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40 MOFFATT RD - BUILDING INSPECTION EI`I'Y-OF BALEDV. -- PUBLIC PROPERTY DEPARTMENT KIMRiFJH.EY DRISCOLL C�)V/A) _6� MAYOR IN WASHINGCON STREET 1*SAi l:ry.HASSACHI.SEIIS 01970 TEL-978-745-9595 • FAx 978.740-9&9 APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION. DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: E�2 _ Building: r dvz ✓� Property Address: Fpc,)k C Property is located in a; Conseivation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EX114MIXG BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (so Renovated construction or renovation of existing building I New Brief Description of/Proposed Work: 1 Mail Permit to: ) S �� What is the current use of the Building?t A i J Material of Building? 1 If dwelling, how many units? Will the Building Conform to Law? Asbestos? A Architect's Name Address and Phone Mechanic's Name Address and Phone Construction Supervisors License# $ Ce HIC Registration# Estimated Cost of r e $ 0 6.5-0 Permit Fee Calculation Permit Fee$ ov Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$100o Commercial An Additional$5.60 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to. build to the above stated specifications. Signed under penalty of perjury l v Date g 9 0 N a � y t� g c � a w o41a o F m of y CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KtaffiEUZV ouscou. $r EST o�y i ssErrs 01970 �1/1YOR IM W ASMSaTM 'M-978-74SAW•FAX.978.740-9" Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code,780 CMR section 111.5 Debris,and the provisions of MGL a 40,S S4; is issued with the condition the as defined by MGL m Building Permit fi 1 licensed waste disposal this work shall be disposed of is a proper y 111.S 130A. The debris will be transported by: (Dom ofhWW) The debris will be disposed of to (name of facility) (ads of facility) si we of pomiit applicaat dau .irlyi,a(li4+c CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASHINGTON STREET#SALEM,MASSACHUSETTS 01970 TEL-978-745-9595 #FAx:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /" Please Print Legibly m \- Name (Business/Organization/Individual): Q&3 k "� ! ptA siryt y �,In �s� Address: 9, Vturi/DI; g -e -e x ' ( !Z�— t� �7 /�lQ N�, r City/State/Zip:d 1_ I. �fn t sF.r! Phone #: ! �U — Q [ ` � Are you 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. t 7. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 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 hive outside contractors must submit a new affidavit indicating such. tContracton that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the pollcy and job site information. /� n n ' \ Insurance Company Name: i� YQ rtb, ! V y V ` -�JA� Policy#or Self-ins. Lic.#: n Pb R S Z S"3 s O r1 �i Expiration Date: Job Site Address:�� Ito t f r� r / C4._ � 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 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. /do her under the pains an es ajperjury that the information provided above is true and correct Signature - �j Date: Phone#: grn o — Official use only. Do not write in this area, to be completed by city or town oJjiciaL 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 11 Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every.state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage,required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth not any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has ont to contact you regarding the applicant. Please be sure to fill-in the permitilicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one,affidavit indicating current d \ , policy,information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or tows)." A copy-of the affidavit that has been officially stamped or marked.by the city or town,may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: r The Commonwealth of Massachusetts. Department of Industrial Accidents. Office of Investigations ' ' : . 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Xwei Hot Tu 11'-1 "b 6'-3" Cal ion 11.10"by 11'.6' 11'-10'by 17'-6' in Original dimension Original dimension I Il ,-3 3.6' I I r 1 Rettig, Existing all to be Jved. Existing doset to be Callerremoved. In it's will be tlwr m Divider wall open space for m .� refrigerator. N Divider wall m m 2 w J-SAnglnal dimension N , tr It li 1f >` v4 /X l 1� i 17-0"by 11'-1 V 40 Moffatt 38 Moffatt t. j I Door Windows Front of House a OR _ CERTIFICATE OF LIABILITY INSURANCE OPIp D I"aB0/06 DAN[�-1 08 30 O6 PROOUe" THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Westford Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 187 Littleton Rd P.O. Box 308 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Westford MA 01886- Phone: 978-692-3073 Fax:978-692-0429 INSURERS AFFORDING COVERAGE NAICX XmuRMw wsuRERA: Preferred Mutual 15024 INSURER a Danner Construction Comp�y INSURER 6 Construction Stree Unit R5 INSURERD_— Chelms£or� MA 01813 INSURER E. COVERAGES 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 TMIS CERTIFICATE MAY BE ISSUED OR WY PERTAIN,THE INSURANCE AFFORDED NT THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REOUCED BY PAID CLAIMS mw PO well TYPE OF WSURINICE POLICY XULIOFA OgTE YBND pAgT�E�MWO '^ LIMITSLTR --. OBI6RAL LNBBITY EACH OCCURRENCE i 1000000 _ A .0 CDwERLB,LtEMERALLIABILITY CPP0110582535 08/12/06 08/12/07 P�au`I�E_,P�a+rlMe s100000 CLAIMSMAOE �OCCURI i I �EXP Nrn PAR PNePm f5000 PERSONAL A AOV INJURY $1000000 ++II I GENERALgGC{IEGATE s 2000000 GEN•L AGGREGATE LIMIT APPLIES PER: PROOUCTS-COMPJGPAGG f2000000 PoLICY 7 TO, Loc AUTp1CBS8 LMBBliY COMBINED SINGLE LIMIT ANY AUTO IEa ePudenp ALL OWNED AUTOS I ` I BODILY INJURY I S SCHEOULEDAUTOS I i IP¢t FPYRPn7 HIRED AUTOS 111 BODILY INJURY T� NON-OWNEDAUTOS I I(Pw P-EMI) '_ F., ERTY DAMAGE �f GARAGE LIABBUTV -AUTO ONLY-EA ACCIDENT f ANY AUTO OTHER EA ALL.i_ . THAN •AUTO ONLY AGG i EKCFESmUNBRELLA LIABILITY - EACH OCCURRENCE i _ OCCUR CLAIMS MADE I I AGGREGATE _s _— I f I DEDUCTIBLE _- .__ i RETENTION JVJ WORKERS core I"ATION AND T YUMIT�_ ETi EM14,0M •IUAMBITY ' ANY PROPRIEFORA'ARTNERIEKECUTIVE E L EACH ACCIDENT 'i OFFICERIWMBER 9XMVDEDI I I EL DISEASE-EA EI@LOY f II YYnn��d I,,mw unWl 6PMAL PROVISIONS BIND E.L.DISEASE-POLICY LIMIT f OTHER CEICAWTIOM OF OPERATIONS I LOCATKINS I VEHICLES I EKOLUSKIXB ADOEC BY ENDORSEMENT I SPECIAL PROVISIONS carpentry-residential up to three stories CERTIFICATE HOLDER CANCELLATION SALE001 SHOULD ANY OF THEABOVE DESCRIBED POLICIES BECAMCELLED SEPORBTMEEKPIIUTION DATETHEREOF.TNEISBWMG URERWILLERDEAVORTOMAR 10 CA"WRITTEN A NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LPPT.BUT FAILURE TO DO SO SMALL Tosm of Salem IMPOSE NO OBLIGATION OR LNBRIT'OF ANY IQW UPON THE INSURER,ITS AGENTS OR Town Hall Salem MA 01970 REPREBENTATMES, AUTNORMED BBNTATWE ACORD 23(2001M) ®ACORD CORPORATION 1988 i, Den Temple "s`'• (978)580-6724 t_. Kerry Packer (978)726-0738 40 Moffatt rd, Salem, MA 01970 CONTRACT This agreement made this day of �Z), , month of //NAT 2006, by and between Peter and Irina Clark, of 38-40 Moffatt rd. Salem Ma 01970, herein referred to as "owner" and Dank r Construction Coan m here in referred to as`contractor". Owner and contractor in consideration of the mutual covenants hereinafter set forth agree as follows: SECTION ONE: STRUCTURE AND SITE Contractor shall furnish all labor and materials necessary to completely remodel the first floor of a home, including a kitchen, bathroom, living room and family room upon the following described property,which owner warrants,he;owns„free and dear of liens and encumbrances: 40 Moffatt rd_ Salem. Me 01970: SECTION TWO: PLANS Contractor shall remodel the structure in conformance with the plans, specifications, and breakdown agreed on by contractor and owner, and will do so in a workmanlike manner. Contractor is not responsible for furnishing any improvements other than the structure, such as landscaping, grading, walkways, painting, sewer or water systems, steps, driveways, patios and aprons, etc., unless they are specifically stated in the breakdown. SECTION THREE: PAYMENT Owner shall pay contractor according to payment agreement, which is that: The owner shall be billed on an hourly basis at the rate of$40 per man per hour. Payment for each week of work must be paid by homeowner to contractor by the Friday of that same week. Homeowner shall also provide payment for materials or special equipment needed in order to complete the agreed upon work. in the event any installment is not paid within ten (5)days after it is due, contractor may take such action as may be necessary, including legal proceedings, to enforce its rights hereunder and to collect payment. SECTION FOUR: PREPARATION Prior to the start of construction, owner shall provide a clear, accessible building site, properly excavated and correctly zoned for the structure, and shall identify the boundaries of owner's property by stakes at all comers Owner shall maintain such stakes in proper position throughout construction. In the event contractor cannot obtain,a building permit within thirty(30) days of the data of this agreement, contractor may declare the agreement bf'no further force or effect. J � SECTION FIVE: RESPONSIBIUTY Contractor shall not be responsible for claims arising out of improper placement or positioning of boundary stakes or house stakes; nor shall contractor be responsible for damages to persons or property occasioned by owner or his agents, third parties, acts of God or other causes beyond contractor's control.Owner shall hold contractor completely harmless from, and shall indemnify contractor for, all costs, damages, losses, and expenses, including judgments and attorneys fees, resulting from claims arising from causes enumerated in this paragraph. SECTION SIX: GENERAL PROVISIONS Owner agrees to promptly complete the necessary requirements to obtain financing and to prepare the site for construction.There are no understandings or agreements between contractor and owner other than those set forth in this agreement and in the documents referred to in Sections Two and Three. No other statement, representation or promise has been made to induce either party to enter into this agreement.This agreement and the documents referred to in Sections Two and Three may not be modified or amended except by written agreement of the parties. In witness whereof,the parties have executed this agreement the day and year first written above. Signed Owner: Ow{'nnner�Name: ed /t k ign Contractor: Contractor Name: iT -P.1M f9 X DANwKER ESTIMATE CONSTRUCTION DATE 8 MIDDLESEX ST. 6/9/2006 UNIT. 5 N. CHELMSFORD, MA 01863 NAME/ADDRESS IRINA CLARK SALEM,MA TERMS DUE DATE PROJECT 6/9/2006 DESCRIPTION QTY COST TOTAL PLANS&PERMITS 827.50 827.50 -SALEM BUILDING PERMIT FEES (20$PER$1000 ESTIMATED COST) -1.5MH DEMO REMOVAL 30 YARD DUMPSTER (WEEKLY RATE 744.00 744.00 FOR$20 AFTER FIRST WEEK) DEMO 32 40.00 1,280.00 -INTERIOR BATHROOM WALL -EXPOSE NEEDED WALLS FOR PLUMBING -KITCHEN PORTION -LIVING ROOM PARTITION -KITCHEN CABINETS -WINDOW AND DOOR TRIM CEILING COVERINGS . -WALL COVERINGS THIS IS JUST AN ESTIMATE WE HOPE TO WORK WITH YOU IF WE NEED TO SAVE MONEY SOME WHERE. SUBTOTAL SALES TAX (5.0%) TOTAL SIGNATURE PHONE# FAX# E-MAIL WEB SITE 978.560724 978-319.9795 DANKER@DANKERBUILDER.COM WWw.DANKERBU 6 ILDER.COM DAN-KER ESTIMATE CONSTRUCTION DATE 8 MIDDLESEX ST. 6/9/2006 UNIT. 5 N. CHELMSFORD, MA 01863 NAME/ADDRESS IRINA CLARK SALEM,MA TERMS DUE DATE PROJECT 6/9/2006 DESCRIPTION QTY COST TOTAL WALL FRAMING 80 40.00 3,200.00T -ADD NEEDED LVL AND FRAMING FOR STRUCTURE (KITCHEN TO FAMILY ROOM)ARCHWAY -FRAME ALL NEEDED WALLS FOR CABINETS -FRAME MOON SHAPED WALL(FAMILY ROOM TO KITCHEN) -ADD SUPPORTS TO BASEMENT FOR LOAD POINTS IN MAIN FLOOR -LEVEL CEILINGS DOORS&TRIM 4 40.00 160.00T -PREP ALL WINDOWS AND DOORS FOR PLASTERING ELECTRICAL&LIGHTING 6,180.00 6,180.00 -NEW WIRING FOR KITCHEN LIGHTS AND OUTLETS (INDIRECT DIMMER LOW WATTAGE HALOGEN) -UP DATE BATHROOM WIRING AND LIGHTING -INSTALL LIGHTING UNDER CABINETS AND OVER CABINETS -INSTALL PENDENT OVER ISLAND -INSTALL LIGHTING ON TOP OF MOON SHAPE PARTITION WALL -GFI PROTECTED OUTLETS(KITCHEN AND LIVING ROOM) THIS IS JUST AN ESTIMATE WE HOPE TO WORK WITH YOU IF WE NEED TO SAVE MONEY SOMEWHERE. SUBTOTAL SALES TAX (5.094) TOTAL SIGNATURE PHONE# FAX# E-MAIL WEB SITE 978-5806724 978-319.9795 DANKERCaDANKERBUILDER.COM WWW.DANKERBUfLDER.COM DAN-KER ESTIMATE CONSTRUCTION DATE 8 MIDDLESEX ST. 6/9/2006 UNIT. 5 N. CHELMSFORD, MA O 1863 NAME/ADDRESS IRINA CLARK SALEM,MA TERMS DUE DATE PROJECT 6/9/2006 DESCRIPTION QTY COST TOTAL PLUMBING 6,600.00 6,600.00 -DEMO OLD RADIATORS IN HOUSE -MOVE PLUMBING FOR BATHROOM SINK AND SHOWER (UP DATE AS NEED PER PLUMBING CODE) -MOVE PLUMBING FOR KITCHEN SINK TO NEW ISLAND LOCATION -UPDATE HEATING SYSTEM ADD NEW BASEBOARD HEATERS(PER PLUMING CODE) CABINETS&VANITIES 8,500.00 8,500.00T -UPON CUSTOMER REQUEST AND LIKING (CONTEMPORARY MODERN LOOK DYNASTY OMEGA CABINETRY)(SEE PLANS) -RANGE 9,000.00-28,000.00 -CABINETS(BASE/WALL AND ISLAND) CEILINGS&COVERINGS 3,600.00 3,600.00 -PLASTERING WALLS AND CEILINGS FLOOR COVERINGS 3.00-8.5OsQ FT 3,500.00 3,500.00 EsT.500sQ FT @ 7.00 -INSTALL AND FINISHED -MAPLE OR BAMBOO THIS IS JUST AN ESTIMATE WE HOPE TO WORK WITH YOU IF WE NEED TO SAVE MONEY SOME WHERE. SUBTOTAL SALES TAX (5.0%) TOTAL SIGNATURE PHONE# FAX# E-MAIL WEB SITE 978-580-6724 978-319-9795 DANKER@DANKERBUILDER.COM WWW.DANKERBUILDER.COM DAN,-KER ESTIMATE CONSTRUCTION DATE 8 MIDDLESEX ST. 6/9/2006 UNIT. 5 N. CHELMSFORD, MA 01863 NAME/ADDRESS IRINA CLARK SALEM,MA TERMS DUE DATE PROJECT 6/9/2006 DESCRIPTION QTY COST TOTAL PAINTING 1,320.00 1,320.00 -2 COATS(PRIMER AND FINISH COLOR) -WALLS AND TRIM CEILING PRIMER AND FINAL GRANITE OR CONCRETE(CUSTOMER OPTION) 3,240.00 3,240.00T (35$-180$SQ FT.INSTALLED) MATERIALS FOR PROJECT 0.00 O.00T -LVL -FRAMING MATERIALS -FINISH MATERIALS -STEAL FOR WALL -ECT. THIS IS JUST AN ESTIMATE WE HOPE TO WORK WITH YOU IF WE NEED TO SAVE MONEY SOME WHERE. SUBTOTAL $39,151.50 SALES TAX (5.0%) $755.00 TOTAL $39,906.50 SIGNATURE PHONE# FAX# E-MAIL WEB SITE 978-5806724 978-319.9795 DANKER@DANKERBUILDER.COM WWW.DANKERBUILDER.COM