44 BRITTANIA CIR - BUILDING INSPECTION (3) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Worlters' Compeandon Insurance AfAdevit: Builders/Contracton/EleetrldneWPlumben
ApDlICant Information Please Prtat Legibly
/'
dame lau.inl:ssnkyniratiorltlmhvldtmn: IPM,�,y\ C n
Address: 13 `('n „ 4 tl- RJ
city/state/zip: 5 a Ion (Y1 c of J zit Phone a: I -7�_g36~�j 6 r
Are you as easpleyor7 Cheek the appropriate box:
1.0 1 am a employer with 4. 0 1 am a garunal contractor and 1 rya of project con (►coon
6. New construction
mpluytxs(full and/or pint-tine).• have kited the sub-cumncton
2. 1 am a sole proprietor or panrter- listed oo the attached sheet t 7. XRemodoling
ship and have no emph*om Them wb•eoauaaora have IL ❑Demolition
working rot me in any capacity. workers'comp.insurance.
9. 0 8uildiag addition
(No workers'comp. insurance 3• ❑ We errs a corporation and its !0. Electrical
required.] officers have exercised their repairs or additions
3.Cl I am a homeowner doing all work right of cxempdon per MGL 11.0 Plumbing repair%or additions
myself.(No workers'comp. C. 132,#1(4),and we have no 12.0 Roof repairs
insurance required.) t employees.(No workers' 13.❑Other
comp. insurance mquirmi.)
•Aiq.p kind the ebxb boa al non a W rill I%II elf Mena Ilelme rhowiaa heir wurko'eump m,"pdiry iofllreWioLL
'Ilw,wrwrem who whnit NIt amewll iadkaitls Noy am&V%Sit waA Sae Iha hhe anise coamoa%anti aubnil a rww aalea•il i%ialina.II.i.
-C w rmm the chak Nice bit must aaaelld ere WIA1110041 Axel Mwinp Me name of ale subcoameem yd thee wuAwa'camp.pWlcy wharamat.
I an an empleyer that Is propldlnll workers'cotapetaraden lsuurats"jot my employers Below is the poHiy and Job nib
in/orueatlaa,
Imurancc Company
Policy a or Sclr-ins. Lie. 0: _ .. Expiration Date:
Job Site Addrua: CilyislatuZIP:
Attack a copy of the workers'compensation policy doclaralloa poke(showing the policy number and explratlua d t
Failure to wcum coverage as required under Seclion 25A uf.IGL c. 152 can lead to the imposition of eriminal penalties of a
rim.up to 51,500.00 and/or one-year ilnpris"I"emt,as well as civil pcnallics in the form ofa STOP WORK ORDER and a run
,)full to MOM a day against the violator. lie advised that a copy urthis slataanlnl may be lbrwarded to the ORice of
Ll\;.hgaumts ul dlc DIA Per insurarcc coverage vcrirtutiun.
!do hereby cerlify under the ' s and penulrirs a/perjury that the lnforaalkm provided above,is true and correct
ii-evun,rT_ Dare _
FA 11:9
6- SE5
0ffkiaf usr am#t Be not write Is fhb area,to tea cuaplete rby city or town a plrlld
City or Town: Pcrmit/Wecatt M
1%swing Aulburity (circle one): _
1. Ruard ur llraltb 2. Building Department 3. City/rowa Clerk J. Electrical Inspector 5. Pl71aspector
6. Other
Gnllael Person: _ Phone p:
Information and Instructions
Massachusetts General Laws chapter 132 requires•ell employers
workers*anotherceu�der any owned of hire.
Pursuant to this stands,an eat09W is defined a`...every person
anpress or implied,oral or writte&"
aaotiauoa,corporation tr other legal entity,or any two or more
An rsie/MPa u de8aed tr"as iadwidusl,paeaterahip to er.or the
of the foregoing cngolped in s Joint esteWiM and including the legal representatives of a deceased tromp y
association at other legs!entity.employing employes However the
receiver or tnustns of as individual,parmerahtP. end who resides therein or the oeeuprw of the
owner of a dwelling house bevies not more teas,muse apartments work on such dwelling haste
dwelling bo uss of another who employs peter to do maintenance.awartuctioa at repair
of on the grounds or building appurtenant miens&hoer not locusts of ad empWyame be designed to be an employer."
or
�tGL chapter 132.423C(b)sin stores dot"wery$tote or local aes.$l g ageney seta wkbb*M the lase ssea
a operate a buslnsa or to eoustrser bWldhW Is the commonweaNh for say
reuwal of a Gees o or permtst Ps with the Issarsace coverage requlrW
applleast wbe bag not produced aexeptabN wfdstec of eompaose areal Lbtiivisioer AWl
�(Iditioaally.MGL chapter 152,;23C(7)states"Neither the commonwealth ant any of its.pol'
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."
Applkasst ,
affidavit completely.by clucking the boxes mar apply to your situation rod,if
Please fill out the workers'compensation$ tea)and photo awnbes(s)along with weir certiRcau(a)of
necessary.Limb Lb�ontrsceoe(s)° )' LLP with no employees other then the
insurance. Limited Liability Companies(LLC)or Limited Liability (If an LLC or LLdod have
members or pactoen,an not required to carry workers compensation
crtP toyed.o policy is required. Be advised that this a ffidavit may be submitted to the to the Department
affidavIL of Industri of a should
Accidents for confirmation of insurance coverage' Ahw sun to alga a
be rctumed to the city or town mat the application for this permit a license is being requested, not the DeParnneat 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
,elf-insurance license number on the appropriate lam•
City or Town Offlelab
Please be sure that the affidavit is complete and printed legibly. The Department has provided a speed at the bottom.
of the affidavit for you to fill out in the event due Office of investigations has to contact you regarding the applicant
!'le ur
ases be se to till in tha permitllicense number which will be used as a reference number. In addition,an applicant
that must subunit multiple Penn
ivlicense applications in any given year,need only submit one affidavit indicating current
te Addrca"the applicant should write"all locations in __(aity or
policy information(if necessary)and under"Job Si
town)."A copy of the affidavit this 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 licensee. A new affidavit must be filled out each
year. Where a hams 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 burn leaves CO.)said pawn is NOT required to complete this affidavit
I'he Ot lie of Investigations would like to thank you in advance for your cooperation and should you have any questions,
:case du nut hesi(ate to give us a call
The Department's address.telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Omen of[avutlptlow
600 Washinswis Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
;toi.Ned 3.26.05 www.man.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR'TNUM
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Construcdom Debrb DisQosad Affidavit
(r%uimd fbr aU dmalifiom and satwvatiatt worst)
t4 aet:onituw w ith du dzdt edldos of the Stsse Buil ft Cods;730 CbQ smd" i I I-S
Oaxi4 and do provisWO of MM a 406 9 SR
8uildin4 Ponds f _ _ is issued with the mWidem that dtt debris mUldng AM
this watt shall be disposed of in a proptrty cleansed waste disposal facility as dented by WX e
ttt.415"
The debris twill be transpoRed by:
Iuame ar hoda)
rho debris will be disposed of
in:
�.MaA.a J(fx:Ltv1
..a4t
This CONTRACT satisfies all basic requirements of the states
Home Improvement Contractor Law (MGL c. 142A), but does not
preclude parties from adding language to protect their specific
interests. Seek legal advice if necessary.
Homeowner Information
Phillip and Darci Mehall
44 Brittania Circle
Salem, Ma 01970
1-978-594-5458
Contractor Information
Teheen Construction
13 Intervale Road
Salem, Ma 01970
1-978-836-6969
Michael Teheen
Ma Lic. CS 089623 exp. 6/29/2008
HIC Reg. 149787 exp. 2/9/2008
WORK TO BE PERFORMED AND MATERIALS TO BE USED
Contractor Agrees To Do The Following Work For Homeowner:
Removal of the existing cabinetry and counter tops and installation
of new cabinetry and trim. Installation of new kitchen appliances
and installation of a new bath vanity and toilet.
Materials Expected To Be Used: y
Materials required for completion of the work include:
Cabinet hardware
a
The following schedule will be adhered to unless circumstances
beyond the contractor's control arise:
Work Scheduled To Begin: 01/16/2008
Expected Date Of Completion: 01/25/2008
TOTAL CONTRACT PRICE AND PAYMENTSCHEDULE
The Contractor agrees to perform the work, furnish the material
and labor specified above for the
SUM of. $9,500
Payments will be made according to the following SCHEDULE:
$500.00 upon signing contract(*Not to exceed 1/3 of the total
contract price OR the cost of
special order items, whichever is greater*).
$4,000 upon commencment of work
$5,000 upon completion of the contract
In order to meet the completion schedule, the following
material/equipment must be special ordered before the contracted
work begins:
1 d S`
Homeowner's Signature ate
-- �� T s
Contractor's Signature Date
No work shall begin until both parties sign the contract and
the owner has a copy of the contract.
ARBITRATION
The contractor and the homeowner hereby mutually agree in
advance that in the event the contractor has a dispute concerning
this contract, the contractor may submit such dispute to a private
arbitration service which has been approved by the Secretary of
the Executive Office of Consumer Affairs and Business
Regulations and the consumer shall be required to submit to such
arbitration as provided in M. .L.c.142A.
Contractor: ���,�{ '/J
Date: D
Homeowner: V)/VAZO
Date: 6g
REQUIRED PERMITS
The following building permits are required. It is the obligation of
the contractor to secure such permits as the homeowner's agent:
Building permit, plumbing permit, gas permit
NOTE: Owners who secure their own permits or deal with
unregisteredcontractors are excluded from the Guaranty Fund
provisions of MGL c. 142A.
NOTICE OF CANCELLATION
YOU MAY CANCEL THIS TRANSACTION, WITHOUT
PENALTY OR OBLIGATION, WITHIN THREE BUSINESS
DAYS FROM THE ABOVE DATE. TO CANCEL THIS
TRANSACTION, MAIL OR DELIVER A SIGNED AND
DATED COPY OF THIS CANCELLATION NOTICE OR
ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM
TO [Name
of Seller], AT [Address of Seller's Place of Business]
NOT LATER THAN
MIDNIGHT OF Z vy (date).
I HEREBY CANCIL THIS TRANSACTION.
Date: /ZI.516g
Buyer's gigniture:
No work may
begin until this
time expires.
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CITrOFgALEX
PUBLIC PROPERTY
DEPARTMEINT 2
ra.978-745-9S"0 FAx,97s.740.9s"
APPLICATION FOR THE REPAIR. RENOYATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY VaSTIN
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Addresr.
rq ' r L
Properly Is located in a;Conservatlon Area Y/N Historic DWbkt Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Wye
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New O
Demolition Existing
Approximate year of Area per floor (sQ Renovated
construction or renovation
of existing building g` New
Brief Description of Proposed Work: A
---- - - --- Mail Permit to:. -- - -
ILL n l fl ,�•.1
What is the current use of the wilding?
Material of Building? If dwelling, how many units?
Win the Building Conform to Law? "�k S Asbestos? �
. CIA
Architect's Name
Address and Phone �� LL ( 1
Medutnids Name
C \,EYE$ xA L "', �
Address and Phone l�J ln�rj )411 5t -p
Construction Supervisors License X 6�6Z3 HIC Registration ft 7
Estimated Cost Of�P�rajjeed$ y Permit Fee Cala Mm
Permit Fee t Estimated Cost X$7151000 Residential
Estimated Cost X i11/51000 Commercial 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
ttttoo build to the above stated
specifications. Signed under penalty of perjury
Date I ZIIZQ
b
0 2W a
02
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