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APPLICATION FOR
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PERMIT GRANTED
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INSPECTOR IDF BUILDINGS
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CITY OF S.U.EM, NWSACHUSETTS
BLrmo,,G DEPARTMENT
120 WASHINGTON STREET, 3m FLooR
a TF1.. (978) 745-9595
FAX(978) 740-9846
KI�iSERLEY DRISCOLL
MAYOR T Hows ST.PI£RRa
DIRECTOR of PUBLIC PROPERTY/BU DDZG CONMISSIONER
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 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 MGL c
111, S 150A.
The debris will be transported by:
Arv)V-tCA- n 75tspas&Q
(name of hauler)
The debris will be disposed of in
(name of facility)
I, 5o A✓bo r I/ycw F h A/A
(address facility)
signature of permit applicant
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date
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NATIONAL
ROOFING
ASSOCIATION
DN ® ® Master Elife
MEMBEfl
SXINGL[ROOILR'
Celteidfeed® INDUSTRIES, INC. o..�npnNmlanwmum
ROOFING CONTRACT
Sales Rep:�/ 1a1.1
This ROOFING CONTRACT(this"Contract")between contractor(the"Contractor")and owner(the"Owner")named below
OWNER / /� CONTRACTOR
Name: _ ���' li« �S-5i, SUPERIOR INDUSTRIES, INC.
AddressT.✓/.�2.I(mil iNc� f� 33 Great Road
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City: ad rS R/.�M Shirley,MA 01464
State: M Zip: 888-618-7663cGJ a D'�
EExt: c�
Mailing address(if different): �``)� 5 63, 7 Cell Number
Address: leiP Registration#: 144428 Exp. 10-4-06
City: Federal Tax ID#:043518271
State: Zip:
Day: �/�K- JVS`_Zew Evening: Alt:
We propose hereby to furnish material and labor-complete in accordance with specifications be/OW:
Existing Roof consists of#of Comp layers of Wood layers Ridge to install
Rooftolnstall: Manufacture CXI:G rsr fK r-/ Type L1r Lliyir` . _Color Ohl
Drip Edge ❑ Vented Drip Edge (Color) ❑ Re-lead Chimney ❑ Soffit Vents (4"X16")Approx.Quantity ;� i
This contract is dated tie4 /Yr)/i 2,�;? (Month/DayNear). The work under the Contract is scheduled to begin
on or about lJ L7D/'•� �� 7iC' (Month/Day/Vear)and is scheduled to be substantially completed on or
about (/t &AY, /7/ 2 1 4 (Month/Day/Year); provided, however(i) such scheduled dates of
beginning and completion are subject to change due to unforeseen circumstances,and(if)the Contractor shall have no obligation to begin work until the
Owner has paid the Initial Advance(as hereinafter defined). The scheduled dates for beginning and completion are estimates only,and the Contractor
shall have no responsibility or liability for reasonable delays in beginning and completing the work hereunder. In addition,the Contractor shall have no
responsibility or liability for any delays arising from permitting requirements,the Owner's loan approval and funding,loan disbursement,acts of God,
weather,strikes,lockouts,boycotts,or other local labor union activities,lob changes requested by the Owner,inability to secure materials,labor shortages,
failure of the Owner to make payments when due,delays caused by inspections,changes caused by inspectors,delays by the Owner in making
selections,or any other cause beyond the Contractor's control. _ Nq / /
The work described below is to be performed at the following property(the"Property"): ,i" �� �R✓6 G Las
The following is a detailed description of me Work to be performed and the materials to be used in Ne performance of this Contract R 1 edachedestlmete.
Such work and materials are hereinafter referred to as the"Work." This Contract shall not be construed as requiring the Contractor to perform any
work or to install any items or materials except expressly set forth above. In the event that the Contractor date/ ices that certain materials are not
readily available,the Contractor reserves the right to substitute materials of equal or greater Value. _ r
Prior to the Contractor beginning the Work,the Owner shall pay to the Contractor the sum of$ J(the"Initial Payment")in
advance,which amount(if this Contract is for Residential Contracting)shall not exceed the greater of o e thmd of the total contract price or the actual
cost of any materials or equipment of a special order or custom made nature,which must be ordered in advance of the commencement to the Work.
Thereafter,the Owner shall make progress payments to the Contractor as follows: 1/3 Deposit-113 Middle Payment-113 Final Payment.
The owner is signing below to acknowledge that the Owner has been advised of this cancellation right described In detail on the back of
this Contract and also on the notice of cancellation form.
OWNER: -' -
Print Name: Print Na � k /t'�✓�`-T � r 4F"r
ALTERNATIVE DISPUTE RESOLUTION
(SEE BACKSIDE OF CONTRACT,NUMBER 29,FOR DE AILED DESCRIPTION)
THE CONTRACTOR AND THE HOMEOWNER MUTUALLY AGREE THAT IN THE EVENT THE CONTRACTOR HAS A DISPUTE CONCERNING THIS CONTRACT,THE CONTRACTOR MAY
INITIATE ALTERNATIVE DISPUTE RESOLUTION THROUGH ANY PRIVATE ARBITRATIOI SERVICES APPROVED BY THE DIRECTOR OF CONSUMER AFFAIRS AND BUSINESS
REGULATION,UNDER PARAGRAPHS(a)TO(a),INCLUSIVE,OF SECTION FOUR F EH ME P VEMENTCONT ACTOR IAW.
CONTRACTOR:SUPERIOR IINDY TRUES,INC.By: �_ Date:
OWNER: �� ��• /�-'-l/U.I.IJ e, Print Name: Date:
OWNER: Print Name: Date:
BY SIGNING THIS CONTRACT YOU ARE CCEPTING ALL TERMS AND CONDITIONS
DO NOT SIGN THIS CONTRACT F ER7 ARE ANY BLANK SPACES.
CONTRACTOR:SUPERIOR INDUSTRIES,INC.By: Date:
V44
OWNER: \ ��.., Print Name. Data:
OWNER: ; /1 7k /:/ L'! ql Print Name: Date:
i
INDUSTRIES, INC.
ROOFING GUTTERS RUBBER ROOFS
September 12, 2006
Janet Giarusso
2 Tedesco Pond Place
Marblehead, MA 01945
SXQ+.ri Roof Will Be Hand Nailed Only
1. Details of area to be completed: SEPARATE SUB_ROOF WITH 2 SKYLIGHTS TO RIGHT
M
SIDE OF FRONT DOOR OVER DINING ROO .
2. First step consist of installing a tarp or tarps from the roof to the ground to prevent damage to the
house or to plantings and or the lawn.
3. Next, remove existing 1 layer of asphalt and dispose of properly.
4. Completely de-nail and prepare decking surface for shingle application.
5. Replace any rotted or broken wood(roofing boards) at $2.50 per square foot for lh"plywood ( 5/8"
plywood will be $2.50.)
6. Apply six feet of Certainteed Winterguard along the eaves of the roof,nine feet at the overhangs,
three feet along the sidewalls, three feet around chimneys and pipes,three feet in all valleys and
three feet along the rakes.
7. Next, apply a Certainteed Roofer's Select felt paper to the remainder of exposed roofing area.
8. All wall flashing will be inspected and replaced as needed. Any and all rotted or damaged trim or
siding that needs to be replaced to ensure proper flashing will require a Master Carpenter and will
be billed out at an Hourly Rate plus material cost if completed by Superior Industries,Inc.Any and
all lead or copper wall flashing which needs to be replaced or installed will be done so at an
additional charge.
9. Chalk lines every five inches.
10. Install eight-inch Aluminum drip edge on eaves &rakes. (MILL)
11. Re-flash 2 skylights with manufacturer's flashing kits. Surround and curb with leak barrier.
1-888-618-ROOF (7663)
978-425-0812 Fax
33 Great Road • Shirley, MA 01464
Serving New England
12. All shingles will be fastened using 1 ''/e-1 '/2 hand nails.
`13. Apply a 30 year Certainteed Landmark AR Architectural Shingle
Color: TBD
14. Work site shall be cleaned on a daily basis and all areas will be gone over with a magnet to pick up
the nails.
15. Superior Industries will supply the customer with any and all permits pertaining to the job.
16. Superior Industries will furnish a Certainteed Surestart warranty that entitles the homeowner to 3
full years of non-prorated coverage including labor, materials, workmanship errors and disposal
costs.
17. Superior Industries will supply the customer with a liability ($2,000,000.00) and workers'
compensation ($1,000,000.00) insurance certificate. (All workers are employees,not
subcontractors.) Massachusetts License#144428. Better Business Bureau#83356.
18. Any alteration or deviation from the above specifications involving extra costs will be executed
only upon written orders and will become an extra charge over and above the estimate.
19. Payment to be made as follows: 1/3 deposit due upon signing, 1/3 due halfway through the job and
the balance due upon completion of the job.
20. Any additional carpentry not included in this proposal will NOT be started until roof is complete
and paid in full.
All Jobs to be started approximately 30— 60 days after contract is signed& deposit is
paid
(Pending Weather)
Job Cost $ 800.00 Complete Roofing System
Comments: Skylight replacement would be an additional $800.00 to $1000.00 per skylight depending
on size and brand availability.
Any questions please call me at 978-580-9786. Thanks,Jeff Berube.
T'
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 144428 Board of Building Regulations and Standards
.,ExgKat orr..]b/4/2008 One Ashburton Place Ron 1301
Boston,Ma.02108
k Tyfie Phvale Corporation
SUPERIOR INDUSTF{ S _NC
SEAN GREEN { ,. ... �
33 GREAT RD
SHIRLEY,MA 01464 Deputy Administrator Not valid without signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
j d Office of Investigations
ti ilt
600 Washington Street
Boston, MA 02111
c www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): SUPEIZIOK In1DLLe_>Mas
Address: 33 6P-eAT OD
City/State/Zip:64 1F—tEtJ . MA CI4U4 Phone #: O be) -U10 -7lotpl
Are you an employer?Check the appropriate box: Type of project(required):
1.91 I am a employer with J— 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. ❑ We are a corporation and its
officers have exercised their 10.❑ Electrical repairs or additions
required.] of
3.❑ I am a homeowner doing all work right of exemption per MGL I LE] 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 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 job site
information.
Insurance Company Name: A I &
Policy#or Self-ins. Lic. #: 9U87913 Expiration Date:
Job Site Address: 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.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Siiznature7 �/rl�^ Date'
Phone# ef50 — lip 10 - 74e493
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#:
i _-
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 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
Fax#617-727-7749
Revised 5-26-OS www.mass,gov/dia
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