36 PHILLIPS ST - BUILDING INSPECTION (4) CnY-OF3A1,EiN
PUBLIC PROPERTY
DEPARTMENT
X,.WFXLEV DiuscuLL
MAYOR 130 WASMNCTO+h rREEr•
Snus4,MnAAalcstM 01970
Tm 978.71S-9S9S•FAx.97&7i0.9806
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR WELDING
1.0 SITE INFORMATION
Location Name: Sc��vvl Building:
property Address. -- ---
361' s�
Property is kxated in a;Conservation Area Ye—Historkc District Y .
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: Z,vk q
Address: 36 P�j 1,lxr . ,5 S
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING 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 New
Brief Description of Proposed Work:
Mail Permit to: -
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law?
Asbestos?
Architect's Name
Address and Phone j j f Sdy uc.¢-
Mechanic's Name C
Address and Phone
Construction Supervisors license# HIC Registration# t S6 q
Estimated Cost of Project$ <2W 0 PwmK Fee Calculation
Permit Fee$ -3-5-, 6-0 Estimated Cost X$71$1000 Residential
- — Estimated-Cost X$111$1000 Cammerciai--
An Additional$5.00 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 X
Date 0-7
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PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
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PAYCHEX AGENCY, INC. HOLDER. THIS CERTIFICATE DOES NCT AMEND, EXTEND OR
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Costello Construction & Remodeling Inc.
89 John Wise Ave.
Essex, MA 01929
Office Phone/Facsimile (978) 768-7015
www.costelloconstruction.us
r This Agreement (hereinafter referred to as "Agreement") made by and between
Costello Construction & Remodeling, Inc., hereinafter called "Costello", and Ali Lima,
F� � hereinafter called"Ow
ner".
Salem
Job Location: 36 Phillips Street,North > MA 01970 (hereinafter referred to as the
``premises")
Section 1 Scope of the Work.
Specifications:
Rebuild 2n0 to 3`d floor winder stairs with oak treads, pine risers, oak Scotia, primed
handrail, primed post and balusters, remove and reframe any framing necessary to make
stairs solid. Rebuilding to be approved by Salem Building Department prior to
commencement of work. Note: This contract does not include any paint, electrical,
plumbing, or hvac.
Section 2. Time of Completion The work to be performed under this Agreement, weather
permitting, pending receipt of 1'` disbursement and necessary permits, is anticipated to
commence on or about December 29, 2007 and be completed within 60 days. Costello
will submit Application for Permit upon receipt of 1s` Disbursement and signed
Agreement.
Section 3. Change Orders. Change Orders directly affect the cost of the contract. Change
Orders also extended the time for completion. Payment for the work outlined in the
Change Order is due immediately upon completion of the items outlined in the Change
Order.
Section 4. Cost Owner shall pay Costello for time, material, and containers, subject to
additions and deductions pursuant to authorized change orders.
All carpentry labor will be billed at a rate of$65.00 per man hour. All labor, material
and container fees will be billed weekly or bi-weekly and due from Owner upon receipt.
Section 5. Deposit:
$1,000.00 Deposit due upon signing this Agreement to be paid to Costello
Section 6. General Provisions
1. All work shall be completed in a workmanship like manner and in compliance
with all building codes.
2. Costello may at his discretion engage subcontractors to perform work
hereunder, provided Costello shall fully pay said subcontractor and in all
instances remain responsible for the proper completion of this Agreement.
3. All change orders shall be in writing and agreed to by both Owner and
Costello.
4. Costello warrants that any subcontractors shall be adequately insured.
5. Costello agrees to remove all debris related to the work conducted under this
Agreement and leave the premises in broom clean condition.
6. In the event Owner shall fail to pay any payment disbursement due hereunder,
Costello and any subcontractors may cease work without breach pending
payment by Owner to Costello or resolution of any dispute between both
parties. Owner agrees to pay Costello's attorney's fees associated with the
collection of unpaid balances, if any. Interest will accrue on balances 30 days
overdue at a rate of 1 ''/2%monthly 18% annually.
7. Costello shall not be liable for any delay due to circumstances beyond his
control including but not limited to, weather conditions, inability to obtain
permits, casualty or general unavailability of materials.
8. Costello agrees to obtain the building permit from the City of Salem for the
work to be performed If a variance or some other special permit is required,
Owner agrees to obtain.
9. Owner agrees to allow Costello to put a 2' x 3' business sign on the premises
while the work is being performed. Owner agrees to allow Costello to use
photos of the work done for advertising.
10. Costello is MA licensed, is a registered Home Improvement Contractor and is
insured.
11. Costello will supply an insurance certificate to homeowner upon receipt of
signed contract prior to engaging in any work.
Signed this ;xq day of December, 2006.
Costello Construction& Remodeling, Inc. By Owner:
By: Sean Costello, President 2
Ali Lima
BOARD OF BUILDING REGULATIONS y.
License; CONSTRUCTION SUPERVISOR '?
Number: CS 086882
Sirthdate; 0 7/1 611 9 7 5
Expires:07/1612007 Tr.no: B8682
Restricted: 00
SEAN A COSTELLO
3 ROCKLAND ST
GLOUCESTER, MA 01830 Adminlelretor
�.e'oPoa+a+�ra+unma�0(o`✓>�aaaaa{rvelld
,Board of Building Regulations and Standards License or registration valid for iodivldul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date- if found return to;
Registration: 145642 Board or Building Regulations and Standards
One Ashburton Place Rut 1301
Expiration: 2/1812007 Boston,Ma.02108
Typo: DBA
COSTELLO CONST+REMODELI
MAN COSTELLO
89 JOHN WISE AVE
ccccv see r1010 . . . . u._...ou..,:•w,...•o n,....e '__""".»
, CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KDIaERIEY DRLfCOLL
.MAYOR 120 WA911r'=0N STREET e SAtEu,MASSACHUSkTIS 01970
TEL 978.7459595 a FAx:978.740.9846
Workers' Compensation Insurance Affidavit: Bullders/Contractors/Electricians/Plumbers
Anuticaut Information Please Print Leemy
Name(Busweas/Orgaaiauonnndivi&w): (fd c ccm 5 91/r4 'I -ten t`
Address: OF J�-7
City/State/Zip: �S / �'`� Phone#: q-78-- ?? 7E$ - 70/S
Are you an employer?Check the appropriate host: Type of project(required):
1 am a emplo wsth 4. ❑ I am a general contractor and i 6. ❑N construction
C employee�nd/or part-time).• have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. RrRemodclizS
ship and have no employees Theca sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp. insurance. 9, []Building addition
[No workers'comp,insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 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 12.0 Roof repairs
insurance:required.]f employees.[No workers' 13.❑Other
comp.insurance required.)
'Any+PPlion tW shacks box el ama gist all our the swdaa below Aovina that wart■.
t Narneorrone who A*mb this atgdavit indcating they an dowli all wort sod e m has ouWds trsuars POLICY ialbm�
=Ca must mhmh s into sAWsvt indkatie8 roeh
etrseton thu cheek thb boa must saeehed m sddidaW sheet ehowma tb rime of the sod their warbwsI eomR polity fidbm sdm
f am an employer that Is providing workers'compensadon Insaroncefo►my e
hiformadonmployees Below Is the policy and Job she
Insurance Company Name:_ � C Q't°
Policy#or Self ins Lie.#: CO ti✓G t76 S Z Expiration Date: C� o/ d
Job Site Address:_ �� Pr`� !S S�t City/State/Zip: S4��^" , ✓l1''�'
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
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of�a STOP WORK ORDER anda ties of
of up m$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 hereby testify and ties ofperJtrry that the information provided above Is tine and correct
Sirnature: �
Phone#: F7f- 2395 — 76�s r
oJjleiaf use only Do not write In this area,to be completed by city or town oQleiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspe7PIumblogluspeactor
6.Other
Contact Person: Phone*
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workets' compensation for their employees.
pursuant to this statute.an employee is defined as"...every person in the service of another under any contract of hum
express or implied,oral or written."
is defined as"an individual,partnership,association.corporation or other legal entity.or any two or mom
o f he for ysr and including the legal representatives of a deceased employer,or the
of the foregoing engaged is a joint entrmrisa+ entity.ern to employees. However the
receiver or trustee of an individtul, of mom theassociation
three a err m other legalresides
employing
house having not more than three apartments and who resides therein.or the occupant of the
owner of a dwelling todo maintenance,construction Of repair work on such dwelling bouse
who employs Persons
dwelling house of another thereto shall not because of such employment be deemed to be an employer."
or on the grounds or building appurtenant
MGL chapter 152.§25C(6)also states that"every state or local licensing agency shag withhold the issuance a or
renewal of a Iteease or perms to operate a business or to construe buildings In tM conweaN h for any
ntmo
applicant who bas not produced acceptable evidence of eampnsaee with the insurance coverage required."
Additionally,MGL chapter 152.§25C(•1)states"Neither the commonwealth nor any of its Political subdivisions shall
contract for the performance of public work until acceptable evidence of compliance with the msuraxe
enter into any ter have been presented to the contracting authority-"
requirements of this chap
Applicants
affidavit completely,by checking the boxes that apply to your situation and,if
Please fill out the workers' compensanona addresa(es)and phone numbers)along with their cudficate(a)of
necessary.supply subcontractors)name( ). with no employees other than the
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)
members or partner,are not required to carry worker'compensation itmuraace. If an LLC or 1 LP 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. Abe be sure to sign and date the atfidaAL he affidavit should
be returned to the city or town that the application for the permit or license is being requested,ant the Department of
Industrial Accidents. Should You have any questions regarding the law or if you are required to obtain a worker'
compensation Policy,Please call the Department at the number listed below. Self-iaeured companies should enter their
self-insurance license m ober on the a line.
City or Town Officials
Please be me that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
ll out in the event the Office of Investigations has to contact you regarding the applicant
of the affidavit for you to fi
Please be sure to fill in the 11 rmitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permi ilicenae applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"job Site Address"the applicant should write"all locations is (oily or
town)."A copy of the affidavit that has beeo 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 afffdavir mart be filled out each
year.Where a home owner or citizen is obtaining a license or permit not misted to any business of commercial ventu a
(i.e. a dog license or permit to burn leaves etc.)said person is NOT requited 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 M telephone and fax number.
The Commonwealth of Massachusetts
Dep rawnt of Industrial Accidents
081ee of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 eat 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26.05 www.massgov/dia
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