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103 MARLBOROUGH RD - BUILDING INSPECTION �`/3 y los, tj The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Revised Mar 2017 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only LP Building Permit Number: Date A lied: / Building Official(Print Name) Signature Da e SECTION 1: SITE INFORMATION ti U 1.1 Pro 103 rperty Address: 1.2 Assessors Map&Parcel Numbers "' Nbo��h �- ri L l a Is this an accepted street?yes no Map Number Parcel Number z .n t 1.3 Zoning Information: 1.4 Property Dimensions: On T rn r < m Zoning District Proposed Use Lot Area(sq 1B Frontage(ft) 1.5 Building Setbacks(ft) Q Front Yard Side Yards Rear Yard rr 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 Owner'of Record: Von U,6%'nSon C nervy M1< 0\q`10 Name(Print) City,State,ZIP 1 n3 Mef\\ocww0,Qz alg-10-a�3 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK z(check 1 that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s) Er I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work': ,%V b&-4 5 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ L / 1. 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 (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ 6.Total Project Cost: $ I �/` Check No. Check Amount: Cash Amount: s ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /'�-6� `L6 6i ��1N n License Number Expiration Date Name of CSL Holder - �y List CSL Type(see below) 6 Newe.e o No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP / M Masonry RC Roofing Covering WS Window and Siding �ryry Q�S SF Solid Fuel Burning Appliances t" 0(� G I Insulation Telephone Email address D Demolition 5.2 Registered�`Home Improvement Contractor(Hp l(94-61` S//Wp/n 0` V\-f_ Q10Y)r10Le\NJ HIC Registration Number Expiration Date C Company Name or HIC Registrant Name So\ �.noCl b�', N .and Street Email address �esver,CIA `A613 Sora&o-ot� O /Town,Stat ,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 f the building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR/��AP�PL..IIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize / I�(Ii`( ,A . J` `ac ��+t to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By enteqin e below,I hereby attest under the pains and penalties of perjury that all of the information contain a lication is true and accurate to the best of my knowledge and understand' Print Owner u o ' ed Agent's Name(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 (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 at www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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" Project 31-47802- Signed Sales Agreement https://nitro.powerhrg.com/project_docwnents/4488787?pages=l "me",31-0802-signori Sales Agreement _ [IJPEG(592a8,1653r2256) spw Von Robinson 7t<78D2 pp�(/ER April 10,2015 . NATIONAL MF,ADOUAA 1901 ��'� 7a015caport Law[hnrLT.PA-19013 � ,.._ gAR�y t66616 r8es-REMODEL ' •' CUSTOM REMODELING AND IMPROVEMENT AGREEMENT April 10,20 Project Number:31-07802 WdAgronnov vdN9�/ahoo.com l uyorpr Information ad Doscdptlon of No Propony: tan)767�0623(Nome) saw wsrn 1 Von Robinson 103 MedtarouBir Road Salem.MA,01070 County:Eater Township: Buyers)listed above hereby lain uy and sevoratiy agrees to purchase the goods andlor services of Power Home Remodeling Group So)its vendors('Contmctof)in accordance with the prices and terms described in this 5 page document and nt Product in S dlat its endor which are tOr)in rm as part of the Agreement(collectively,Nis"Agreement"). This Agreement represents a Cash hase- 6m ng rn�Mand of any s Bunl rrtBu gr yer()s 10 pay snapseeke Cost ofIT the goods and services purchased as described herein,regardless of oval $13, 0.33 Pre installation inspection Dales: Purchase Price: TM1u Ll Srlvmef.1Z55p+orl t:55p Down Payment: $0.00 i Eating to Project Start:6 to 7 weeks 33 0.94 Balance Due on $13, Estimated Project Completion:1 to 2 days Substantial Completion: Other er,eno)rowr.+allo mina Eradmstrnana mmpar darmmo NOT dfha oaenor or"wrton Method of Payment: coni,warr¢n,,na1 indwrw er'do'wlra cm,armor,sae DwIrtu Grown Cnmubns Buyers)hereby acknowledges receipt of a cep);of Nop amPhis,'The Lead-Sale Cen rated a Guide to Renovate Right",informing Buyer(s)of the DiwesBuyer e)received Ae pi so amph fro tin mn date of m li! to ant,betom commencement of worrk, at the nI ,5�+^Buyer(SyAnilials. .w� ll This Agreement owed Votes the entire agreemonl and understanding between Na parties,and this Agreement replaces any and e prior negotiations,representations,or effector either wdltenor oral. No ementlmenl,motliricetion or waiver of this Agreement shall be valid or eHecive gainsaid wli0ng and signed by both parties. Buyer(s)hereby acknowledges that Buyers)1)has read the entire Agreement and has receive tl a Completed,signed,and dated Copy of this Agreement,indutling the two accompanying Notice of Cancellation forms,on the date first written above and 2)was orally informed of his/hor right to cancel this transaction. Buyer(s)also agrees and understand$that if atyer(s)finances the work with a third-party,the terms of that financing will be contalned on separate documents,including an o finance Charge. Future promotions Trot applicable. DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK SPACES. 1 have read and a ad each page of this 5 page agreement. P er meR otleling Group I Buyer(s) 104/10115 �)DVIDM5 Signature o odating Consultant Signature Daniel Abate Von Robinson YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. I I II II April 10,201517:11 II III I II IIuI IIII� III�� I) Page 1 of 5 1 of 1 6/3/2015 2:13 PM NATIONAL HEADQUARTERS A Von Robinson 2501 Seaport Drive,Chester, _Y PA 19013 j►�'OWER 31-47802 April 10, 2015 888-REM:0:D::EL]FUZJ •• • •• ••• MA HIC#168616 PRODUCT SPECIFICATIONS Buyer(s)'Information and Description of the Property: Project Number: 31-47802 April 10,2015 Von Robinson Date&Agreement 103 Marlborough Road (976)767-0623(Home) vdr09@yahoo.com Salem,MA,01970 e-Manaddrea r County: Essex Township: Buyer(s)listed above hereby jointly and severally agrees to purchase the goods and/or services listed on the accompanying specification sheets, in accordance with the prices and terms described in the Custom Remodeling and Improvement and the Product Specifications (collectively,this"Agreement"). Pre Installation Inspection Date: Your pre installation inspection is tentatively scheduled for Thu 5/7 between 12:55p and 1:55p. - Windows-SL 2700 Inclusions: Includes metal reinforced meeting rails and nighttime safety locks on double hung windows only, welded corners,foam injected frames, Sashlite technology, Heatshield, Duraglass, exterior custom capping, installation, clean up and haul away of all job related debris. It is agreed and understood by and between the parties that the Product Specifications, along with the Custom Remodeling and Improvement Agreement, constitutes the entire understanding between the parties,and replace any and all prior negotiations, - representations,or agreements, either written or oral. The Product Specifications may not be changed, modified,or varied in any way unless such changes are in writing and signed by both Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read the Product Specifications. I have read and received each page of this 3 page agreement. Power Home Remodeling Group Buyer(s) 104/10/15 /04/10/15 Signature of Remodeling Consultant Signature Daniel Abate Von Robinson YOU,THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. April 10, 2015 17:11 II III IIIIIIII II IIIIIIIIII II IIIIIIII I IIII Page 1 of 3 NATIONAL HEADQUARTERS Von Robinson 2S01 Seaport Drive,Chester,PA 19013 POWER 31-47302 April 10,2015 888-REMODEL •• • •• ••• MA HIC#168616 Project Specifications Windows: Downstairs Bathroom 1 33.0"x37.5" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Co/or White/White: Grid Pattern: Both Sashes: Colonial: Standard i Removal Aluminum/ Vinyl I Additional Details None Windows: Kitchen 2 20.5"x63.75" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None 9 OPTIONS: Color White/White: Grid Pattern: None i Removal Aluminum/Vinyl Additional Details None Windows: Dining Room 2 33.0'`x64.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None 6 OPTIONS: Color White/White: Grid Pattern: None I Removal Aluminum/Vinyl Additional Details - None 61 Windows: Living Room 3 33.0"x64.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None 6 OPTIONS: Color White/White: Grid Pattern: None Removal Aluminum/Vinyl I Additional Details None Windows: - TV Room 2 33.0"x64.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None !4 OPTIONS: Color White/White: Grid Pattern: None i Removal Aluminum/Vinyl i Additional Details None Windows: Guest Room 2 33.0"x55.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None 6 OPTIONS: Color White/White: Grid Pattern: None i Removal Wood I Additional Details None Q April 10, 2015 17:11 II III IIIIII IIIIIIII III II I IIIIII I II Page 2 of 3 NATIONAL HEADQUARTERS Von Robinson 2501 Seaport Drive,Chester, PA 19013 SOWER- 31-47802 April 10, 2015 888-REMODEL Be •• ••• MA HIC#168616 Project Specifications Windows: 2nd guest 1 - 66.0"x55.0" WINDOWS: Models SL 2700 Styles Slider Types 2-Lite Configs None OPTIONS: Color White/White: Grid Pattern: None i Removal Aluminum/Vinyl I Additional Details None � Windows: 2nd Floor Bathroom 1 33.0"x39.75" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None 9 OPTIONS: Color White/While: Grid Pattern: None I Removal Aluminum/Vinyl i Additional Details None Windows: . Von Jr's Room 1 33.0"x55.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None Cr OPTIONS: Color White/White: Grid Pattern: None I Removal Aluminum/Vinyl I Additional Details None Windows: Master Bedroom 3 33.0"x55.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None 1, OPTIONS: Color White/While: Grid Pattern: None I Removal Aluminum/Vinyl i Additional Details None Windows: Master Bathroom 1 33.0"x39.75" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None !4 OPTIONS: Color White/White: Grid Pattern: None i Removal Aluminum/Vinyl I Additional Details None April 10, 2015 17:11 IIII III IIIII I II IIIIIIIIII II IIIIIIII I III Page 3 of 3 POWER-1 OP ID: EL CERTIFICATE OF LIABILITY INSURANCE D09/1112014ATE YI 09N1/2014 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 endorsements. PRODUCER - CONTACT Lacher 8 Associates Ins Agency PHONE FAX Lacher Insurance GroupIA IC No Ex:215-723-4378 Nc No: 215-723-8604 632 E Broad St P O Box 64398 EMAIL Souderton,PA 18964 ADDRESS: Chad Lacher INSURERS AFFORDING COVERAGE NAIC p INSURER A:Harleysville Preferred Ins.Co 36696 INSURED Power Home Remodeling Group, INSURER B:Harleysville Worcester Ins Co 26182 LLC 2501 Seaport Drive,Suite B110 INSURER c:Nationwide Mutual Ins Company23787 Chester, PA 19013 INSURER D:Pennsylvania Manufacturers 12262 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR DL AD SUBR POLICY EFF POLICY E%P LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDD EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE OCCUR MPA00000089793N 1010112014 10I01I2015 PREMISES EacccuRence $ 1,000,00 MED EXP(Any one person) $ 15,00 PERSONAL B ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,00 POLICY[PET LOC PRODUCTS AGG $ 2,OOD,00 OTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 Ea accident B X ANY AUTO BA 00000089796N 1010112014 10101/2015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accitlem) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peracadent F S UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 10,000,00 X EXCESS LIAR CLAIMS-MADE CMBOODOOO89794N 10101/2014 10/0112015 AGGREGATE $ 10,000,00 LIED I RETENTION$ $ WORKERS COMPENSATION X PER OTH- ANDEMPLOYERS'UABILTY STATUTE YIN ER D . ANY PROPRIETORIPARTNER,EXECUTIVE Fy- 2014006620967 10101/2014 10101/2015 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1.000,00 B Mass Auto BA 000DO018227P 10101/2014 10/0112015 Auto Liab 1,000300 B NY Auto BA 00000074849R 10101/2014 1010112015 DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD 101,Additional Remarks Schedule,may be attached H more space Is required) CERTIFICATE HOLDER CANCELLATION SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Salem 3rd Floor AUTHORIZED REPRESENTATIVE Sal Washington St 4/ -/ /let/\_ Salem,MA 01970 ����(' �l ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 4a Mass achuseris Ge he.�mem or PuL-Itc Sateiy kl Pcarc: ct"Eui;>;ir,c Rcc+.•!aicn, ano Sandsrys LICenSe CS Ld�7fika t 18 ATE'WELL DR - 7F A7 T'LEBORO MA ( I i s Expiration Convnisslonei ospl Als C-/J .r/i V DtfEIMPROVEMENTCDNTRACTDR egistration: 16 Expiratl --, . 88516 316 7 TYpr POWER HOME REMO*IN upplement -GROUP LLC. S MARK MORDINI 25D1 SEAPORT DRIVE STE Bl lD CHFSTER, PA M13 ^Undersecretary The Commonwealth of Massachusetts Department oflndustrialAccidents ] Congress Street,Suite 100 Boston,MA 02114-2017 UW www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE ITMED WITH THE PERMITTING AUTHORITY. AnPlicam Information Please Xljlt Legibly Name(Business/Organizafonr/Individual): dti �1�11) �L 1 Address: CS'vi �C-)ymz Azl1 r City/State/Zip:C C1TCk 1? 0613 Phone#: 508- Z80- 015 t Are you an employer?Check the appropriate box: Type of project(required): 1.11I81naemployerwith 5 employees(fuuand/orpart-tim,).* - 2. 1 am a sole 7. ❑N construction . ❑ proprieworparme`shipandbaveno employees working formem S, 21emodeling �y capacity.[No workers'comp.imamanr regwred.] 3.0 1 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition . 4. I am a homeowner and will be contractors to conduct all work on m 10❑Building addition ❑ his y property. I will ensure that all co�actors either have workers'compensation insuumee or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general w�biactor and I have hired the sub-contractors listed on the attached sleet. These subcormact rs have employees and have workers'comp.insuuance.t 13.❑Roof repairs 60 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required] 'Any applicant that cbecks box#1 must also fill out the section below showing their workers'compensatioa policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him 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 ntn ctors and state whether ornot those entities have employees. If the subconnaciors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compenradon insurance for my employees. Below is the policy and job site information. Insurance Company Name: Atmc- ram U otanga, / LI&AAICtz Pohcy#or Self-ins.Lie.#: 110110J). t t 2D q b 7 Expiration Date: 10-1 -fZ,�01 S Job Site Address: �� 1 `(A���(y r�l1t�G�n R rVi4�- City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 fore of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veri I do hereby ti the pains and penalties ofpetjury that the information provided above is true and correct. Si Date: Phone#: 5A-Z(Fb 126 Ojrwial use only. Do not write in this area,to be completed by city or town gjficiaL City or Town: PermWLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• SL2700 DOUBLE FUNC- VVINDOVV VINYL FRAME DOUBLE GLAZED .c 1 FOAM,FILL CFIDS LOV EIARC-ON d2Sianal Fen=sYra4lon �nFric cF_Dp. n__ p K s-ooceaccoo--F kaflngCaundl` 1° ENERGY PERFCRMANCE RA T INCS ADDITION PERFORMANCE RATINGS i . .. . ..:.r ,.. I '�`,• £'l',yY YRn SkN -. jtr �VN*I'A - +t'"f'._.3.1i •m�G5'9S1(�F- K' i_..y C'G479.] $�•+k'�F:ISi„elr l'�" t "� d +43 ' tsaeq 3" r ebs 4�" 79Pf 5 .w y ' }t..,, a�+�zftgnaX�tlfi®GkpsC{'q.'> SEII e � � ,57. i4tYHtS'5�+1>�aaYs,+- in4tUr,= � fdau,"ontd Yesyft'1i4ata+Cl1 f Tgp s fi5 cti .�•..... 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