16 SETTLERS WAY - BUILDING INSPECTION a
CITY OF SALEM
PUBLIC PROPRERTY
mot,.y
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PARTMENT
w l4rai'WAY UatQanL
M.Xyt* ItrWA*fi2%tTONSTAEErsSAtt3t,MAZACtn. 1r1801971
'fka_978-743-9595 s FAX:9M740.9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricfans/Plumbers
ArifillIC34t information Please Print Le ibl
NaMC tauaincsstorgmiratioNlndtvtdiop: V. 1 .c J'IN 5,
Address: S'Z k-1 (,kt &" k
City/Stateizip: � Veer Nkdk ( WP1 Iknone a: tO c1
Are you in employer?Check the appropriate box: 'type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractor
1 am a sole proprietor or partner- listed on the attached sheet t ?• ❑ Remodeling-ship and have no employees These sub-contractors have S. ❑Demolition-
working for me in any capacity. worker'comp. insurance. 9. ❑ Building addition
(No worker'comp. insurance S. ❑ We are a corporation and its
required.) officers have excrcisd their 10.0 Electrical repair or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repair or additions
myself.(No worker'comp. c. 152,§1(4),and we have no 12.❑ Roof repair
insurance requirtd.j t ctriployces. (No workers'
comp. insurance mquird.) 13.❑ Other
-Ally applicant tills eureka boa NI mac also tilt out 111e secliaa twluw diowiaa IhMr wurktax'eumpaaaoiva policy infunmuwa
't lumwowtaxs who submit this amdsvit indkatins Clary,ate Joins all work aid Thee hire out"contraaon must oubma a new airldava imiaainx wch.
-C.>,Itrxyora that Awk this box nun attaohad an addiliaul Alm showina tba nuao of dw tubeontraoma sad thew wurken'comp.policy mformativa
i um an employer that Is providing workers'compettsadon Insurance for my empiayees. Below Is the policy and job site
information.
Insurance Company Name: --
Policy li or Sclf-ins. Lie.q: _.. . .._... Expiration Date:
Job Site Address: City/State/zip:
.%track a copy of the workers'compensation policy declaration page(showing the policy number and expirativa date).
Failure to wcum coverage as required under Section 25A of.%AGL c. 152 can lead to the imposition of criminal penalties of a
tine up in S1.5410-00 and/or one-year imprisonment,is well as civil penalties in the form of a STOP WORK ORDER and a fine
n u m 5250.00 a day against flit violator. 1 advised
p y g fie ad st.d that a copy of this sfab:mcnt may be forwarded to the Office of
Ins a,mluuos of the DIA for iosurarc• •ov. a,p;v. ._� � �fht. �fltfeallUn.
III
i do hereby ter 'y i ider the pr ' u penalties afperjury that rise laformatlan provided above is true and correct
Si,.a:unr•: r12.. Dge. J11-13'r ku 7
Plumcz: f der?4b9—f�tZ�
O/Jleial use only. Do not write in this area,to be f omp/ded by dry or town offichd
City or'rown: _-. Permit/License tY
Issuing Authurity (circle otte):
I. Board of Ilbalh 1. Building Department 3.Citylfossn Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other
Clriituct Person: _ Phone It:
Information and Instructions
Massachusetts General Laws chapter 1 32 requires all employers to provide workers' compensation for their employees,
pursuant to this statute,an empfoytt is defined as"...every person in the service of another under any contract of him
express or implied,oral or written.'
An tarpfoyer is defined as"an individual,parmenhip,associaao4 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.partaershup,association or other legal entity.employing employees. However the
owner of a dwelling hours having oat mote than three apartments and who resides ttterei4 or the occupant Of the house
' work on such
dwelling dwelling house of soother who employs persons.ro do inainreaance,construction or repo¢ or g er»
not because of such eat be deemed to be an employ
building ap
purtenant thereto shall employment or on the grounds a g Pp
IstGL chapter 152.¢2SC(6)also states that"every state or local Ikensiag ageaey shall withhold the issuance or
renewal of a license or permit to operate a basilica or to coustruet buildings in the commoawealth for any
applicant who has net produced acceptable svidemest of compllauoe witb the insurance coverage required."
.additionally.MGL chapter 1 S2, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
performance of public work until acceptable evidence of compliance with the insurance
enter into any contract for the
requirements of ibis chapter have been presented to the contracting authority '
Applicants
Please fill out the workers'eompensaaon affidavitcomplately.by-checking-the boxes am apply to your situation a"if
necessary.supply subcontractor(s)name(s).addreas(es)and phone number(s)along with their certificates)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 duce 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 Aceideats. Should you have any questions regarding the low 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 thew
.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 till in the pemtittlicense number which will be used as a reference number. In addition,an applicam
that must submit multiple permitilicense 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 now 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
(ix. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Otiix of Investigations would lice to thank you in advance for your cooperation and should you have any questions,
please du 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 Iavestlptla"
600 Washington Street
Boston,MA 02111
Tel. # 617-7274900 ext 406 or 1-977-MASSAFE
Fax M 617-727-7749
Revised i-26-05 www.mm.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
a.":L M 1 r.Y• ea:Jl1.
A%u a[ 12C W.%a W::as S.,Rf1tT CIS S:04
Construction Debris Dispossi Affidavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
0,abris, and the provisions of MGL c 40.S 54.
suildins Permit 0 _ . _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as detLted by.\tGL c
It t.31.30A.
The debris will be transported by:
_ (nama of hauler)
fhe debris will be disposed of in :
�J.:rep. of fxiLty)
At,
+FOUrPoInts
Services
Service Beyond The Cali
August 30, 2007
Mark Magee
16 Settlers Way
Salem, MA 01970
IG Re: Attic Space renovation
Dear Mark
Thank you for the opportunity to provide this estimate to remodel your
attic space. I am enclosing my standard agreement, payment schedule
and a scope of work.
The total estimated cost to complete the work as discussed is
$21, 447.0D. I will need a copy of the signed agreement (attachment A)
along with a deposit equaling 60% of the total cost ($12,899. 00) to
commence the scheduling phase of the project. Once received, I will
publish a tentative calendar of events for your review.
I have also enclosed some tips on "Surviving the Process".
I value your business and look forward to working with you.
Be regards,
Paul V. De&tefa�46
General Contractor
Massachusetts HIC License # 135119
Massachusetts Const. Su v p # 85458
52 High Street, Methuen, MA 01866
Tel. 617-869-1929 Fax. 270-918-0564
o
FourPoints Services
"Servke Beyond The Call-
AGREEMENT BETWEEN OWNER AND CONTRACTOR
Athwhment-A
THE OWNER: Mark Magee
16 Settlers Way
Salem, MA 01970
And
THE CONTRACTOR: Paul V. DeStefano
D/b/a FourPoints.Services
52 High Street
Methuen, MA 01844
Agreement Date: August 30a', 2007 Agreement Amount: $21,497.00
WORK AIITHORIZATION/SCOPE OF WORK: Owner authorized Paul V. DeStefano
d/b/a"FourPoints Services"(herein referred to as the Contractor)to renovate my attic space at:
16 Settlers Way as per the estimate prepared August 3&, 2007. The work involves adding a
living space and closet over the master bedroom in newly found attic space.
CHANGE ORDERS: A change order is an order authorized or directed by the owner to the
Contractor to change the work as shown on the estimate. There is a$50.00 minimum charge.
Payment is due at change order authorization and contract signing.
PROPOSALS: If owner requests.Contractor to submit a proposal for changes in scope of work
or for-additional work and then elects not to proceed with the wok shown on said proposal,
Owner will be responsible to pay Contractor$70.00 for each proposal prepared. Payment is due
upon receipt of invoice. If owner accepts proposal,payment schedule will be covered in
proposal agreement
ADDITIONAL WORK: If owner elects to use the services of other patties to perform
additional work in conjunction with work covered by this contract that cause delays to the
contract,Contractor,has the right to bill Owner for any and all work completed to the point of
delay.
52 High Street, Methuen, MA 01866
TeL 617-869-1928 Fax. 270-919-0564
+FourPoints Services
".Service Beyond The Call"
CONTRACT T1ME: The Contractor will provide services expeditiously as is consistent with
reasonable skill and care and the orderly progress of construction. Contractor cannot be held
responsible for any expenses incurred by Owner because of delays in construction time due to
Owner Initiated Change Orders, nor can Contractor be held liable for delays in construction due
to supplemental work,code upgrade regt .m .n a and/or weather.
PAYMENT SCHEDULE: Homeowner(s) will be responsible to pay direct to Paul V.
DeStefano the sum of twenty one thousand, four hundred and ninety seven dollars.
Uih� 60%at contract signing
64 42;9.yo
201/o at framing inspection
t1Z39•Yo
$.t398L Balance to be paid at completion of work
NOTE: PAYMENT CANNOT BE WITHHELD FOR PUNCH LIST WORK(punch list
items are items that do not restrict homeowner from full use of their home and/or an area of their
home. They include but may not be limited to: touch-up painting; additional work not covered
in the original scope of work;miscellaneous wood trim installation or miscellaneous
cabinet/counter-top repairs.
LEGAL FEES: Owner will be responsible for any and all legal costs incurred by Contractor for
non-payment per above agreed payment schedule.
Agreement Accepted by:
)&.f��r
i f
Owner Date
Date
Contractor Rep Date
52 Hlgh Street, Methuen, MA 01866
Tel. 617-869-1928 Fax. 270-918-0564
o
FourPoints Services
"Service Beyond The Call'
16 Seders Way - 2nd Floor Study
Changestadditions from last meeting are in red
GENERAL CONDITIONS $1,000.00
Planning/Design $250.00
Permiits $150.00
Disposal Charges $600.00
MATERIAL $5,097.00
Insulation(12 rolls) $600,00
ridge ventilation at floor joists(30) W 00
(2)venting skylights (44 3/4" x 46 3/4")VS606 w/shades �� $1,521.00
(30)Blue board $330.00
(20)3/4"tongue and groove plywood (sub floor) $580.00
f (12) 3/4"tongue and groove plywood for crawl space $348.00
I Oak flooring to match existing plus closet $970.00
Base Board Molding and door trim • $330.00♦
(2) 30" Pre-hung Masonite 3 panel doors to match others $338.00
i
ELECTRICAL $2.950.00
Now Line to circuit breaker $800.00
(8)4"recessed lights $600.00
(2)Lamp receptacles/switches $150.00
(8) Plugs $600.00
p Cabletphone(run from basement) $500.00
Electric baseboard heat $300.00
HVAC (Central Cooling and Heating to estimate when wall is
opened) $1,200.00
LABOR $11,250.00
Frame,Sub floor $1,800.00
additional framing for closet and moving wall back 12" $800.00
Insulation/vents $1,800.00
Hardwood floor $1,500.00
Plaster skim coat $2,300.00
$ !�*
Trim and finish work $1,250.00
Paint(prep, prime, and 2 coats) Benjamin Moore $1,500.00
TOTAL49T�1_ 0
52 High Street, Methuen, MA 01866 Lt, r 9 7.Oo
Tel. 617-869-1928 Fax. 270-918-05"
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EITY-OF
PUBLIC PROPERTY
DEPARTMENT
1:1�01FJibY DRISCW.L
MAYOR 130 W"MN1(.fW b'MEWr
1N.E1k VALSAC.lIMPIS 01970
TEL-979-745-9595•FAfc M740.9W
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY FMSTIN fg
STRUCTC�Ii' OR BUILDIN
1.0 SITE INFORMATION
Location Name: (10 Se4�S W Building:
Address:- -- (i u-s - OVi- — - A do-
((,- Se 1l -te,.c (J ' S
Property is located in a.Conswvatlon Area Y/N Historic OtsMd Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name: m/A e v- m kF e e,
Address:
WtAr Ot9 "70
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing y
Renovation 1/ Number of Stories Renovated Z
Change in Use New
Demolition Existing
Approximate year of /� �� Area per floor (st) Renovated
construction or renovation
of existing building New
Bcief Description of Proposed Work:
— ---- Mail Permit to:
What is the current use of the Building?
,tip�� if dwelling.how many units?
Material of Building?
Asbestos? w 0 —
"a the Building Confform" to Law?
Architect's Name W�lCnowrJ .
Address and Phone
Mechanles Name
Address and Phone 3S
HIC Registration#
Construction Supervisors License#
Estimated Cost of Project S Z� l q PemM Fee Cak, Won
Permit Fee S� Estimated Cost X$7151000 Residential
Estimated Cost X$41/51000 Commwciai------._
An Additional $6.00 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 jo b lid to the above stated
specifications. Signed under penally of perjury
X
Date (66 0
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