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14 HERSEY ST - BUILDING INSPECTION CYPY OF SALEM PUBLIC PROPRERTY ` d DEPARTMENT ..v ■,rt• ,,a..+a L al,u l'l r.�tN::oui 7tER•SA UM.WAVL1r:h1*&'Ir LI Construction Debris Dispossf Afiidsvit (reyuimi for an demolition and mnovadon work) In =onbmc with the sixth edition oohs State Building Cods,7110 CUR section l l l.S Debris,and the provisions of M. GL c 40.S $* Building Permit 0 _ . _ is hom d with the condition that the debris nmddn' Doan this work shall be disposed of in a proparly licensed waste disposal fbcility as dented by\dGL.c l 11.9158A. The debris will be transported by: C Z— Lt/ t/ (nam of haul&) rho&-btis will be disposed of in : s oz ACORDN CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDfrn-Y) 04/02/ZO07 04/02/200i PRODUCER (781)447-5531 FAX (781)447-7230 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mason & Mason Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 458 South Ave. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Whitman, MA 02382 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Meaghan Walker INSURERS AFFORDING COVERAGE NAIC# INSURED A uma T t, Inc. INSURER A. Western World 000071 SO Getchell Way INSURERB: The Travelers Indemnity Company 256S8 Canton, MA 02021 INSURER C: Penn America INsuRER D: Savers Property & Casualty Ins. 000203 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MATH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POUCYEXPIRATION DATE IMMMD/YY1 DATE(MNUDnIrf)O uMITS GENERAL LIABILITY REN OF NPP1011831 04/01/2007 04/01/2008 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ S0,OO CLAIMS MADE OCCUR PREMISES(Ea—ss-4 MED EXP(My ena parson)\ $ 1,OO A PERSONAL S ADV INJURY S 1,000,00 -' GENERAL AGGREGATE S 2,000,00' GE AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPA G S 1,000,00 X POLICY PRO- ECT OC AD MOBILE LIABILITY BA424D7o1807SEL 04/O1/2007 04/01/2008 COMBINED SINGLE LIMIT ANY AUTO � (Ea a derv) S 1,000,00 ALL OWNED AUTOS X SCHEDULED AUTOS i BPeDIL )INJURY S B X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Pere ded) $ PROPERTY DAMAGE $ (Per ac nt) GARAGE LIABILITY AUTO ONLY- EAACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSNMBRELLA LIABILITY REN OF SUB1014078 O4/Ol/2007 04/01/2008 EACH OCCURRENCE $ 1,000,00 OCCUR CLAIMS MADE AGGREGATE $ 1,000,00 DEDUCTIBLE E X RETENTION g lO,OO S WORKERS COMPENSATION AND REN OF WC0002363 04/Ol/2007 04/01/2008 WC STATU- X OT EMPLOYERS'LJABIL BY I D ANY PROPRIETDR/PARTNER(EXECUTNE E.L EACH ACCIDENT $ Soo,OO OFFICERRdEMBER EXCLUDED? OFFICERCS) INCLUDED 11 yes,des under EL DISEASE-EA EMPLOYE $ 500,00 SPECIAL PROVISIONS Below OTHER E.L.DISEASE-POLICY LIMIT S S00 00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS perations: Home Improvement, Installation of windows, doors, vinyl siding, roofing CE T FICA T O DER C C ELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Hartwell Exteriers BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABIUTY 50 Getchell Way OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Canton, MA 02021 AUTHORIZEDREPRESENTATIVE ACORD 25(2001/08) CACORD CORPORATION 1988 BAa�tl 9F 9u#di.ng Regulations and Stagdo - IM��ttyjYEMENT CONTRACTp License or registration valid for individul use only HtlIf7E (2`" before the expiration date. If found return to: Registration: 100468 Board of Building Regulations and StandardsI Wki - Expirativn: 6/18/2008 One Ashburton Place Rm 1301 Type: Supplement CardBOston,Ma.02108 ALIJMABILT, INC JO$EPH FOX / 50 GFTCHELL VJAY CANTON MA 02021PIM�� r Nithout signal re � I el I j�C ! rI ,d AP D III L ! 'Ot t 3 L. CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT nr\tla'R[F.Y aaetk:ULL �i.vYaa l2r.Vlasmw'roty STREET a Satgst,lttmAct n a7 rtx 0197. Tea:978-745.9595 a FAX:97a-74c.9946 Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumben Anallcant Information /) / — Please Print Leeibly Name ttu-im uA)gpniratiiowIndiv/Must): [�} 2— yYl /� t ` (y T�v Address.�� G LTV 1 �,��/ C itylsmteiZip:eft-v7a"✓ ,v(A Phone M °7 71 —2l/0 3 — 2 CrJ A,rc�yo an employer?Cheek the appropriate box: Type orproject(required): I.Ly'I •rm a employer with / Co 4. ❑ 1 am a general contractor and 1 6, ❑ New construction employees(full and/or part-time).` have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 7• ❑ Remodeling ship and have no employees These sub-contractors have a. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition f Ko workers'comp. insurance S. ❑ We are a corporation and its 10. Electrical re requircd.) officers have exercised their ❑ pairs or additions 3.❑ 1 am a homeowner doing all wort right of exemption per MGL 11.0 Plumbing repairs or additions myselL(No Workers'camp. c. 152,§1(4),and we have no 12,Q Roof repairs /(� insurance required.j t employees. (No workers' 13.�ther C a l� comp. insurance required.] •A,q applicar that elw•eka boa el mea also rill at the.scrim bcbw dtowia tlrsir wurtota cum* e paarn moats iafurmairat• 'I lunw,wron eau subm Mia it affidavit indicating tkY am Juicy all m wk and rhea hoc owrJda euntrscrawrota met sulxnit a race atRJavit inJioaing nark. CaurawK's that chork This box mutt aaached at additional slat showing ilia mono of dts rub-comracMa aM their wurtnn'rnnp.policy infMmatios. /am an employer that is providing workers'compensaden Lnsarance for any employdex, Below is the polity and job oe injarmmion. Insurance Company Name: tl Pit S' V Policy gorScir-ins.�r Lie. 0: /-UCH ��) /tit3� r pirruonDate: Job Site Address:,/ >°�!SP✓ S,� Y/C pOt �� CilyiSlatVzip:Q /q '-70 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 uf.IGL c. 152 can lead to the imposition of criminal penalties ofa tine up to S1.500.00 and/or one-year imprisomncm,as well as civil penalties in the form ora STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Ile advised that a copy of this slatr:tncnt may be forwarded to the Office of Inv;angariutu ul'thc DIA for insurance coverage verification. l do hereby cersijy use he pains mid penalirs of r cry that t/re information provided above is true and correct tii•n:uure' r-,' Date /O 78 /- �� j 77 ,Z / tl/jWa a)•e only, Do not write in Nfis Orem,ro be rumrp/eted by city of fawn ofjleild City or Town: PermitlLicense A Issuing Authority(circle one): -- 1. Iluard of Ilealth 2. Building Department J.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone N: Information and Instructions ,%tassachuseus 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, empress or implied,oral or written" An ewOluyer is defined as"tm individual,partttashhp. 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 of trustee of An individual,partnership.association or otter legal entity.employing employees. However the than carve apartments and who resides therein.or the occupant of the owner of a dwelling house having not mere struction or repair work on sorb dwelling house dwelling house of another who employs persons to do maintenance,con or on the grounds or building appurtenant thereto wall not because of such em at be deemed to be as employer ployme " StGL 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 commonweslth for say applicant who Yea a"produced acceptable evidence of compllsnee with the Insurance coverage required." Additionally.MGL chapter 152,§25C(7)states'Neither the commonwealth nor any of its political subdivisions wall enter into any contract for the performance of public work until acceptable evidence of compliance w ith 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 art if necessary.supply sub-contractor(s)name(s),address(es)and phone nwnber(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 afndavlL 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 Indusriai Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Depatment at the number listed below. Self-insured companies should enter their self-insurance license number on the a cute line. City or Town O(f clsb 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 rill out in the event the Office of Investigations has to contact you regarding the applicant. please be sure to fill in the permtitllicense 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 rile 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I'he 01111cc 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 Onus of lavesdsadoos 600 WashwSM Street Boston,MA 02111 Tel. #617-7274900 ext 406 or 1-877-MASSAFE Fax k 617-727-7749 Revised 5-26-05 www.mass.&ov/dia re 'IQ iJ /'Kir lv•rrt,,•- 1 "G vvvi " F>1�`-CI�.tJ� p CONTRACT TERMS AND REQUIRED NOTICES HARTWEM Notice:All home improvement contractors and subcontractors engaged in home improvement contracting,unless,specifically exempt from registration by the provisions of Chapter 1 42A of the general mW laws, must be registered with the Commonwealth of Massachusetts.Inquiries about registration a Er arw0® crtstatus should be made to the Director,Home Improvement Con or Registration,0 hburt Vn tlLTmz"" M+,�,w mi Place,Room 1301,Boston,MA 02108. t� M 1959 K� ^t� 50 Getchell Way, Canton, MA 02021 781-963-7900 I/We hereby agree and authorize you as contractor,to furnish a ecessary materials,labor`a-nddJwVorkmanship,to install,consWct and place the improvements according to the specificca/ayy'mm//ggs,terms an /opdi,tipor��s on the premises below described,which IANe represent that we have good record title in our own name. Owners Names /�/2 tJ� ] /P� T76 — Home Tel. No.,4; tg�•ar5� Bus.Tel. No b7� e-mail Job Site Address � Ci ST 10- 0 - - — Massachusetts Contractor Ri4iistration # 100468 R ode Isl d Contractor Registration # 17166 Work Specifications described attached on pages: _ Z of�, of I of Permits: The contractor agrees to apply for and obtain all construction related permits(Building/Electrical/Plumbing)but shall not be deemed responsible for delays in the work described in this agreement caused by regulatory,permit granting or inspection agencies,authorities or individuals. Notice:The homeowner who secures his own permits will be excluded from the guarantee fund of MGL Chapter 142A. Price:The contractor agrees to do all work described by the contract for the total price of $ Notice: No agreement for home improvement contracting work shall require a down payment(advance dep it) of more than one-third of the total contract price or the total amount of all deposits or payments which the contractor must make,in advance,toprdder/and/or otherwise obtain delivery of special order materials and equipment,whichever is greater. yr � -7/� D7 7� f/ Payment Terms: Advanced Deposit $ �JJ — Payable on sign ng of ontract Interim Payment 1 $ Payable Interim Payment 2 $ Payable Final Balance $ 41Z X7� Payable Security Interest: Yes No -To be held in the form of a UCC-1 form to be filed only if payment is not made on completion. Notice:The contractor does not have the right to request payments in advance of the times set forth in this agreement,although,by agreement,the parties may jointly agree to escrow any portion of the contract amount. In the event that it becomes necessary for the contractor to employ an attorney to collect any balance due hereunder the owner agrees to pay in addition to the said balance,the costs of chon and reasonable ttom y' ees. Work Schedule: The contractor will not begin wo k or order rgater' Is b ore h ay following the lgm o this agreement unless specified in writing.The contractor will begin work on or about "f' at ring delays caused by circumstances beyond the contractors control,the work will be substantially completed in aZ weeks ays.The homeowner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the contractor shall not be considered as violations of this agreement.The contractor shall not be liable for any delay or non-performance caused by strikes,accidents,weather or any other contingency beyond its control. Insurance:The contractor agrees to maintain workers compensation and comprehensive general liability insurance during the operation of this job to cover the acts of its employees and or agents. Warranties:The contractor warranties its workmanship for up to a period of seven years and assigns the rights to any manufacturers warranties to the homeowner after the substantial completion and payment of the contract terms. You may cancel this agreement if it has not been consummated by a party thereto at a place other than an address of the contractor,which may be his main office or a branch thereof,provided you notify contractor in writing at his main office or branch by ordinary mail posted, by telegram sent or delivered, not later than Midnight of the third business day following the signing of this agreement.See the reverse side of this form for an explanation of this right. This instrument and any and all other documents attached hereto and signed by the parties set forth the entire contract between parties and may be modified only by a written instrument executed by both parties. Receipt of a copy of this contract and duplicate notice of cancellation and explanation thereof is hereby acknowledged. HOMEOWNER: Do o ign thi ontract if there are any blanks ace IN WITNESS WHEREO th artie unto signed their names thisday Alumabilt, Inc. Representative Homeowner Accepted Alumabilt, Inc. Homeowner Page 1 of-.,;2, HOMEOWNER: You have a right to a copy of this contract. CQNTRACT WORK SPECIFICATIONS NAff rw EM, to M'ti: S. Mass HIC # 100468 RI HIC# 17166 Initialing this page indicates receipt of the CONTRACT TERMS AND REQUIRED N TICES s page 1 of this agreement. o"g10f o1A `I ffwl °0"O'°` w 171MR est 1959 Owners Names Ltw1/��y Cy g 50 Getchell Way, Canton, MA 02021 781-963-7900 Home Tel. No. iT/IJ/ 7� 7 �13 Bus.Tel.No./� ` 76Z e-mail c� Job Site Address6 S� Clty STAIN— 7 0 Details of work to be performed and materials to be supplied follow 1 "14 df oo S{� mol zF ii/1�rry 9� ,�� ✓s �G��= 3z �I ,� %fir/Cr�� ID S4� 6 -T2y uo 2 Initials Acknowledging this page:Alumabilt, Homeowner 1 Homeowner Date HOMEOWNER: Do not sign this contract if there are any blank spaces. You have a right to a copy of this contract. Page _ of �. � I t ° ' c� �',)�� ✓lam CrmoF 4 PUBLIC P'iVROPERTY DEPARTMENT ,ti M745430 0 FAX M7404 M IN FOR TM RIRFAIIL BIR CommOf USE OR (IMCCUERANMCI FOR A REMNG �LTCI MZ OR B m.D NG to SITE IN omAnoN Loaatlon Name: S -- Property In kxatbd in a;COn"Milon Am MMlorb Oi lat M 10 OWNE 61W INFORMATION 2.1 Owner of Lsnal Name: Address: Telephww. 7 - — O `L kApproximate MPLETE THIS SECTION FOR WORK IN E><ISIW BUILDINGS ONLY n Ex(sdng tion Number of Stories Renovated In Use New on �s�g year of Area per floor (at) Renovated tlon or renovationg building Nmy add Description of Proposed Work: ccyw� --- -- ---Mail Permit to: u«d ttte guildinp9 � S `"� � What is do cuff" Q J. t{dtwaMinp.how many unW ( Mat rtal or Bumw i nY IDti((� Asbedo&7 — Wfr ttte 9uMM Conform to Lawn' /trchmaCs Name I ) Mdra«and PhOw Medwft%Narr►fa Adder and Phone S o HIC Reps+8 Ccr4Wucpn WPOVISM LIC,an«# - EslYnaud Coat ofProjaat'...C)— —OCR Parma F«Cala+iMfo� Eswnaad Cost X VISION ResWer" Parma F«i Estlmated Clot X$41/i1006 C "wrArd ---!4 —_._-- - -- _-._ _ M Addltlonal:6.00 is added as an Adminbt udvs chr'pe' Male aura that aU}lelds a»properly and wRittarr to avoid delays In proweelnp- The and mWod does hereby apply for a SuUdinp Permit to Wu to the above stated pacUlptbM. Signed under penalty OfPWNM s Date �o S �I At r o