498 LORING AVE - BUILDING INSPECTION 2 -7 CK- 12.10-7
k The Commonwealth of tMossachusetts
Board of Building Regulations and Standards CITY OF
ulh
SALE&I
Massachusetts State Building Code, 780 CMR Rsvised,tiI r 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section Far Oflioial Usc•Only; '
Building Permit Number:- Data.Applied; �f;;�:co; :. '`-
1 V Building Of icial(Print Name) - Signattae Al Date
1 SECTION 1:SITE INFORtIVIATfON'
Ll Praoerty Address , _1.2 Assessors Slap Sr Parcel Numbers
N9 �! Lo1Z I N CU
1 L l a Is this an accepted street9 yes_ no Map Number Parcel Number
1.3 Zoning information: 1.4 Propert)Dlmeitlelons�• Ox�
1 Zoning Distrito -� Proposed Use - Lo[Area(sq it)) fFrontage(R)
1.5 Building Setbacks(R) .
Front Yard Side Yards
Rear Yard -
.
Required Provided -Required - Provided � � Required - Provide
1.6\Vater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone?Cbedtif esD. Municipal O On site disposdsystem ❑ ..
-
SECTIONS. PROPERTY:OWNE"I IPl
2.1 tv < r ro--__ LL// /
1-4
Rime �/ - - _ City.State,ZIP
No.and Street Telephone Email Addrtss
SECTION 3:DESCRIPTION OF PROPOSED%V0_ (check oil that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 13 1 Alterrtion(s) 0 Addition ❑
Demolition ❑ Accessory Bldg.❑ NumberofUnits_ Other ❑ Specify:
BriefDescri do/p�o(pProposed Work=:
-- p
i
SECTION a:ESTIMATED CONSTRUCTION COSTS : .
I(cm Estimated Costs: Official Use Only
Labor and Materials)-
1. Building g -5 7au 1. Building Permit Fee:$ Indicate how f;unt:
is determined:
2.Electrical S ❑Standard Citylrown Application Fee..
❑TotalprojectCost'(item 6):c Mal
tiplier 3. PlumbingQtherFees: S
4. Mechanical (HVAC) S List.
5.iMechanical (Fire
Su ressiun) STotalAll Fccs:S
Check No. Check Amount: Cash r\6. Total Project Cost: .S SC? .� �❑Paid in Full ❑Outstanding Bal:nce Du
1t19a \1_�►J t N Sqss 3 I 1
I
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SECTION 5: CONSIRUCFION SERVICES
5.1 Construction Supervisor License(CSL) Q-7 Gf 2 �] y L3 (p
License Number — Expiration Date
Name ofCSL[[older List CSL'rype(see below)_LA,
Uric W. Palm Typ oeseriplian ,
_ ._
No.and Street 3 1 tOrl treet - U Unratricted Butidtn a to 35.000 cu.It.
Salem MA 01970 R Restricted 1&2 Famil Dwellin
M Rtoso
Cityrrown.State,ZIP
RC Raolin Coverin
%VS Window and Sidtn
SF Solid Fuel Burning Appliances
71 • 911-f 3 1 Insulation
Tcle hone
Email address D Demolition
5.2 Registered dome Improvement Contractor(HIC) 107-199"L 3 ii
HIC Registration Number Expiration Date
HIC Company Nom IC egi N
Email address
No.mid Street
Ci rrown State ZIP Tel
.. hone
SECTION 6.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I e.15L$25.C(%
Workers Compeasadon Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isivance 9MO building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7n.OWNER AUTHORIZATION TO BE.COMPLETED.W HEN? ;:
O\VNERrS AGENT OR CONTRACTO[t APPL tES FOR BUILDING.PERhIIT'
[,as Owner of the subject property,hereby authorize
EV-1 C Pk lrYr
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
✓// Date
Print owner's None(Electronic Signature)
SECTION lb:OWNERt 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 this application is rue and accurate to the best of my knowledge and understanding.
C
ale
Print O.mer•s or Authorized Agent Vs Namr.( ecuomc Signature) -
NOTES:
I. 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 Hame.lmprovement Contmctor(HIC)Program):will not have access to the arbitration
program orguaranty Fund under�1.G.L.c. Id2A.Olhei important mfarmnfion on the HICYrogra--m can be
.vw.v m as uov,,oca information on the Construction Supervisor License can be found at.v.vw.mass.eov!Jns
---------------
2. \Vlien substantial work is planned,provide the information1 inglgarage,finished basement/attics,decks or porch)
Total floor area(sq.ft.) :(
Habitable room count
Gross living area(sq. ft.) Number of bedrooms
Number of fireplaces Number of hldl7baths
Number of bathrooms Ntiuiber of decks/porches
Type of healing system Enclosed Open
"type of cooling system
j. "Total Project Square Footage"may be substill"'I fur"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 rigbt 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. -
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,the con )(iayt�lte dispute to a private arbitration firm which has been approved by
the Secretary of the Exechtive`�O�",.�o;5f�o er Affairs and Business Regulation and the consumer shall be required
ro submit to such arlla64appa,aspro wa��)n ]�sachusetts General Laws,cha er I,2A.
Homeowner's Signature - Contractors Signature
NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. 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 seem their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contactor 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 worbou nship 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 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 yourconsumer/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 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 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 My executed copy of
the contract,and the three day rescission period has expired!
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 offimds 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 Affims and Business Regulation
10 Park Plaza,Room 5170,Bosun,MA 02116 - -
617-973-8787,888-283-3757 or visit the OCABR w ebsite at htto://wwnv.mam.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 Contractor Law,contact
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 http,/hnwv.mms.20v/0cabr/
Go online to view the status of a Home lmprovement Contractor's Registration:
http,//db.state.m&us/homeimproi,ement/limnseelist.asp
For assistance with informal mediation of disputes cr to register formal complaints against a business,call:
onsufner plaint Section
omey General
. 617-727-8400
AND/OR
Better Business Bureau
508-652-4800.508-755-2548 or 413-734-31 I4
Version 11-112212010
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Let=ibly
NatI1C (Business/Organization/Individual):
AtWitie Weathcttaatton,LLC
e rtsim venue
Address: Salem MA.')1970
City/State/Zip: Phone#:
Are yo n employer? Check th/e appropriate box: Type of project(required):
l. am a employer with Z 2— 4• ❑ I am a general contractor and I 6 ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet.. 7. ❑ Remodeling
ship
2.❑ I p a sole proprietor and have no employees partner- These sub-contractors have employees and have workers' 8. ❑ Demolition
working for me in any capacity. 9. ❑ Building addition
o workers' com insurance comp. insurance?
re P• 10.❑ Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof r pairs 1
insurance required.]t c. 152, §1(4), and we have no 13. ther ✓S"4,
employees. [No workers'
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 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 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. //
Insurance Company Name: Y r G h
Policy#or Self-ins. Ljc.#: ::`6 a7 0 j Z Expiration Date: U�l
Job Site Address: b/(7 2S Z—�/ City/State/Zip: —S,7— lei
1114
Attach a copy of the workers' compensation po • y 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certifv under the pains and penalties of perjury that the information provided above is true and correct.
Signature. �dC.�.. EA Date•
Phone# 9�� 7yti �iti 3
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
3
I
�C-77��' �.r?'�,�/.l
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor,Registration
Registration: 142089
Type: Ltd Liability Corpor
ATLANTIC WEATHERIZATION L.L.C. Expiration: 3/12/2018 Trp 285e61
ERIC PALM
61 R JEFFERSON AVE
SALEM, MA 01970
Update Address and return card.Mark reason for change.
soA1 0 20M.05fl1 Address [ newnl U Employment Lost Card
r'��r Yin,ri�nrnnrnnn�/�r�(',��r.nnc�n.m/G
Office of Consumer Affnirs&Business Regulation License or registration valid for individul use only
R,�5riJUME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
rg� Iggegistradon: 142089 Type: Office of Consumer Affairs and Business Regulation
Vst",Expiration: 3/12/201 B`. Ltd Liability Corpor 10 Park Plaza-Suite 5170
Boston,MA 02116
ATLANTIC WEATHERIZATION�LiLiG.'
ERIC PALM
61R JEFFERSON AVE.
SALEM,MA01970 ___
Undersecretary _-_____?Mote validW\`s.L.
Not without signature
3oard of 87--iM.ig Rcjuic oils E-a'$ c ua a II'an:morimeal!>'r a�@ a a7Al1
Cnil4Fritcs2uuS :eninrr _ fBce of ConsumerAlfairs&Busin�Regulation -
L", -SG:C$0$7971 MEIMPROVEMENTCONTRACTOR
ERIC W PALM ` . , iration: 3/92/2076 Ltd LiahSdY COPo',
31MONSr
Salem MA 01970= ATLANnC WEATHERIZATION L.L.C_
Salem M 14 ,
-•' '� - i EPIC PALM
__- .. eiRJEF'FERSONAVE - -�
�a-..-i Z.-. 04123120'IB ��—
!_.. SALEM,MA 01970 undersecretary
Il Unrestricted'
�35,0 0 cubic fed
���� License or registration valid for individul use only
contain less then 35,000 cubic few(991m�of before the expiration date. If found return to:
enOIOSCd SQBCe_ ice of Consumer Affairs and Business Regulation -
10 Park Plaza-Saate 5170
Boston,MA 02116
Failure to possess a current edition of the Massachusetts ?
State Building Code is cause for revocation of this license_
For OPS llcensinginformation vffiC vnvw_Mass.Gov/DPS Not valid without signature -
_. J