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46 RAYMOND RD - BUILDING INSPECTION (2) CITY OF SALEM �- PUBLIC PROPRERTY 31 1f I �� DEPARTMENT alV::v xl GT"M1iM:i 11. \L%IoK I1C WA.-jjNc":OKS:REET • SAU M. MASNA a rn:978-74i-')595 G.vc:')78.7iG9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 7S0 Cb1R section 111.5 Debris, and the provisions of`vtGL c 40, S 54; Building Permit # _ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by v1GL c 111. S 150A. The debris will be transported by: ��- {name of hauler) The debris will be disposed of in NynGLo w- (name of 1'acihty) i ad.:res. of t'J�il:ty) . CITY OF SALEM `?` PUBLIC PROPRERTY j DEPARTMENT KIMBERLEY DRISCOLL MAYOR 1-20 WASHINGTON STF.EET • SAI.FN,VtA.SSACHI i.SET1'S 01970 TEL: 978-745-9595 • FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): /Yl/h/ �� - Address: �49 City/State/Zip: L-6�t�o�i �af /Jo2�a l Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.0-1 am a employer with 1170 4. ❑ 1 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. 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. ❑We are a corporation and its required.] officer's have exercised their 10.0 Electrical repairs or additions. 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4), and we have no 12.0 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 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. / Insurance Company Name: Policy#or Self-ins. Lic. #: GI/C�6� /O,?�6� Expiration Date:ny�jo�� Job Site Address: og zez,: 1 �c ✓�� City/State/Zip: JA/G",w 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 tine up to S 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 S250.00 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 certif under the pains and penalties ofperjury that the information provided above is true and correct. Si nature: Date: Phone /�/- 942-'lw 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#: 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 ofhiie,' 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 nor 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 to contact you regarding the applicant. Please be sure to fill in the permit/license 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 policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)." 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: 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 Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia ACORD CERTIFICATE OF LIABILITY INSURANCE DATE 2007 ra 04/02/2007 PRODUCER (781)447-5531 FAX (781)447-7230 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mason & Mason Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 458 South Ave. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Whitman, MA 02382 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Meaghan•Wal ker INSURERS AFFORDING COVERAGE NAIC# INSURED Aluma i t, Inc. INSURERA Western World 000071 50'Getchell Way INSURERB: The Travelericas Indemnity Conpan 25658 INsuRER c: peon Amer Canton, MA 02021 V INSURERO Savers Property & Casualty Ins. 000203 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 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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR DO TYPE OF INSURANCE POLICYEFFECTNE POUCYEXPIFUITION POLICY NUMBER LIMITS GENERAL LIABILITY REN OF NPPI011831 04/01/2007 04/01/2008 EACH OCCURRENCE S 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $CLAIMSSO,OO MADE O OCCUR AMED EXP(Any«,a parson) $ 1,00 PERSONALS ADV INJURY $ 1,000,00 -" GENERAL AGGREGATE S 2,000,00- GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00 AlPOLICY PECOT M LOC AUTOMOBILE LIABILITY BA424D701807SEL 04/01/2007 04/01/2009 COMBINED SINGLE LIMIT ANY AUTO (Ea amad.1) $ 1,000,00 ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY S B (Per person) X HIRED AUTOS X NON-OWNED AUTOS BODILY INJURY $ (Per aoidenl) PROPERTY DAMAGE $ (Per erridem) GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ - AUiO ONLY: pGG $ EXCESSNMBRELLA LIABILITY REN OF SUB1014078 04/01/2007 04/01/2009 EACH OCCURRENCE $ 1,000,00 OCCUR O CLAIMS MADE AGGREGATE $ 1,000,000 $ DEDUCTIBLE X RETENTION $ 1 0,00 S WORKERSCOMPBILITY AND REN OF WC0002363 04/Ol/2007 04/01/2008 We srATu- X DTH- EMPLOYER5 LIABILITYPR D ANY PROPRIETORIPARTNERIEXECUTNE E.L EACH ACCIDENT S S00,00 OFFICE"EMBER EXCLUDED? OFFICER(S) INCLUDED 500,00 It yes,deslribe under E.L DISEASE-EA EMPLOYE $ SPECIAL PROVISIONS below OTHER E.L.DISE&SE-POLICYLIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECUIL PROVISIONS Improvement,Aerations: Home Installation of windows, doors, vinyl siding, roofing CEETIFICATE HOLDER, C ELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Hartwell Exteriers BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 50 Getchel l Way OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. Canton, MA 02021AUTHORZED REPRESENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 CONTRACT TERMS AND REQUIRED NOTICES � o y tYia it0 s, x s Notice:All home improvement contractors and subcontractors engaged in home improvement contracting,unless speci;ically exempt from registration by the provisions of Chapter 1 42A of the general ® i laws,must be registered with the Commonwealth of Massachusetts.Inquiries about registration and status should be made to the Director,Home Improvement Contractor Registration,One Ashburton Division of LU NDIl cu loos W mse ai Place,Room 1301, Boston,MA 02108. 1.1959 50 Getchell Way, Canton, MA 02021 781-963-7900 INJe hereby agree and authorize you as contractor,to furnish all necessary materials,labor and workmanship,to install,construct and place the improvements according to the specifications,terms and conditions,on the premises below described,which IMe represent that we have good record title in our own name. Owners Names�r d Z,n. a:r �:V Home Tel. No. tom$- 74`{- 23(rFS Bus.Tel. No. U-1- y"1y— 7Z9I e-mail Job Site Address h , RA City LO M ST y1k Zip Wit_`_7� Massachusetts Contractor egistration # 100468 Rhode IslanA Contractor Registration # 17166 Work Specifications described attached on pages: Z of Z ""of ----of Permits:The contractor agrees to apply for and obtain all construction related permits(Building/Electrical/Plumbing)but shall not be deemed responsible for delays in the work described in this agreement caused by regulatory,permit granting or inspection agencies,authorities or individuals. I� I Notice:The homeowner who secures his own permits will be excluded from the guarantee fund of I Chapter 142A. y Price:The contractor agrees to do all work described by the contract for the total price of $ 1 6r Notice: No agreement for home improvement contracting work shall require a down payment(advance depdsit)of more than one-third of the total / contract price or the total amount of all deposits or payments which the contractor must make, in advance,to order and/or otherwise obtain delivery of I�1 special order materials and equipment,whichever is greater. Payment Terms: Advanced Deposit $ �5 (tC)(` Payable on signing of contract Z� ? Interim Payment 1 $ Payable Interim Payment 2 $ Payable Final Balance $ 4) zoo Payable Security Interest: Yes No -To be held in the form of a UCC-1 form to be filed only if payment is not made on completion. Notice:The contractor does not have the right to request payments in advance of the times set forth in this agreement,although,by agreement,the parties may jointly agree to escrow any portion of the contract amount. In the event that it becomes necessary for the contractor to employ an attorney to collect any balance due hereunder the owner agrees to pay in addition to the said balance,the costs of collection and reasonable attorney's fees. Work Schedule:The contractor will not begin work or order materials before the third day following the signing of this agreement unless specified in writing.The contractor will begin work on ur about 1_0a-(date).Barring delays caused by circumstances beyond the contractor's control,the work will be substantially completed in__weeks/ The homeowner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the contractor shall not be considered as violations of this agreement.The contractor shall not be liable for any delay or non-performance caused by strikes,accidents,weather or any other contingency beyond its control. Insurance:The contractor agrees to maintain workers compensation and comprehensive general liability insurance during the operation of this job to cover the acts of its employees and or agents. Warranties:The contractor warranties its workmanship for up to a period of seven years and assigns the rights to any manufacturer's warranties to the homeowner after the substantial completion and payment of the contract terms. You may cancel this agreement if it has not been consummated by a party thereto at a place other than an address of the contractor,which may be his main office or a branch thereof, provided you notify contractor in writing at his main office or branch by ordinary mail posted, by telegram sent or delivered, not later than Midnight of the third business day following the signing of this agreement. See the reverse side of this form for an explanation of this right. This instrument and any and all other documents attached hereto and signed by the parties set forth the entire contract between parties and may be modified only by a written instrument executed by both parties. Receipt of a copy of this contract and duplicate notice of cancellation and explanation thereof is hereby acknowledged. HOMEOWNER: Do not sign this contract if there are any blank spaces. IN WITNESS WHEREOF, the a herbu signed their names this 25 day of ilCv 200--&-. Alumabilt, Inc. Representative /Vt/ HomeQv ner �GL1 Accepted Alumabilt, Inc. Homeowner Page 1 of Z. HOMEOWNER: You have a right to a copy of this contract. i . rq � s � i� t s.� 5 � r g s� •xi Ft:�S P ` 4� .Zl 3' CONTRACT WORK SPECIFICATIONS �, e � ,, Mass HIC# 100468 RI HIC # 17166I d Initialing this page indicates receipt of the CONTRACT TERMS AND REQUIRED NOTICES,as page 1 of this agreement. Dmsi«,or �,�&p@�//i NEffo HU#1�W 171W A� ���°"' eM 1959 Owners Names KQv-et1 TQ"l�i�• 50 Getchell Way, Canton, MA 02021 781-963-7900 Home Tel. No.97 $- 7 44— T3(va Bus.Tel. No. (pi-7- ` -71-4 e-mail Job Site Address Ala .,::: c, bY1 . . City-5 ST 1 _Zlp C)i720 Details of work to be performed and materials to be supplied follow �i U CQ r12C 2SJ� Yy 34 r rn i icy h4 •�v�'S�a\l w��J r� CF� y ev�� ct ,1 P Wlv�-vt Cc✓ti,Pl��'� c-�c� •� �b 'Sic_ . Initials Acknowledging this page:Alumabilt, Inc. 61AP Homxer Homeowner Date HOMEOWNER: Do not sign this contract if there are any blank spaces. You have a right to a copy of this contract. Page 'L of 2— _ The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR �. I MUNICIPALITYMassachusetts State Building Code. 780 CMR, 7ih edition USE Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Anwar) One- or Two-Fandly Dwelling 1. 2(H)3 This'Section For Official Use Only Building Permit Number: L I Date Applied: 3 .3 TO 8" Signature: h/ 3 /3 AJe B tld ' Commissioner/Ins oor of 1hildings Date SECTION 1: SITE INFORMATION i�1.1 Pro erty dress: 1.2 Assessors Map & Parcel Numbers 02 ;, � 1.la Is this an accepted street?yes_ no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq tt) Frontage(tU 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard 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: Zone: _ Outside Flood Zone? Munici al ❑ On site dis sal stem ❑ Public❑ Private❑ Check if yes❑ P �' y SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner[of Record: y6 /Y�trecr rs 6 e*"ccr+aIX Fdl Name(Print) Address for Service: See Cam,[ 495/7-92 / Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied A,I Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': e / � / J SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ l6 �� 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: $ /6 �� ❑Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 2_0-/4 6 � 3/moo/b ��e- License Number Expiration Date Name of CSL- Holder List CSL Type(see below) l/7Ei G �/LI Addr• J T Description. t U Unrestricted(u to35.000Cu. Ft.) R Restricted 1&2 Family Dwelling S nature ERC Mason OnlResidential Roolin CTelephone Residential Window and SidinResidential Solid Fuel Buming Appliance Installation D Residential Demolition 5.2 Registered HomeT I rovement Contractor(HIC) . L HIC Company Plariv or HIC gistrant Name Registration Number Addre 7F/-963—r/�OD Expiration lmtion Date S' ature 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 of the building permit. Signed Affidavit Attached? Yes ........... No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. '3-3 i ature of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION 1, ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the pains and penalties ofperjury) NOTES: 1. 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5, respectively. 2. When substantial work is planned, provide the information below: Total Floors 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" may be substituted for"Total Project Cost"