD name and logo are registered marks of) CORD 1988-2010 ACORD CORPORATION. All rights reserved.
assz- r ➢eoe meet or PuLliz Say !y - -
ca_,-d > mnd_rds
=ian St p r.b,ilr t Unrestricted-Buildings of any use group which
nse: CS-087977 F contain less than 35,000 cubic feet(991 m')of
IN enclosed space.
ERIC W PALM t
3 HILTON S'E -
SALEM MA.-01970 A-
J..Ge•-J.�l.�r ;=:" :`ripir,;_�,; Failure to Possessa current edition of the Massachusetts
Commssirne- 04/23/2014 State Building Code is cause for revocation of this license_
- For DPS Ucrosinginfurmation visit:. v .Mass.Gov/DPS
O(Tice ---
�}.
HOME IMPROVEMENT CONTRACTOR License or registration valid for individuf use only
S�`.o Regishation 142089 Tye - before the espira5on date. If found return to:
-yr Expiration: 311212014 Lid Liability Carper ; Office of Consumer Affairs and Business Regulation
,ttWd Yf7C WEATHEWZATION-t.L:C. - I YO Park Plaza-Suite 5170
1 .Boston,NIA 02116
ERIC PALM { ( !
61R JEFFERSON AVE
SALEM,MA 01970 Lindersecretat7• i{ fj`• // '
Not valid-[bout
k'
!
Massac Hone $In rovement Sample Contract
ii
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IMIMIlosem ConnmerGuide t�IH1 egad advice ifnecaunry.ApYPosonDl®nmghomoimorvvements shau!d flrs[obmm ar_.,
t 'a maImprevemeaf'befom .7 of--,A
Omce of CmsmterAEaits mdBtteparReguled §Co¢mmsagmmg to my tvorkon yomresidmee;You tray obtain aire-cey'by mllingthe
_ u 3othne ttt 617973-88 or1888-'r81757 or oa ovtv_.•yit-..Homeowner InfGrmahon
.Contractor Information
_ Tamel(C�
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.-s.rdacsao not rM< "r•, � nreaPostoffieenm.dd[esay ... P tr°n c{T�„ra,
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(it -7 D a' �nre •7•�✓,S Pkidog Phone
__ - -J - Cirylfor:n a¢:e Zip Code -
::+cl ing hddrs(![diieeat flea eb eve)
. 3asiness 2bm:c pe+-...,cmploremorsS.Nembs
La:evs�im:Ccv:L a
1 gnat:lsi•Tw�Y'6-..�rS I y 7 ..'� - ,
Tnc Contractor agrees to dofhc follow!nybgthe fartbeHomeoumer. n
cd0.inearil the putkfa dear a iy'g t17c,bmnd.mdgrde of maaJisto be
W,�e spat m to �nra,aaa;eert--�=a.-
�YS-ea� 't
Re°niredPcrmils-TL b
eibllorvmg;tugdiagpe5e2, - --
-?Smed Proposed Smrtmd Completion Sche
c dulc•The following scLaaole
t ers who sec e e
will
�e:d wrli best by thamnnatu(-estehoneotsnets" ant be adhered
°$ ozd touUess choumstancs ayand the conhxcto?s cm�,l arse
(Ovaar thm diva permits will be
escluded L'om the Guaranty Fund provisions of u whm I -=-!�L-}'-!•--llGLchapter142A.) D contraCor vrill begin matrzUed wore
. I �(/ Dara whm mntrscted{tn;kwill be suba'tentiUly completed. I{
T hl C trnetFnea dP }me tSchcd I rt
7hec-taemra,^ees to per6rrm tee wad;thodsh the material and lzbmsotcilled above for the tend s®oi• -r100-yo
(°)
?a}mahts will be cede mmNing tole foL...1Ogsehadtde;
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apana _----
gong mn,acC(ao:m excern7i3'6i[he tatztccc¢'zc[9Tce m me ws vFspxeei o�eifeiasTvei¢nevdcl;g�;i:.�.- _
S °Y /_rt�//_a; erunoa coapleloa o_` )S 1�0U.�,LL)�)1:� ac aeon compleCm of 'fOTC I �.dN'1 {rJ�Q�`%Jl-.r
a'oU•/ man mmpletim bfthe aoanaat ,�; (Lewfotidsdemnndingiullpaymmtmtuwnuacris omalete to bath t'ssreon)
part}•'ssa
'Cho totlpudng mateiellryv-'pa:,"—I he speci c
emo"d bate"the tt_necMxot'c begin,Lcdc to bepld for
a fast to wmci:dan sthCuta.Y?:) c
' to to paid in,
10TE5:(°)ric;jn3 ell Fm3co r^•es(aa)?'<,v[ey-ui.s a`ea d•wft.rdoxn.,mmt red
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reerea wamnr.- ar,cart nm``,n[r b im rxsided bV the coot.ear? ❑Ya v
rs fold t• ortheaarmnw mast b•atfich to the contictl
S•heoncaeto:s-tea mt[tat =ms to basal^lyzespanrbla fa:m=.pL--den pe't yurr.kdateued rag-Uess of the zntia t aeany t],a
viicdbi me aatrzcroc Toe mnaxcariicchc emirs on sotUYrapansiole far aln
' ato-e!'-n lab run - is ee:-='ene aymems m ad s,hMnt!For
Contract,tettpmnce•IIpm siguihe,its doc�ehtbecames ebiudxg mnnnR mdvl�w,unless oterv.iseaomd tviddn Ibis decutrI me
before
mmd'&that am lieab:otmsaesityint.resthas bam o!ecad oa tbo residatam liev!esv the fallowing ouations andanIieea
GaeiUty before sigaidg this caauacd
DI be p:cIiato.igniagjhe aomma Take time to read and dill
'T.a emrethec tra rnh .Sdg Y't.nd estendit .iktiwsdons it soma thing is unclear.
C he it n . 'iAe l_{VIC 1PS mn5thame:�taCantt ems to a-rec[s�=!LIxt:the Draac afHenoa lMpm.aoan[Cantu ctor cation. Yvu^• .vomvemmt eon.trots and
regimzdm by tv,+.tiag to the D_*ecm:zt 10 P3!;p1aa,Room it Regis s}•inquire abou[mntrsCor
Doa>_e cn�acmr bay,m a t. 7o,Bosme,h•L4 02ll6 r.by celling 617-973.8787 Or 888-28i-i757.
-:�'�"-ce. ;sIcthe Contractor nor his insate ce mmI i eematim so that yen can"mire coverage,o.ask to ate a mpy ofa'btmfo'.iaslm3c:"dan,'Taor -
11a1t•}'e`slgC9 mdra5ae Slptll'aaS. ai to aCant lla-ladC.mf",,V2.Se side ofins_n:S and-gat acppl'o"=a Qlainmar
GUda m the-^ _ _ei,Com_�o; _
eau ma}•cmci:,isa�-mm;.t-;:yu been sgaod= t e.
1 z n.z-ors than he concern:s aetxal plane OFbrsiaess,aravided yin nail^'/to
w C,Car_{v_gathil&asi.•[Ici�cerbzrche_G by e.•dc+=�m;:!!oas:ed,by Leg;am seat orb del.tz�bvenss�yfoPor4in3faesiyis[g net sc Y aver�not le[sihmv;dnigc!of:he
gr-=^mot .a-..,.____o_ro of r�clz_*'oa-_r3 f�c:ea�!ay.u-�'cn oftcis riget
DO NOT SICK THIS CO?VTR�CT IF THERE ARE A11�'BLS\TK SPACES!11
VV — '-T== 3=T_-car c:_,n�•�ax-_:�c_va�j�_�...'x__,ay c:cc:=m:.
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Contractor s Signature
D.[e
Date
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- Contractor Arbitration -
The Home ImprPVelnent Contractor law provides homeowners with the right to inidate awarbihxtien action(as an
alternative to court action)if they have a dispute with a contractor. The same right is not air; a to to a
contractor,however. The contractor would have to resolve any dispute he/she has with a ho,Oeowner in court omatically afforded to
both parties agree to the optiongl clause provided below. This clause would give the contractor the same right to
arbitation as is afforded to the homeowner by the Home Improvement Contractor Law.
The uonOn for and the homeowner hereby mutually agree is advance that in the event the contractor has a dispute
concerning ths.contractr.the,cp�actor may,submit the dspute to aprivate arbitration firm}vich has been approved by
the Secretary of tha'Hxecmve O�ceoConstmrerAfiairs and Business Re
submit to such etbitdahon rovided In Massachusetts General Laws,c gulatioa and thelcoasumer shall be rzouired
a 1S3A.
QLvs
Homeowners Sr us �
toftheparti
NOTICE:The srgoat", of the parties above a Co°tract°>'s Stgnanne
sesoluaoa initiated by the contractor
The homeowner may initiata a[tmamaan tve dispute dispa
reso,'lestoetion even whereed'-is
section s not separately signed by the parties.
Homeowner's-Rights
A homeowners rights under the Home Improvement Contractor Law(Mal,chapter IS2A)'and other consumer
Protection laws(ie.MGL chapter 93A)may not be waived in any way,even by agrzement.iHo wever,homeowners
- may be excluded from certain rights if the contractor they choose is not properly scree erect 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 contractors responsible for compleflng the n?ozk as described,in a
timely and workmanlike manner. Homeowner,may be entitled to other specific legal tights if the contractor
, on to guarantees contractor
guarantees or provides an express warranty for workmanship or materials Ia additi w=r�!ties
provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and n"tuess 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 w they do not restrict a homeowner's basic consumer rights. If you have
questions about your comemer/humeotner rigors,contact the Consumer Information Hotline(listed below).
E.cecution of Contract - _
The contract must be executed in m1icate and should not be signed mtil a copy of all exhibits 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 coutiact with attachments is to
be given to the owner and the other kept by the contractor. smy modification to the original contract mustbelnittiting --"
and agreed-to by cothpartizs.T,outmete8wo'3maT}"norfiegta imtil�tiotn paifie--b rec"i;fed a filly executed cony o; - -
the contract,and the three day rescission period has expired -
Accelerated Payments "
A connector may,not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deea,s]i{m/herszif to be iinaacially insecure. However,in instances where a contractor deems him herself
to be finandlelly insecure;the contractor may require that the balance of funds not yet duejbepiaced in a joint escrow
account as a prerequisite to continuing the contracted wor'.cthdraw•al of fiords from said account would require the
signatures of both patties.
Additional Information
If you have general questions or need additional information about the Home Improvemerif Contractor Law or other
consumer rights,or ifyou wish to obtain a free copy of °A Massachusetts Consumer Guide to Home Impmvemen+°contact
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,lvL4 02116 j I
617-973-8787,888-283-3757 or visit the OCA13R website at bM,//www-rnass.aov/ocabr/
Uyou want to verity the registration of a contractor or if you have questions or need additional information specifically
about the contractor registration component ofthe Home Imorovement Contractor law,contact:
Director of Home Improvement Contractor Registration r
Office of Consumer Af;,airs and Business Regulation
10 Park Plaza,Room 5170,Boston,MS 02116
617-973-8787,888-283-3757 or visit the HICwebsiteathtm://wwwv.rn Pov/ocabr/
Go online to view the status of a Home Improvement Coutractor's Regisratimi:
hM:/Jdb.smte.ma.usl.lomeimumv mentilicenseelistasp
For assistance with informal mediation of disputes or to register formal complaints again3t a business,call:
Consumer Complaint Section
_. `Office of the AKomeyGeneral
6177-7-727--884 0
Better Business Bureau
- 508-652-0800,508-755 2548 or413-734-3114
Vcion 2.1-I1=010
I
CITY OF SUZNf1 Aks&wi-jusETTS
i Bt.'tLONG DEP.1R-M&NT
130 W.19HC4rTGN STREET,3 w FtioOR
TFL (979) 745-9595
KEN MERt Y DRISCOLL F•I-X(973) 7.1 -9345
`,L1YOR T1I051LU ST.PIERM
DIRECTOR OF PC OLIC PROPEATY/BC IL OLYG CMNISSIO V ER
Construction Debris Disposal Affldavit
(required for all dcmolitiun and renuvation work)
In accordance with the sixth edition of the State Building Coda, 730 C&fR section 111.5
Debris, and the provisions of tLIGL c 40, S 54;
Building permit !k this is issued with the condition that the debris resulting from
l 1, S l SOA.1 work shall be disposed of in a properly licensed waste disposal facility as defined by tbfGL c
1'Ite debris will be transported by:
/yOr41 5 j l Gtrtlt cf
(11Un1C p( 116UICf1
The debris will bedisposed 0(in
rft�-
(namc
_ ✓r�0r t V1 v1 01 o
(j,"ess Of rdlnhty)
so
signamte fit permit applicant
21
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aanlicant Information Please Print Legibly
Name(Business/OrganizationtInclM. OXTICMEATHERIZATIONs LM
6IRJEFFERSON AVENUE
Address: SALEM, MA 01970
EAX(978)745-2200
City/State/Zip: Phone #:
Are y an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner-. listed on the attached sheet. 7. ❑ Remodeling
ship.and have no employees These sub-contractors have S. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P ty 9. ❑Building addition
[No workers' comp. insurance comp.insurance.*
required.] 5. ❑ We are a corporation and its ME]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. o workers' com right of exemption per MGL
Y Ill P• 12.❑R epairs
insurance required.]* c. 152, §1(4),and we have no
employees, [No workers' 13. Other TSufa
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
.t Homeowners whosubmit this affidavit indicating they are.doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or notjthose entities have
employees. Ifthe sub-contreWors have employees,they.most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: =22� t C
Policy#or Self-ins.Lic.#:s ) aJ 2?a ) z { Expiration Date: -�q
Job Site Address: La G h Sf City/State/Zip: hA--) )%1I 67/976
Attach a copy of the workers' com ensation 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$250.0Q a day against the violator. Be advised that a copy of this statement maybe forwarded to!the Office of
Investigations ofthe DIA for insurance coverage verification.
I do hereby certify andL�i(�the�p YES Date:
and penaltlees of perjury that the information provided abov is tru�'and correct.
Signature: n {/`M p Date: �c2 7 / 13
Phone#: 9 p 7 y y �� `/
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical_Inspector 5.Plumbing Inspector
6.Other .
i
Contact Person: Phone#: