38 SUMMER ST - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
u
MAYOR
120WASFIDOUM S1MT a Sauk MAS&ACMWM 01970
7
Workers' Compensation I11111s see Affidavit: Bnllders/Cootractoi yF,iecuicfan&7h mbm
ApplIcant WON
Name l i , 1: Cl t l S I ►�L „s LL C
Address:
c(tyistawz(p: C ae(>`26 ,Jj AA {�} Phone#
Are you an employer?CLoek approprlata boat
1�"y am a employer with 2 4. 0 I am a iseud contractor and IDOdw�
)�( :
empbyea(tbB and/,pact time).• have hired the suds eonnacton caostrlFcdon
2.[3 1 am a sole Pmptidor a partner. listed on the attached sheet,todeling
ship and have no employee, Theta mb mntracoOn have
wotidng for mein ate•capacity. woduns•comp,ioarscae. olition
q�wroff°'eon'camp.insane S. 0 We Am A don and its Oi addition
3.0 I am a homoownar doing all work right of exercised theiruwll rspams or addict top
myself.(No workers'co per MGL bing repairs a additions
top a 152,¢1(4�and we have no
mstrraau requital f =Ployeera,[No workers' repairs
comp iaanaoce required) r
•Any *ACtrdm box el mere go tal nut�6e Ocdm 6woM amens drlr Morkws't Nemeore Mho aadt nY e "owns dry a awes 4 emit ad duo hie pdky ietwarwlCa
rl'aeseetwa Nr ChCek tide box stom w m mehed m eddttlerol phew arMtq dr none w'�omads 00oeaaen,mnw wama a eve weave hdketler ash.
manor WM and dmir amrhee•Comp,sea"law an amPlOyee slat&Provtaing works'compnson Insurane or
ayemployees. Beow 4Injormaw thePo&7 and job sAir
Insurance Company Name.
Polity#a Self-iris Lie # W C )�� — I
Expiration Date:
Job Site Address 17
CitylShltelZip: �A i<�
Attack a copy of tIr war ken'compensation policy declaration a
Failure to secure coverage as Pie(showing the Polley number and expiration date}
fine up to s Icure co and/or one-year r��on�won 25A of MGL a 152 can lead to the imposition of criminal
unPritonment as well as civil penal in the form of a STOP WO DER an of a
in es ig lions 0 a day against fo * the violamr. Be a ised that a copy of this statement may ORDER and a flee
investigations of the DU for ururmce v n erifieatioa Y Forwarded to the Oflice of
/Jo hereby cs fj+u air an
°fRer/my that at informadon provide/ b/rue and correct
Si
FIssuint
*onIA Do not write Le this area,to be Completes by city a town oQletai
ws
PermiNLkease#
thority(circle one):
P Health 2. Building Department 3.Clty/rowa Clerk 4. Electrical Inspector S.Plumbfag Iwpeetor
Contact Person:
Phone#•
Information and Instructionsvideorkec° n�"tom
�a�y°yena General Lawn chapter�3�fined as ev� mas to�ehQ mvm of anodes under any conned o(hisQ.
purwanr to this stasuM an swpfeyn
express or implied.ad cc wrtam'
association.eospetatias or°�legal�,�any two a none
An s defined as"an indlYi&A patmarsh'P. ves of a deceased employe*,or the
Bing engaged in a joint tmterptir.and incha�the legal taptdmtati
rof the eceiver oc trustee of an individ A parmerahtp.auoetadm at other legal entity.emPlOY1°`0 of�W
ownw of a dweHW$hour havW$t►ot mote tbm three sparomeasr sod who=sides that"AWMMM s er�ir m such dwdlin{bo°M
dwelling house of another who empbYQ P� not because of such employment be de�to be r empbyer
or on the gtounaa or building Appurtenant d"withbom W yip or
MGL chapter 152,¢2SQ6)do state that a tsudaasa or eeatraet btalidlaga V W coesmoawealth far W
feaewat of a kew or p"zW to operate coverage o
oduced accept"evidesics of conplas"with W haanranea
who halt not
applicant
p plicanallY,,MGL chsPoerge 1 "Neither the commonwealth�°f s veins shalt
of public welt uoti7 acceptable of COOPHOW with the insurance
enterof this chapter bon b Costs"for dia �per°Onted to the cottoracdM authority• ENOMMIN
req
APPBp b compictely,by checiang the boxes that apply to-yaa simetion and.if
Pleat till our thsupple C0 s �(s� number(s)parresealpalms� )� W
ea aqd
n"esoMY at Lunized Liability
ineuree". Liability Compwr
uaurance Nan I f C or I I.P don haw
arafcera eompensathr
at pis,are not so4vitrd to cariY be submitted to tha Department of hrdustisi�
members a policy is ntpdmd. Be advised that ha may
to alp and tine W a®davlt. The afAdav+t
employ"
i�for ran8tmatlori°f 1°�000 coveraga
Department Of
be returned to the city or town that the application file the permit or license is being requited.�as wmk6 '
Should Yen have say questions regarding the law a if you are required should enter their
compenutim policy.p�pit the Departinmt it ln&utrw the number listed below. Self-imt:ed companies
self iaatrtmea lloenr member oa tha
City or Town OAklab Department has provided a spats at the bottom
Please be sure that the affidavit is complete and printed legibly. The ions has
of the affidavit for you to fill out� event w�°�be u�as a�ference numbers in addition'an applies
Please he sure to fill in the permi . lots in any given year.need only submit one affidavit indicating current
that nowt submit multiple pamit/ltcemQ app the a should writs"all locations in---(city or
policy inforreadon(if neceaaaty)and under-job Site Address"ills the city of town may be provided to the
town):"A copy of the affidavit.that has been officially stamped or mstluh d� A now af"-&vu must be filled ever each
applicant as that a valid aiidsvit is on file for!Mutt or permits not or eommetcial venture
Yew.Where s home owner of eitlzen is obtaining a license is proms qu related to any business
or to burn leaves use.)said peso°is NOT required to complete this affidavit
(i.a. a dog lice°°° permit nand should you h1VQ any Queatio»a.
The Office of Investigations would like to thank you in advance for your cooperatio
please do not hesitate to give us a call.
The Department's address.telNbO°e IU v Wth of ML awb11SettS
of Iadt Oid Accwnta
OAU@ of Iff"d;ndong
600 W"hWPA Sant
gout%MA 02111
TeL M 617-727-4900 eA 406 of 1-877-MASSAFE
Fu 0 617-727-7749
Revised 5-26-05 VYVYVV.mL4t.8ov/din
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Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 134775
Type: Ltd Liability Corporation
Expiration: 1/17/2008
PORT CITY BUILDERS & RENOVATION LL
WILLIAM CLOUTIER
162 ASH ST.
W. NEWBURY, MA 01985
Update Address and return card.Mark reason for change.
;-CA1 0 5OM-04106-PC6698 Address Renewal Employment Lost Card
CrrY op SALEm
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BOARD OF BUILDING REGULATIONS r
e License: CONSTRUCTION SUPERVISOR
Number: CS 053486
a, Birthdate: 07/01/1969
Expires: 07/O1/2007 Tr.no: 3179.0
Restricted: 00
WILLIAMT CLOUTIER
ASH ST W �j
NEWBURY, MA 01985
Commissioner
r '
CONTRACTOR'S NAME: PORT CITY BUILDERS& RENOVATORS, LLC
ADDRESS: 2 MARTEL WAY
GEORGETOWN, MA 01833
PHONE: 978-352-8830
FAX: 978-352-8851
LIC#: CS 053486& HIC 134775
FED ID#: 01-0670339
DATE: April 7, 2007
OWNER'S NAME: David &Bonnie Henry
ADDRESS: 38 Summer St., Salem, MA 01970
PROJECT ADDRESS: 38 Summer St., Salem, MA 01970
I.PARTIES
This contract(hereinafter referred to as"Agreement') is made and entered into on this
the 7t" day of April 2007, by and between David& Bonnie Henry, (hereinafter referred to
as"Owner"); and Port City Builders& Renovators, LLC (hereinafter referred to as
"Contractor"). In consideration of the mutual promises contained herein, Contractor
agrees to perform the following work:
II. GENERAL SCOPE OF WORK DESCRIPTION
The Contractor proposes to renovate the existing dwelling based upon the attached
scope of work referenced as"Henry 3rd Floor Renovation", dated 4/7/07 (Refer to
Attachment'A') and Henry Interior Renovations, date 4/7/07 (Refer to Attachment'B')
LUMP SUM PRICE FOR ALL WORK ABOVE: $59,650
III. GENERAL CONDITIONS FOR THE AGREEMENT ABOVE
A. EXCLUSIONS
This Agreement does not include labor or materials for the following work(unless Owner
selects one of these items as an Additional Alternate):
1. PROJECT SPECIFIC EXCLUSIONS:
• Design drafting
• Lighting fixtures
Window hardware
2. STANDARD EXCLUSIONS: Unless specifically included in the "General Scope of
Work"section above, this Agreement does not include labor or materials for the
following work: Plans, engineering fees, or governmental permits and fees of any kind.
Testing, removal and disposal of any materials containing asbestos (or any other
hazardous material as defined by the EPA). Custom milling of any wood for use in
project. Moving Owner's property around the site. Labor or materials required to repair
or replace any Owner-supplied materials. Repair of concealed underground utilities
not located on prints or physically staked out by Owner which are damaged during
construction. Surveying that may be required to establish accurate property
boundaries for setback purposes (fences and old stakes may not be located on actual
property lines). Final construction cleaning (Contractor will leave site in "broom swept"
condition). Landscaping and irrigation work of any kind. Temporary sanitation, power,
or fencing. Removal of soils under house in order to obtain 18 inches (or code-
required height) of clear space between bottom of joists and soil. Removal of filled
ground or rock or any other materials not removable by ordinary hand tools (unless
heavy equipment is specified in Scope of Work section above), correction of existing
out-of-plumb or out-of-level conditions in existing structure. Correction of concealed
1
i f
EI'I'Y-OFSXLE,C
PUBLIC PROPERTY
DEPARTMENT
MAYOR 120 WASMNGTON MVEEr•&M.H ,N,hSAC1iLSM-S 01970
Tt7.97e-74i959S•FAX 978.740.99"
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTIONS
DEM, OLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1 AE�TEFORMATIONLome: D-pj;: .e Building:
Prdress:
Property is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address: �r� J ,, �., pJL ti\C��, VLn lLG
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
Rdpl Description of Proposed Work:
r
qe J r���l r.✓ c w(ti V15 k c e`� 1 t ��.5. L1�c (fit J
--- --- ---Mail Permit to: Ct%,_,�1 -"I S "► . / ac4vU Z7 ti ltor/9 Gf6'��
What is the current use of the uilding?
Material of Building? if dwelling. ho many units?
Will the Building Con t �l ?^ a Asbestos?
Architect's Name
Address and Phone
Mechanic's Name "Y ''�
Address and Phone �-*hl S� w, lit^ltk 0�8'33 7�
Constnution Supervisors License# �-S US3`( � NIC Registration# 13` 177
Estimated Cost of Project$ Permit Fee Cakulatim
Permit Fee$ �' 'O Estimated Cost X$7/111000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional$5.00 is added as an
3 3`� 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 b 'Id t above stet
specifications. Signed under penalty of perjury X
Date
of
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