9 MARCH STREET CT - BUILDING INSPECTION _
r 6 - N- 1 9 Soo ZS.6--z,
f
The Commonwealth of Massachusetts RECEIVED
Boaz of Building Regulations and Standards SMI%
Re '
Mass chusetts State Building Code,780 CMR SALE
nno�nh IX 8 nnrrT edMar2011
Building Pel it Application To Construct,Repair,Renovate Or Dtkt 1 Q
One-or Two-Family Dwelling
-� This Section For Official UseOnly -
Building Permit Number: Date Applied:
- Building Official(Print Name) - Signature Dale
i
SECTION I:SITE INFORMATION
1.1 Propertv.Addr7 1.2 Assessors Map&Parcel Numbers
Rr
L i a Is this an accepted sheet?yes no Map Number Parcel Number
1.3 Zoning Information: L4 Property Dimensions:
Zoning District Proposed Ust Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard ( Side Yards Rear Yard
Required P�ovided Required Provided Required Provided
1.6 Water Supply:(M.G. c.40,§ 4) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
I` SECTION 2: PROPERTY OWNERSIIIP'
2.1 Owner'of /^^
f- S f-� �a �zwt 91,A01970
Name(Print) City,State,ZIP
Ma" � .
No.and Street Telephone Email Address
SECT[ON 3: D ESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ E:Cisting B iilding❑ Owner-Occupied ❑ Repairs(s) ❑ eration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other Specify:
Brief Description of Proposed Wo kZ:
- �
I ovr
. SECTION 4:ESTIMAT D CONSTRUCTION COSTS
Item I Est mated Costs: Official Use Only
Labo and Materials
1.Building $ a W 1.�Building Permit Fee:,$ - -Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x '
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ I 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
f 5.1 Construction Sui ervisor License(CSL)
8�97 � y a3 i&
License Number Expiration Date
Name of CSL Holder ; Eric W.Palm
Hilton Stut List CSL Type(see below) LAI
No.and Street S lem ARIA 01970 Type Description
U Unrestricted Buildings u to 35,000 cu.ft.
City/Town,State,ZIP R Restricted 1&2 Femil Dwellin
M Maso
RC Roofin Cove rin
WS Window and Sidin
•1414 b_1 SF Solid Fuel Burning Appliances
Telephone I Insulation
� Email address - D Demolition
5.2 Registered Homel Improvement Contractor(IHC)
MC Company Name or C egggs e don
' HIC Registration Number Expiration Date
Oy GLIe(StN1 Avoue.
No.and.street I MA 01970
(f y.�/q� Email address
Ci /Town,State,ZIP Tele hone
SECTION 6:V�ORKE 'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insuran a affidavit must be completed and submitted with this application. Failure to provide
this affidavit will resul,in the denial of the Issuan of the building permit.
Signed Affidavit Attached? es.......... No...........❑
SE ION 7 :OWNER AUTHORIZATION:TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES BUILDING PERMIT
I,as Owner of the subj Ict prope ,hereby authorize C ri7c �Gt !ky✓n
to act on my behalf,in all matte relative to work authorized by this building permit application.
Print Owner's Name(Eleclt o le Sig ature) Date
—
S ICTION b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pepury that all of the information
contained in this application is a and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent' Name(Electronic Signature) /O O—
Date
.NOTES:
1. A:Owner who ob ins a but ding permit to do his/her own work,or an owner who hires an unregistered contractor
( stered in thhe Home I provement Contractor(HIC)Program),will not have access to the arbitration
p or guaranty,fund un er M.G.L.c. 142A.Other important information on the HIC Program can be found at
wss.gov/oca nformat on on the Construction Supervisor License can be found at www.inass.gov/dDs
2. When substantial work is pl ned,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 Footag "may be substituted for"Total Project Cost"
Massachusetts�o>7Ie I>n rovefnent 5aen le Contract
This form smis0es all basic requirements oFWemutes Home lmprovernau Contmdw law
language to protect homeowners•Seek legal adWmifnecapa (MGL dteptw l4?A).hutdoesnutmdtidemlm&rd
Masset mUsConsumer Guideto Aomelmpmvmteot"befbm ry ingw son mkmy homeimpro%emmtashodd first gbminampyof"A
Office ofCmsumwAffa(rs and HusinesaR a °groaoy swrk onyowtaidmm You may obLtin a lice copy bycalingthe
agWaein"o Consmnet lefonnadon"Wine a 617-973-8787 w I-MR-283-3757 or'm,owuayate
AOmeOWOer lnfOrmatlOB
- Contractor Information
N
,p S y Company Nam,
racer Address(der nwv aP ecP ar-c—
Qn l7A<rAppozoddrea Coouane saespemN
a /h J!hI ef�of(Avenue
City?tar Sore Zip
Husmess Address inc
ct,�2wt O1970
ugime Phone Evening Phone _
Ciry?oun Store —�'_-----
1 Zip Code
MaiGngAd--dt unmddf(1 from abosi)
Business Phme Federal Fvnpl%ermarSSNumbw
t' •. •..• � _. ., r+nnnm,..nv mvn0®e rlparvNo,m�r�yg�Ncl2v _ r�ene -
tmPme®rtmaamnaart
'Ate Cmtrodoragrms to do the fo0owing wort for WeAomtmvaer IDescri be in derv)the nmk ro rompteed•epedfying me sypq br
and aMgmdeof m,Ui*to betaM,
Required Pertain_ythecnam gbudd'vigpetmitsamrequired Proposed Stu end Completion Scbedde-ThefogoaioB suhedWeavill
and anti be sensed by WeceatractwazWe homm%wets agent: beadhered to milessd(Owners who secure their own permits will he R°"�°CazbeYa°dWece°tradorsmntrolarisc
excluded from the Guaranty Fund provis(ons of 6)
hIGL chapter 142k) DatewLm matractwi%al6eg n centramed w L
/U / - Date%Am concocted%rod:writ be substantially mothim, .
Total Contend Price and payment Schedule
7fieCmbaclwagrees to perform the%vosl4 fitrnisb We reataial and labor .
- specified above for the total ham af.
Payments will he made according tothe Polloniog uheduk:
S upon signing eantrad(not to exceed 113 aftbe that contract
prim Pr the mst ofspeod coder itmaz,s,Ndremr isv..W)
S
by !_/or upon mmpletim of
i
S by L W/,�arupon mmplerion of
Sa, upon mrepletim ofthe malmet (Lane full paymm umtl mntraer is mmpleredmboW .
Ordered ohneforre Wnareriapevescuot must eesp.W s roc pad f,/ pWs satisfaction)
co,vaaed cork hegimmorder. 7
to men themopiaio,sdmdWm(') S
NOTES:(*)Iadud'mgall fm,nmehmga(•'1 LuvngWrra then any depusit ordoan paymem mguirrd 6y tM1a momenterhefore unrk buns map'
not cumd rboigm,"of(a)orx-thin!ofWetaml eontmct primes@)Ueachadeost ofa°yspmid etrydPm hmcustoI,made may
ahieh taus bespeeiel ordered in advance se tam thecomsimen sduduk
cial
PIlyb
Th mntranot ❑N ❑v b agrar to he minty tesponabie forcamptmon of the%sock desmbW t
So
orunirzed b)•We contractor-The centradorfunhw ��oFWe anions oFeny thud
agrms robesoldy responabie fwa11 payments to all mbcontraclors for
rooceess Wtimpisigningthis contract. -
Dort be ptetaned into signing the tnnaact_Take time to read and fall un
° MalR vm.lhemntm twhazeval'd Hamel Y detstand it Ask questions ifsomeWipgis endear.
subcontradprs to be cot ° sn a .Theta%v requires most homeiogsmv®cot conirocfors and
registeredwith dhh,MmmofHume leapmvemm[ConbactorRegistratioii Yhu
registration by writing to We Director at lO Park Plata,Room 5I70,Boston,MA 0211fim My inquire about comrador.
o Does the Contractor have inswance? Ask Use Cuatractorfwhis insurance
�calling orggg-283-3757.
set a mpy Ofa'proofofinsurasce^document mpaoy mfmmatia°so'hot you can mafirm coverage,or ask no
GaidetowrightaeImpro elegmCn Read Welmpmiaotlaformatim on We re%arseside ofthis fare budget a copy ofthe Consumer
Guideto the Harae lmprovaneot Cantractartaw.
r
JIW:bm-
y eatml Wisalpmmmtifit has been signed utap7amoWerWmi We mnhactofsnormd tare ofbusin
orin writing at hiUhermain office arbmnch olfire by ordinary mall p ass.provitkd younotify We
iness day fo0owiag thestgdn 0r ribr ported,by seat or by delivery,am law Wm,middghrof the
Ipeeremt. See the attachednWm afwnce0atim form forgo naaDmOea Nw Opm oOrbe�PGml ma1 TA,a
Ho�aIbeS�CpO�N„T�RAC�TIF THEwRmE�A�RwEr%Ary
epiana tim of1�thi s
ELAIVf(SPACESto
HomcenaeihStgaure
Date 10 CntrM&rgrc1o/6
Date
rigbJL
Contractor Arbitration
The Home Improvement Contractor Lavv provides homeowners with the right to initiate an arbitration action(as an
alternative to watt action)if they have a dispute with a contractor, The same right is Lto�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 herebymutually agree in advance that in the event the contractor has a dispute
concerning this contract,the contractor may submit the dispute co a private arbitration firm which has been approved by
the Secretary of the•Fxecutive'Off'ide of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbitradgn.as,provided In Massachusetts General Laws,chapter 142A.
t» AA
Homemnees Signature ` ContriMofVSignature
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 Lmv(MGL chapter 142A)and other consumer
protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by ameement. 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 La%%% 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 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 consuunedhomeowaer rights,contact the Consumer Information Hotline(listed belmv).
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 fully 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 maytequire that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work Withdrawal of funds from said account would require the
signatures of both parties.
Additional Information
If you have general questions orneed additional information about the Home Improvement Contractor Law or other
consumer rights,or if you wish to obtain-a free copy of eA Massachusetts Consumer Guide to Home.Improvement -
contact -
Consumer Information Hotline ..
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 3170,Boston.MA 02116
617-9Tr8787.888-283-3757or visit the OCABRwaebsiteat '•!sr.:.+hr:,; r:, <.>.= w'o=_ai_
If you want to verify the registration of a contractor or if you have questions or need additional information specificalh`
about the contractor registration component of the Home improvement Contractor Law.contact:
Director of Home improvement ContractorReeistration
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170.Bosun,MA 02116
617-973-8797.888-283-3757 or visit the HIC wabsite at aan:iAw'.SIC iia£ <OYiet„hr,
Go online to viewv the steno of a Home Improvement Contractors Registration:
aieena.u :ncmeimnrov eniLwOicen Seel i St.Pso
For assistance with informal mediation of disputes or to register formal complaints against a business.call:
I
Consumer Complaint Section
Office of the Attomey General -
617-727-8400
AND/OR -
Better Business Bureau
508-652.4800.508-755-2548 or 413-734-3114
vmion21-11M'3010
TJie Cols 2Otzwealtlt oflYfassacliusetts _
a -DepralmenteflndustrialAccidents
Office oflitvestigations
I Congress Street,Suite 100
Boston,ALL 02114-2017
Workers' Compensation Insurance A>Ndavi#:Builde s/Contractors/Electricians/Plnmbers
AnnHcant Information
PPease Prin#I.e blv
Name (Businesslorganizatior✓lndividual):
Address:
City/State/Zi 71017 O Phone#: g7 9. 7t W. �r/y 3
Are yo employer?Check the appropriate box:
1• 1 am a employer with�_ 4. ❑ I am a general contractor and IF[]
ect(required):
employees(full and/or part-time).* have hired the sub-contractors onstruction
2.❑ I am a sole proprietor or partner- - listed on the attached sheet.
ship and have no employees deling
These sub-contractors have ition
working for me in any capacity. employees and have workers'
[No workers' comp,insurance comp.insurance t ng addition
3.❑ required.] 5. We are a corporation and its 10.n Electrical repairs or additions
I am a homeowner doing all work officers have exercised their
Myself 11.[]Plumbing repairs or additions
Y [No workers comp, right of exemption per MGL
insurance required.)t c. 152,§1(4),and we have no 12.E Roof repairs
employees.[No workers' 13•Ly Uther 'L w�ti
i�
comp. insurance required.]
`Any APPlieaot that checks box s1 must also fill out the section below showing their wodcers'compensation policy intbmretion.
'homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit ind[cetiog such_
tConhaIXors that check this box must attached an additional sheet showing the name of the sub-contracroa and start whether wnot those entities have
employees. If the sub-contractors have employees,they,must provide their workers'camp.policy number. or
2. m an employer that Isprovitift workers compensation insurance for my
Information employees Below is the paliey and job site
Insurance Company Name U,r; e 4
Policy#or Self-ins.Lico.#:_�LB//Q-70/ Z Expiration Date: ,3Ig,011
Job Site Address:_ I mgnr i� S�': C
Attach a co City/State/Zip:
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 a 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
In es to S250.bons 0 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 ria hereby cent der th Ie, aUles of eiqury that the tnformabon provided above is true and correct.
Si afore: _ F.-.,
;.
-- - -Date:
Phone#: 9 7 7Girt-J- M-/3 --
Official use only. Do not write in this area,to be completed by city or town official
City or Town:
Permit/I icense#
Issuing Authority(circle one):
I.Board of Health 2.Building Departrnent 3.City/Town Clerk 4.Electrical Ynspector 5.Plnmbing Inspector
6.Ot11
Contact Person:
Phone#•
- - g� (�5p "• "/��,i� , •'., .rye/ nt7 pYHSUpcp 00/000 g�r�apxx Server
•� CER tl 9FIC TE OF LIABOLI II V �0�1o�URd' NCE 3 i2-2ola
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 ODES NOT CONSTITUTE A CONTRACT BETWEEN
THE ISSUING INSURER(9),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(es)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 Oeil of such endorsemem(s).
PRODUCER
CONTACT
EASTERN INS GROUP LLC ! NAME:
233 WEST CENTRAL ST a O N� u,. FAX
NATICK,MA 01760 / No:
EM N
INSURER(SIAFFORpeIGCOVERAGE NAIL:
INSURER A:AMERICAN ZURICH INSURANCE COMPANY
L\SUPED _
ATLANTIC WEATHERIZATION LLC ! INSURERS:
61 REAR JEFFERSON AVE INSURER C: —'
SALEM.MA 01970. i ' IrvSURER D:
INSURER E:
NSURER F:
COVER -CERTIFICATEU B :
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED N ED
UMBER-
ABOVE FOR T THE INSURED NAM
PO
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.
I ADD SOB
LTR iWBIUry URANCE INSR WV POLICY NUME&A hw�OmYY) POLi�EXP LIMITS
GENERAL LIABILITY
C(AMMERCIAL GENERAL LIABILITY EACHOCCURRENCE S
CLAYS$-MADE❑ OCCUR �9E 1cETOR-WEGOng 5
MEOEXP(Aw onoww,) S
i FERSONALBADVIIUUA S
a'HL AGGFCMATELaw APPLIES PER. GENERALAGGRECATE $
POLICY ,E LOC I PRODUCTS-CCMPAPAGG S
ulovAoan.ELweanv ).
5
ANY AUTO a1•1�0eD SLNGLE LIMIT S
ALL OYRJED SCHEDULED ECDILYIWURY(Pe,Pe,yun) 5
AUTOS NQV-0WNED BODILY IWURY(Pei a¢dwi) S
HIRED AUTOS AUTOS diOPE Y AAGE S
UMBRELLA LWB S
OCCUR
EXCESS UAB EACH OCCURRENCE 9
CLAIMS-MAOE
OF.G RETENTIONS AGGREGATE S
%WORKERS COMPENSATION S
AND EMFLOYERS'LIABILTY X YICSTATU- OTH.
ANYPROPRIETORIPA,TNEREXECUTN�YM TORY LDAITS ER
OFFICERAIEMa-R EXCLUDED?
6ZZUB 03-20-2014(AnarmyrnN! 03.20.2015EL.EACH ACCIDENT $500,000
II Ye;C ='tl uMe, 58270121 EL.DISEASE-EA E/AFLOYEE $500,000
0 SCRIPTI NOF OF A TICNS Dab EL-DISEASE-POLICYLIMR $500,000
DESCRIPTION OF OPERATIONS LOCATfONSI VEHICLES(Ahaeh%CORD 101,Add)Ibna1 ROMV10,Sehadub,If more spun is mgWrad)
CMEICATE IPR CAtICELLATION
CITY OFSALEM - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
93 WASHINGTONST CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
SALEM,MA01970 NOTICE WALL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS. )
AUTHORIZE)REPRESENTATVE
ACORD 25(2010/05) The ACGRD name and logo are registered marks ACORDCORPORATION.All rights reserved,
1 Massachusetts-Department-of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS4)87977
'11, [[
ERIC W PALM S'
3 HILTON ST -
Salem MA 01970=
�r
Expiration .
Commissioner 041=016
Office of Consumer Affairs&Business Regulation }
ME IMPROVEMENT CONTRACTOR
gistration: U2089 Type:
piration: 31,12/2016 Ltd Liability Corpo:j
ATLANTIC WEATHERIZATION`LL.C.
ERIC PALM _
61RJEFFERSON AVE
` _
SALEM,MA 01970- -Undersecretary