15 HARBOR ST - BUILDING INSPECTION AUG-23-2007 08 :26 PM Pell
Authorl»ed"
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FOUR SEASONS ROOFING la 'lh0nX ike St.,Event,D LA 02149
AND CONTRACTING INC. Office: 617.387.8333 www1 roofing.cotn
5503
(wick, Clean&Dependable GAF.I Ceuth license
#AL 11706
Matt Philbin
Salem, MA
Rubber Roofing Specifications
1. Area to be completed: Entire Building
2. Building and landscape will be protected as needed 6'om falling debris.
3, Remove o dsting layer of tar and gravel rooting
4. Any loose or rotted wood will be re-nailed or replaced as needed.
5. 100 l.f of board or 100 t,f. of plywood will be replaced at no charge. Above and beyond that the addit ional costs will
bc:-S3J0/l,f of board or$2:25/91 of t,J"plywood
6. Mechanically fatten %s"iso-board with plates and screws to roof sheathing
y. Fully adhere.060 rubber roofing membrane to iso-board
8. New white edge motal will be installed at all roof edges
9. All penetrations will be properly flashed and sealed
10. All necessary permits will be supplied by Four Seasons Roofing.
11. All dumpster and disposal fees are included in the price.
12. The work site will be cleaned on a daily basis and a magnetic sweep performed to pick up all the nails.
13. Four Seasasts Roofing has proper liability and worker's compensation insurance and will supply our cu.tomers with a
certificate of insurance from our insurance company,
14. Four Seasons Roofing offax a 10 year workmanship warranty on at1 complete roof installations
15, Payment schedule: one third will be due upon signing,one third half way through the project and the ba Dance due upon
completion
Ali projeab wW bdVin 2-4 w#wks 4aw the cone'act is signed,pending weothd?
Total Investment: S 10,900.00 Rubber roofing system
Comments: Existing solar panel will be removed. Solar panel should be drained prior to the roof installal ion
Please call me with any ques&ns. Thank YOU, AWWO dli/ko 617.908-8016
1 have reviewed end agree with thejob speci eons described above and authorize Four Seasons Roofing perform work ea s` 8 to P� pooi6od
Cormlow's Signature:_ Date:
Customer's signature:
Date:
I
SUN-26-2007 09 : 10 AM P. 01
qPR-24-2007 02:40P FROM: 70: 16173877150 P.3
COMMERCIAL LINES COMMON POLICY DECLARATION B
*A
* INSURANCE IS PROVID
ED SV THE COMPANY DESIGNATED • ••QNA'MED BY AN X .PENN•AMERICA INSURANCE COMPANY Company
KuRt PENN•STAR I yr * ❑ NSURANCE COMPANY
t3tete control Vumber
A i l Penn
Hatboro, Pennsylvania IiIi Renewal Number W—
POLICY NUMBER: P 6 E
1
?MAKER SPECIAL RIBS
i. NAMED INSURED; 4 Seasons Roa}Inq a Contracting Inc. b1,leneroane �kq
. - waranrv.Mu��MM:rnb sties 0
OBA , `,uxi rse•et,e rsz tea)rat.ee1te•000)el14WO
www.euskenne.eom
MAILING ADDRESS: 18 Thomdlke 8traet V
Everen MA 02149
2, POLICY PERIOD: your Fran 04 10/2007 To 04/,0/2008
Standard Time at mallIn g a dyes shown-&Tov0. —_ at 12:01 A,A'.
3. FORM OF BUSINESSr CORPORATION_- _ -_ - .OTHER OESC:--
4. BUSINESS DESCRIPTION: In IIS& Re Its Residential Lta pa dentlal Roofs
IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POu v,WE
AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY,
a THE FOLLOWING COVERAGE THIS POLICY CONSISTS OF OE PARTS FOR WHICH A PREMIUM I$11I7ICATED.
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT,
Commercial General Liability Coverage a Patt PREMIUM
Commercial Property Coverage Part III; NOT CO
Commercial Crime Coverage Part $ NOT COVES=
Commercial ,p arclAl Inland r g
Professional Liability Covers e parts Part $ � �_
U q $ NOT C
OtJOr Liability Coverage Part ACE
g a
Commercial Umbrella Coverage Part $
Owners Contractors Protective Coverage Part $ NOT
TRIA COVBRSD
Ill
a. TOTAL PREMIUM PAYABLE AT INCEPTION 6 101 3!0 00
AAA 9/L Tax S 4
FILING FEE S �9
INSP FEE S 0. 00
POLICY FEE S (1,. 00
S
TOTAL $ ��!
7. FORM(B)AND ENDORSEMENT(S) MADE APART OF THIS POLICY AT THE TIME OF ISSUE:*
R R O HIS Op CH
E FO M OM9C f c/ 1 ATTA
'Oman appkoable Forms and kndom&rients if shown In specMe Coverage POtt/Coverage Form Declarations.
THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART
DECLARATIONS, COVERAGE PART COVERAGF FORM(S))AND FORMS AND ENDORSEMENTS, IF ANY, it iBUED
TO FORMA PART THEREOF, COMPLETE THE ABO✓E i�iUMBERED POLL Y.
Agency Code; 01146Qer r
Worcamr,�Me of MA, Inc, by hj
A rlaad Representative
RP1 04/18/07
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
atvtaratfr DatSt:ULLL
f•' MArsla 12C WASMK:(ON STREET 4 SALms,IsfnssAc i w,%.-rv%019T'
Tea:97}745.9595 •FAX:9M74d-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/Ptumbers
Appiit:ant information Please Print Legibly
Name tBuaiiwsyOrganizaiiowindivtdmii): �m� ( S r?, o I
Citylstateizip:�' Pc a214 o Phone N: / Z 2
Are you an employer?Cheek the appropriate box: 'type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or part-tine).• have hired the sub-cuntn n cto
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling
ship and have no employactt Than sub eonaacmn have & Q Demolition-
working for me in any capacity. 1 workers'comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. QJAWc are a corporation and its 10.❑ Electrical repairs or additions
nquirerl) officers have exdrcivcd their 3.ElI am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'cornp. c. 152,01(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' 13.�Other N 2 —
comp. insurance required.)
•Any upplicasl this checks box 01 mull also fill as ate section hcluw showing thine wsukats'emstpattsuioo p Aicy iorunrcuiwa
'1 i.rtr eownen who submit this affidavit indixating assay"doing all wort and thin hire outside eomracron must sutunii a now afradava indiasing itch.
�Cotuncmrs thss chair sus box must atliched m additional Wtuat showing the name of the su!-coatrarhan and their work=,comp.puii y information.
END
I am an employer that Is providing workers'compensaton buuralice jar my employees. Below is the pu/icy and job site
information. (�
Insurance Company?lane: Y t- rn 1�✓+,.. r ,Cry. r_
Policy g or Self-ins. Lic. N: `P CLC .CQ 4 SIQ 1 .17-4 ._ ._-- Expiration Date: 47 —I0 — D R .
Job Site .Addruss: I !�E F- ,uIb y—. Sk CityiStata2ip:&—,Ie,, - M a
Artach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Vuilurc to secure coverage as required under Section 25A of.1GL c. 152 can lead to the imposition oferiminal penalties of a
fine up to S1,500.00 and/or one-year imprisomncnt,as well as;civil penalties in the form of a STOP WORK ORDER and a rise
of up to 5230.00 a Jay against the violator. tie advircd that a copy of this statement may be forwarded to the Office of
Imcangauuns ul'ihc DIA for insurance coverage verification.
l do hereby rerti under the psi�s nd prnahies of perjury that floe iufarination provided above is true and correct.
tii,•aamr• _ . � Date• l24y10 z
O/jitial au and. no not sprite in this area to be roar tied city r town a y pI by rye o n /jiriuL
City of Town: __. _ Permit/License
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: . . _ __ Phone p•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
pursuant to this statute,an empoyee is defined as`...every person in the service of another under any contract of hire,
c%ptess or implied,oral or written."
An aaproydr is defined as"an individual,parme-A*association.corporation or other legal entity,or any two or more
of the foregoing engaged in aloint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,prrmershmp,us iation or other legal entity,employing employees. However the
owner of a dwelling hwus having not mnete then three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,cuostruction of repair work on such dwelling house
or on the grounds or building appurtenant thereto shag not because of such employment be deemed to be an employer."
MGL chapter 152.§23C(6)also states that"every state or local licensing agency sbsg withhold the issuance or
renewal of a lieesse or permit to operate a busiaeas or to coastrud buildings In the consmoawealtb for SAY
appllesu who has not produced acceptable evidence of eompthtnee with the insurance coverage required."
Additionally.MGL chapter 153,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any far the
performance of public work until acceptable evidence ofcompliance with the insurance
_contract perto
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(,)name(s),addresses)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 requi red to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidaviL 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 thew
,elf insurance license number on the appropriate line.
City or Tows Official
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 applicane
Please be sure to till in the purmit/license number which will be used as a reference number. In addition,an applicant
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 tilled 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.
1'he Otlicc 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
O®tee of IsvesdPdoos
600 WashingM Street
Boston,MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 11617-727-7749
Rcviscd 5-26-O5 www.mass.gov/dia
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'EVERETT,MA 02149 Admin �„;
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EI'I`�OF
PUBLIC PROPERTY
DEPARTMENT
KINGWA N DRISCL&L
Srwroe 120 WAslulfc.-1m S�tEEr•S"4%&%Ao L.SkI-rs 01970
TVL 976.745.9S"•FAX 973-740.98"
APPLICATION FOR THE REPAIR RENON—ATIOX CONSTRUCTION
DEMOLPPION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: j 44 Building:
Property Addresw—---
--- --
Property is klcated In a:Consamtlon Ares Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name:
Address:
S 1
Telephone: o
3.0 COMPLETE THIS SECTION FOR WORK IN EXISLNLi BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Bdef Description of ProposedWork:
--_-- Mail Permit to: _-- - -
What is the current use of the Building?
Material of Building? S � dwelling,how many units?
WIN the Building Conform to L Asbestos?
aw?
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone 1 g �1 � rn r�
Construction Supervisors License 0H{C Registration#
Estimated Cost of,R 1*ed �. IU`' Permit Fee Calcuww
PertnN Fes i v1 Estimated Cost X$7/$1000 Residential
Estimated Cost 541/S1o00Commercial
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 to build to the above stated
specifications. Signed under penalty of perjury [
Date Z �'
el
96
r � n
x a a
3.
a - � - or--- a- ----- -- -�- 4-
4— . .. .