216 LORING AVE - BUILDING INSPECTION J
9 CAL l I (A3
The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEIvED CITY OF
Massachusetts State Building Code, 780 CMKSPECT ION AL S ERVICEG�EvI
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate 1�'��p)Q its)�a 1. 48
One-or Two-Family Dwelling CC�Y J
_ •This Section For Official Use Only
(3 Building Permit Number: Date A plied: .. .. -
u ' Building 0119cial(Print Name) Signature Date
a
SECTION 1:SITE INFORMATION
1.1 Property Address: A 1.2 Assessors Map&Parcel Numbers
Ma
l.la Is this an accepted str . yes no Number Parcel Number Map
Number
Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
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? Municipal❑ On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow ' f Recortziwz& r a S Swept AI'A
Name(Print) City,State,ZIP
02/(p Gor 7y[�-
No.and Street Telephone Email Address
.SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Gi-Sp ify:
Brief Description of Proposed Work:
SECTION 4:ESTIMATED CONSTRUCTION COSTS '
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 757V- I. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ -
4. Mechanical (ITVAC) $
List:
5.Mechanical (Fire $
Su ression 'Total All Fees:$
Check No.L"4J__Check Amount: Cash Amount:
6.Total Project Cost: $ 7 SVb 0 Paid in Full 0 Outstanding Balance Due:
d
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) a 7 9 7 7 y 3
' License Number Expiration Date
Name of CSL Holder
Enti W.PShl1 List CSL Type(see below)ti(�
No.and Street Type Description
Salon MAL 01970 U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
QC ��� �/ SF Solid Fuel Burning Appliances
3 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) �yZok� 3 /�
Afintic WealI1CF)i Awn,LLL HIC Registration Number Expiration Date
H1C Company NaM-(R�Pr1� C
No.and Street Sal6h MA 0 1970 Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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 Issuance of a 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 &/L
to act on my behalf,in all matters relative to work authorized by this building permit application. p
Print Owner's Signature) //ate
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
containe this app�tion� accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires anunregistered contrac]at
(not registered in the Home Improvement Contractor(HIC)Program),will not 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dus
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross 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
3. "Total Project Square Footage"maybe 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 not automatically afforded to a
contractor,however. The contractor 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. r
The contractor and the homeowner hereby annually agree in advance that in the event the contractor has a dispute
concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the$S edutive'Offreeo C Macau Affairs and Business Regulation and the consumer shall be required
to submit to such gkltittntidTt: i%[de Massachusetts General Laws,ch er 142AAA
Homeowner's Signalaiuri- Contractor's Signature
NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contactor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties-
Homeowner's Rights -
A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other 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 Food provisions of
the FIome 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 if the contractor
guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for
a particular purpose.An entmeration of othermatters on which the homeowner and contractor lawfully agree maybe
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 yaw consmrer/homeowner rigbts,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 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 contract with attachments is to
_ be given to the owner and the other kept by the contactor. 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 three day rescission period has expiredi.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself
_ to be financially insecure,the contractor may require that the balance of fiords not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of fiords 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 if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCABRwebsite at http:/Ii ny.ma .00v/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 Contractor Law,contact:
Detector 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 httn:/A+ww.mass.sov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration
hfty://db.state.maus/homeimorovement/limnseelistaso
For assistance with informal mediation of disputes w to register formal complaints against a business,call:
Cons omplaint Section
. ,taps 0 Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-6524800.508-755-2548 or 413-734-31I4
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TBze C'ommoszwealtlz ofll�assaelzzzsetrs
a 7DepartnZent of Indrsh'ialAccidezzts
7 Congress Street 5tzite 700
3ostosz,Its 02774-apT7
Workers' wwluzzzassgov/dia
Compensation Insurance Affidavit-.BuiiderstContractorstElectriciaas/€'Inmbers.
TO BE FILEID tVITH THE PERtiITTTLYG AUTHORfly.
Aa licantiufol:�nation
N11e(Business/or.anization/Individual): A€agitie i1j� Please Print I e "bl
Address: 1. P,-Tp
City/State/Zip:
ACheCkSiE
ua employer?_heck then p Phone#: Ci' 79 _
PPro rule 60::
am a employer with Type Of project r
aC--+_atnptoyces(full and/or part-time).= ( equired):am a sole proprietor orparmership and have no employees arod ing forme iny ca aci Z ❑New construction
P ry-[1.ouvri;ers'comp.insurance required) _ S. ❑m a homcorvner doing all u'orkm elf - RemodelingYs pJo uoda:rs`camp insurance required]t 9- Demolitionm a homemimerand uvll be hiring commerors 1a conduct all work an my property- f aia 10 Q Building additionsure that all eomracmrseither have workers'compensation insurance a are solepdemm with no employees. - _ I I-Q Electrical repairs or additions
a general comractorand I have hired the sub-contractors listed on the ❑ese sub-contntclms have employees and hawwkers'comp.ed oranci shed Shy' i" Plumbing repairs or additions area corparadoa and its a vers leaveeurejsed lheirrieht ofesemption per MGt.c 3"❑Roo•repairs§I(3),and us have no emplayem.[No xwrkrers'com .in l�- they y�U tP surance required) T 6 t 'antthat cheds box RImust also fill outthe section below shon4ng lheirwork-eM ornaffid
oahmcmers who submit tboxhis must
indicating they are doing all wade and than hire outside contractors oneasubmit a nets affidavit indicating such
ampjay etors ftat check this cm must attached an additional shmrshowing the rrdme of the sub•contraemrsaaad lstate um rhedrerror not those entities nave
employees ffinesub-conramors have emplaYeeg tkey mutt provide their he not comp,policynumber
i ae as emploper flint ispso»idiag workers'compeasaVon irzsararzcefor rzrp ear la,ees r3e7oty is fire oli ,
iaforazadan. p J .
Insurance Company�lame: P ci and job site
�uv"i Gk
Policy n or Self-ins.Lic-#:_Job
Expiration Date: 4 i
Att Site Address: ll �r
Attach a copy,of the worke s compeasa n Policy City/State/Zip: Le
P y declaration page(s@owing the pokey number and expirationdate)-
and/or _
Failure to secure coverage as required under bIGL C. 752, c
one-year imprisonment,as well as civil penalties in ffie fots a rm criminal STOP violation punishable by a fine up to S1,500-00
day against the violator.A copy of this statement may be forwarded to the Office ofInves�hp s of the DIA for insurance
coverage verification. and a fine of up to 5350.00 a
I do hereby M&IM,under the n„-2--— --
Signature: rotidedabovefstraemrdcorrect
v .�
Phone : . � a �_-- Date• -
F[6;.(0)ther
only. ➢o not write la this area,to be completed bj,cdj,or tolvrr o
lfictaL
m:
hor7 (circle one); Permit/License
Health 2.3ui!diugDepartment 3.Cityll'own Clerk Electrical inspector 5.plumbing 7
g_nspector
on:
Phone ale;
.4CQR®®
CERTIFICATE OF LIABILITY INSURANCE DATE"N'°D""M
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER5THIS
CERTIFICATE DOES NOT AFFIRMATIVELY INS OR INEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sl AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certifipte holder is an ADDI I JUNAL INSURED, the _the terms and conditions of the policy,certain policies may require an endorsement statemeendnt on this rsea. It certitificate does notnot older rights t su to
bject
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
Eastern Insurance Group LLC PHONE Construction
233 West Central St (800)333-7234 a o
ADD L
Natick MA 01760 INSU AFFORDING COVERAGE NAICa
INSURED INSURERAArbella ProteCt7.on IRS. Co. 1360
Atlantic Weatherization INSuRBReNautilus Insurance Co
61 Rear Jefferson Avenue INSURERC:
INSURER 0
Salem MA 01970 INSURER E:
COVERAGES CERTIFICATENUMBERMASTER 2015 suRERF:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDEVNAMED A80EOR 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.
INSR
LTR TYPE OFINSURANCE GENERAL him POUCYEXp
LIABILITY N UM B D UMnB
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
A CLAIMSaYIADE ®OCCUR 500042816 /20/2015 /20/2016 P EM Ea S 50,000
MEOEXP onepdrson) S 5,000
PERSONAL B ADV INJURY S 11000,000
GEN'L AGGREGATE LIN(AppUES PER: GENERALAGGREGATE S 2,000,000
POLICY X PRO, LOC PRODUCTS•Col AGG S 21 000,000
AUTOMOBILE LIABILITY S
C SINED LIMIT
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AUTo5S X SCHEDULED 020015871 BODILY BJJURY(Perperson) S
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X HIRED AUTOS X NON-OWNED BODILY INJURY(Pe,acadaa0 $
AUTOS PROPERTY OHMAGE S
X UMBRELLA LIAR X OCCUR pip-B4sip S
A EXCESS LIAR CLNMS4ADE EACH OCCURRENCE
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DED RETENTIONS 600058654 AGGREGATE S 1,000,000
WORKERS COMPENSATION /20/2015 /20/2016
AND EMPLOYERS,LIABILITY 5
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(Mandatory ❑
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DESCRIPTION OF OPERATIONS below -
ELDISEASE-EA EMPLOYE S
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$1,000,000
EA POLLUTION CONDITION $1,000,000
?SCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(Attach ACORD 101,Additional Radial
atlW SeUk HmOe
space 6:regVtre�
cRTiFICATE HOLDER
CANCELLATION
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBER POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE 93 WASHINGTON STREET ACCORDANCE WITH THE POLICY PROVISIONS. WILL BE DELIVERED IN
SALEM, MA 01970 AUTHORIZED REPRESENTAIfVE
DRD 26 '2010105) John KOegel/PMA
025 nmmsl Ot Thu pf:flRT1 nanw anH IMn aro ronicferorl make nF2AnRnoRD CORPORATION. All rights reserved.
_. acaa U=X Ycl
CERTIFICATE OF LIABILITY INSURANCE
T DATE IMM/DD/YYYY)IFICQTE IS ISSUED AS q MATTER OF INFORMATION ONLY AND CONFERS NO RIFI
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
O DUC D T OLD -
G HTS UPON THE CERTI CATE HOLDER. THIS
.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE Q CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
C
I.IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the oll i
terms and Conditions of P (es mu f the policy,certain policies may uire and � st at endorsed- If SUBROGATION IS WAIVE certificate holder' re9 endorsement D,Subject to th I.Ileu of such endorsemen s, M- A statement on this certificate dyes not confer rights to the e
PRODUCER
CONTACT
EASTERN INS GROUP LLC NAME:
233 W CENTRAL STREET PHONE
(A/C,No.Wi. - FAX
NATICK,MA 01760 E-MAIL
22MLW ADDRESS:
INSURED INSURERS)AFFORDING COVERAGE
MERLCAN ATLANTIC WEATHERIZATION LLC INSURER A: A zlrgrcRINsugwrrca COMPANT' NAICg
INSURER B:
INSURER C.
61 REAR JEFFERSON AVE INSURER D:
SALEM.MA 01970 INSURER E:
COVERAGES INSURER F:
CERTIFICATE NUMBER:
FY HAT HE POLICAISpFNSUR gT®BELON NAVE BEEN EI TO TNENB11q�NAM®ggOVE FORTNE REVISION NUMBER:
ANY REOUIREMEM,TERM OR CONORIpN OF ANYCONTRACrpp OTNEN
AFFORDEDBYTHE POLK7E9O DOCUMENT LUSRESPECTTOWHX:H THIS CE1rTIFICATE MAYBE ISSUED OR oX:AT®.NO7WffHSTANpNG
PAD CLAIMS. EarCR1aED HERBN 63UBJFDT TOALL THE TEAMS,IXCLU910NS AND CONOmONS0,CERTPOLICIES UNITS SHOWN MAYHAVVEE6EEN REDUCED BY
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LTR TYPE OF 24SURANCE ADD SUB POLICY FFF GATE POLX:Y EXP DATE
L R POLICY NUMBER M
(LWMYYVY) ( M10U1VYV17
GENERAL LIABILITY Laing
COMMERCIAL GENERAL LIABILITY ACH OCCURRENCE
CLAIMS MADE $
®OCCUR. AMAGE TO RENTED
REMISES(Ea accerrence) $
GENT.AGGREGATE LIMIT APPLIES PER: EDEXP(Anyowpena ti $
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POLICY PROJECT❑LOC ENERAL AGGREGATE $
AUTOMOBILE LIABILITY RODUCTS-COMP/OPAGG $
ANY AUTO COMBINEDSINGLE ALL OWNED AUTOS LMIT(Esaccidere) $ -
SCHEDULEAUTOS BODILY INJURY $
HIRED AUTOS (Per Person)
NON-OWNED AUTOS BODILY INJURY $
Par accident)
PROPERTYDAMAGE $
(Pe accident)
UMBRELLA LIAR OCCUR
EXCESS LIAR CLAIMS-MADE EACH OCCURRENCE $
DEDUCTIBLE AGGREGATE $
RETENTIONS $
A WORKER'S COMPENSATION AND $
EMPLOYERS LIABILITY y,N
ANY PROPERITOR�PARTNERTXECUTIVE U86B270121-15 03Q02D15 03r2Df2018 X WC STATUTORY OTHER
OFFICERRAEMBER EXCLUDED, N WA LIMITS
It -a.deory)n NH) E.L EACH ACCIDENT $ 5OG.660
Ryes, IPTIOe Omer E.L.DISEASE-EA EMPLOYEE
OESCgIPgON OF OPERATIONS OaIow $ 500,000
DESCRIPTION OF OPERATIONS/LOCAT1ONSiVEHICLES)RE E.L"DISEASE-POLICY LIMIT $ SD0,110(t
7IOS REPLACES ANY PRIOR CER7IF[CA77i ISSUED TO THESTRICTIONSlSPECIAL ITEMS
CDt7TRCAT'EHOWER AFI IRd(I WORIGTRS COMP COVERAC&
CERTIFICATE HOLDER
C177Y OF SALEM CANCELLATION
93 WASHINGTON ST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION GATE THEREOF,NOTICE WILL Be DELIVERED
IN ACCORDANCE ThE POLICY PHOY151ONS.
SALEM,MA 01970 AUTHORIZED REPR
IL "E :..
ACORD 25 _ i� -± "' ,--.•:.Y:
5) The ACORD mama and Logo are registered marks or ACORD
T9 :ZpTOACORDCORPORATTON. All rig/Ha reserved.
t Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supenisor
License: CS-WO77
ERIC W PALM
3 HELTON ST 't -
Salem MA 011707
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ERIC PALM
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SALEM,MA 01970" Undersecretary