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OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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Como Construction Q.,
45 Bowler Street
Lynn,MA 01904
Phone: 781-581-5490
Cell: 781-953-0446
Fax: 781-581-5493
Construction Supervisor License# 75917 Home Improvement Contractor Registration# 148139
Serving Massachusetts and Sou them New Hampshire since 1974
We accept MasterCard& Visa
Angelo Zervoulias May 29, 2006 revised June 25, 2006
62 Hathorne Street
Salem, MA 01970
Scope of work: Build bay garage with second story storage area
Demolition: Remove and dispose of, off site, existing 4 bay block garage except for the
bottom 3 rows of block and the existing slab.
Electrical: Install new 100 AMP sub-panel. Install receptacles along the back wall of
each bay and a receptacle in the ceiling for the each door operator. Install a 4' fluorescent
light fixture in each bay. Install one motion sensor light fixture near the side entry door
and two motion sensor light fixtures on the front of the building. Install receptacles along
4 walls on the second level and 2- 8' fluorescent light fixtures.
Plumbing: None
Carpentry: Construct a 4 bay two-story garage with a hip roof. Install a 36" wide rough
stairway to second level with plywood treads and risers. Install one 36" x 80" steel door
unit on the house side of the garage. All wall framing will be 2" x 4" construction. Two
door openings will be finished to except 8' x 7' metal overhead door units and one bay
will receive a 16' x 7' metal overhead door unit. There will be 2"x 4" stud walls
between each interior bay with CDX plywood sheathing. The roof will be framed in
hip style and receive asphalt roof shingles. There will be 8—24310 Series 8500 vinyl tilt
take-out windows- 2 on each end and 4 across the front on the storage level.
The wall sheathing exteriors will be covered with vinyl siding. There will be aluminum
gutters and downspouts on two sides.
Overhead doors: Install 3 metal overhead units with electric door openers and remote
control access.
Page 1 of 2
Page 2 of 2
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 this estimate. All agreements are contingent upon strikes, accidents
or delays beyond our control. Building owner will carry fire and other necessary
insurance upon above work. Public Liability insurance on the above work will be
the responsibility of Comito Construction and their sub-contractors.
All material is guaranteed to be as specified, and the above work to be
performed in accordance with drawings and specifications submitted, if any, for
the above work and completed in a substantial, workmanlike and timely manner.
On all projects over$1,000.00, please read the State Board of Building
Regulations and Standards form accompanying this proposal. If you agree that the
contractor has met all the requirements, please sign it and return it with your
signed proposal. If you have any questions regarding the State Board of Building
Regulations and Standards form or the proposal, please call the contractor for an
explanation.
DO NOT SIGN THIS CON77?ACTIF THERE ARE ANY BLANK SPACES.
Total materials and labor: $62,500.00
Materials deposit: $27,500.00
Due after framing is complete $27,500.00
Balance due upon completion: $7,500.00
Respectfully submitted: Accepted:
Lxh�' AaJV4'x Q
Rlt�y Co6to Angelo ouli
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOII.
MAYOR
120 WASrINOl'ON$'miEET* SAt.EM,iVtASSACHGtiETIS 01970
TEL:978-745-9595 ♦ FAx:978-740-9846
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:
(name of hauler)
The debris will be disposed of in :
-- (name of facility)
(address of facility)
signature of permit applicant
date
d6tisaf.doc
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOIl
MAYOR
I20 WASHINGTON$'I'RF..EI'♦$ALEM,ist:t.SSACHliSE11S 01970
TEL978-745-9595 • FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information f� Please Print Leeib[V
Name (BusinecsiOrganizatiordindividual)ypsm*lt,
Address: rot 1p"% 6 a x fk
City/Statc/Zip:-.Sc,1\oty_ Phone 9:
Are you an employer"Check the a_Vpropriate box: Type of project(required):
I. I am a employer with 1 4. ❑ 1 am a general contractor and 1 6. ❑New construction
era to ces full and/or art-hlllc).* have hired the sub-contractors
p Y ( P 7. Q Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet i
ship and have no cmployces These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp. insurance. 9. Q Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.Q Plumbing repairs or additions
myself.(No workers' comp. c. 152,§1(4),and we have no 12.Q Roof repairs
insurance required.)t employees. [No workers' ME]Other
comp. insurance required.]
-Any,,plicaut alas checks box 41 most also fill out the scaian Wow showing their workers*compemution policy inhumation.
'1Lomwwners who submit this affidavit indicating they are doing all work and then hie outside contrreson must submit a new affidavit indicating such.
�Conuactun dial chuck this box most attached an additional shoot showing the name of the sub-contractors and their workers'comp policy information.
I am an employer that is providing lvorkers'compensation insurance for my emplayees. Belosv is the palicy and job site
iafonnatiort.
Insurance Company Name:---.--..,
Policy#or Self-ins. Lie.#: ____..___ Expiration Date:
Job Site Address: ChyistateiZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure Lo secure coverage as required under Section 25A of:vlGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 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 veriticatiun.
I do hereby ce fy larder the pains and penalties of perjury that the information provided above is true and correct.
Sienalure: D te: r, -2C" O ,
Phunc±i:
79Z- '>(S'4 e
Official use only. Do not turite in this area,to be completed by city or to un official,
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Ilealth 2, Building Department 3.City/(own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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."
� 1
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 nunmber(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 retumed 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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/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 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 bur leaves etc.)said person is NOT required to complete this affidavit.
1'hc Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate tagive'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
Revised 5-26-05 Fax#617-727-7749
www.i-nass.gov/dia