68 HIGHLAND AVE - BUILDING INSPECTION \ 4 The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'"
assacuse edition
C➢� ' Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo- eO(ing
This Soction For Official Use Only
Building Permit Numb Da e Ap ied: N 0
Signature:
Au
Building Commissioner spectoro Buildings Date
SEC ON 1: SI INFORMATION
1.1 dRroFjert�y/Address•/ 1.2 Assessors Map& Parcel Numbers
I.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(tt)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow er of R cord: /
Name r nt) AddressYdr Service:
S (' 917 9'79 - ��i
Signature Telephone,/
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': 2 it f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multi lier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ ._
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7 a ' 0�
�S �DR�Z
License Number Exp' ation Date
Name of CSL- Helder
O Lis[CSL Type(see below)
�J O
�
Address T Description
U Unrestricted u to 35,000 Cu. Ft.)
R Restricted I&2 FamilyDwellin
Signatur - M Mason Onl
RC Residential Roofing Covering
Teleph000fffiiie _ WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
Y5 Registered Home Im roveme t Contractor(HIC)
i�l,= 4T�ivr
HIC Company Name or HIC Re istrant Name _�^ Registration Number
L O X / 7d a /(/ 0,9 0 7 1r
Add ` d y /D
ra v O�j1 tY94-�FU6 Ex iratio ate
'Sign re eleph e
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1� as Owner of the subject property hereby
authorize 06 anc5 ' to act on my behalf, in all matters
relative o ork authorize by this building permit application. -
—W 2A lo)Y
Si nature of Owner Date
// SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, y'J7O 1-d �---T i 1 A ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. ti / A j
/
Print Nam �
, y�of
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total Floors area(Sq. FL) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
r
' CITY OF SALEM
DEPARTMENT OF PLANNING AND
Kimm'RLEY DRISCOLL. COMMUNITY DEVELOPMENT
MAYOR
LYNN GOONIN DUNCAN,AICP 120 WASEIINGTON STREET♦ SALEM,MMSACRUSEM 01970
DiRwroR T);L:978-745-9595 • FAx:978-740-0404
HOUSING REHABILITATION LOAN PROGRAM
WORK WRITE-UP
PROPERTY INFORMATION:
August 12, 2008
Homeowner: Amanda Cutone Date: REV: August 21, 2008
68 Highland Ave. Salem C'e� 97A — q 7c(— V V 1 a
Prepared by: Cliff Ageloff Case #: 09-01
Housing & Construction Consultant
1. LICENSE: The contractor must meet all local and State licensing requirements and be duly licensed.
2. INSURANCE: Contractor must show proof of adequate liability insurance and workmen's compensation
-coverage be provided.
3. PERMITS: The contractor must obtain all required building permits prior to starting work. Copies of the
required permits must be submitted to the Housing Program.
4. CODE REQUIREMENTS: All workmanship must conform to the Program's guidelines, all applicable
Massachusetts Building Code and local codes and must be of acceptable quality, as determined by the
Housing Programs Inspector.
5. WORK AREAS: The owner must completely remove all furniture, stored items and other obstructions in the
work areas identified herein. Items must be moved to a non-work area and covered by the owner or
relocated to temporary storage as needed. Neither the Program nor the Contractor is responsible for
owners' items improperly relocated during construction. Work cannot proceed unless work areas can be
freely accessed by the contractor(s) on a regular basis during the term of the contract. Failure to provide
regular and unfettered access to work areas may be cause for contract termination.
Contractors are responsible for verification of field conditions. measurements and quantities
Submission of a bid is presumptive evidence that contractor has evaluated all site conditions which
pertain to the work herein. Permits and Permit Fees to be included in all bids.
I
WORK SPECIFICATIONS for REPAIRS
•1. ELECTRICAL UPGRADES and REPAIRS for CODE COMPLIANCE
1. Remove existing load center
2. Remove existing electrical components from bathroom, 2nd floor
3. Provide and install 1 30 Switch 100 A Breaker Assembly, Square D or equal. Complete load centers on
new meter board; mounted to foundation.
4. Remove or otherwise render inoperable all existing knob and tube wiring
5. Provide and install new receptacles throughout the dwelling including
A. Two new receptacles for each bedroom (restore or upgrade existing where 1 exists and add
additional receptacle)
B. Install new switched light fixture for the attic and the basement with new EnergyStar fixtures in each
location on the new switched circuit
C. Provide and install one new switched ceiling circuit for each bedroom; provide and install Energy
Star fixture for each bedroom on the new switched circuit.
D. Provide and install one new switched light circuit for the office, living room, kitchen and dining room
and provide and install one new Energy Star fixture in each new switched circuit location.
E. Install switched lighting at the top of the stair stack, 1 s'to 2nd floor
F. Provide and install new bathroom vanity lighted mirror provided by owner.
6. Provide and install new GFI in 2nd floor bath
7. Provide and install new switches and fan for new fan light combination unit, Panasonic Whisperlite with
compact fluorescent light and EnergyStar rating.
8. Vent to exterior new 2"d floor bathroom ventilation unit.
9. Include new service drop as needed and new PVC masthead assembly for entry service, including
masthead, new socket and meter to meet all current code requirements.
10. Install Fire Protection NFPA and Mass. Code Compliant for new construction.
11. Include all CO detection in dwelling unit and basement and smoke detectors in all bedrooms, hallways,
landings, basements and at combustion appliance locations to meet all applicable code requirements.
12. Obtain all permits and sign-offs for fire detection and warning system.
13. Install GFI receptacles in all locations required by code in bathrooms and kitchens including utility and
exterior areas. Install dedicated lines where required.
14. Provide and install new dedicated 20 A line for 1 Gt floor refrigerator location
15. Repair all exterior and porch lighting; replace to match existing.
16. Label all panel(s) and breaker(s) to accurately indicate all existing and newly installed circuits.
17. All cutting and patching shall be included to make all impact areas ready for paint.
18. Provide and install new EnergyStar thermostat for each existing heating zone
19. Allow up to $75 for each fixture
20. Owner shall supply new fixture for the electrical contractor to install in the hallway stair stack and the
dining room
2. LEAD PAINT REMEDIATION
DE-LEADING & FULL-COMPLIANCE ABATEMENT
PART 1: GENERAL
1.01: FULL COMPLIANCE SCOPE
A. See Lead Hazard Abatement Report for full-compliance scope.
2
1.02: DEFINITION OF WORK INCLUDED
A. The lead paint remediation required under the Specifications. Plans, and Contract Documents shall
include all labor, materials, tools, equipment, insurance, and related services as needed to perform
the specified lead paint abatement work.
B. Lead Paint Abatement shall include, but not be limited to:
1. Paint removal;
2. Paint stabilization;
3. Component removal;
4. Installation of enclosure systems;
5. Supply and installation of replacement components;
S. Refinishing, complete priming and repainting of impacted and adjacent component surfaces;
and
7. Legal disposal of all lead-based paint waste and contaminated materials.
1.03: FEDERAL & STATE REQUIREMEMENTS
A. Federal and state regulations mandate that all housing properties being rehabilitated using public
funds must be inspected for lead paint and that, if found, all said lead paint shall be either removed
and/or stabilized.
B. The Owner shall assume that the Contractor's bid incorporated only the highest levels of lead-
based paint abatement compliance set forth by the U.S. Department of Housing & Urban
Development ("HUD") and the Massachusetts Departments of Public Health ("DPH") and Housing &
Community Development ("DHCD") unless otherwise specified herein.
C. All abatement work shall comply with the standards set by all applicable federal, state, and local
laws, ordinances, regulations, and guidelines in place at the time the work is implemented. The
Project is subject to compliance with, but may not be limited to, the following standards:
1. MGL c.111, §§55.190-199A;
2. 105 CMR 460.000;
3. 454 CMR 22.00;
4. 310 CMR 30.00;
5. 29 CFR Part 1926; and
6. 29 CFR 1910.1025.
D. It is incumbent upon the Contractor to modify, as needed, all practices, means and methods as
amended, modified or changed in any and all applicable regulations.
E. Only Massachusetts-licensed lead abatement contractors are authorized and shall be permitted to
perform any or all of the lead paint abatement work.
1. If the Contractor is a Massachusetts-licensed lead abatement contractor, the Contractor may
perform the work in accordance with the Plans, Specifications, and Contract Documents.
2. If the Contractor is not a Massachusetts-licensed lead abatement contractor or chooses not to
perform the work, the Contractor shall hire only Massachusetts-licensed lead abatement sub-
contractors to perform the work and shall be no less responsible for those sub-contractors full
compliance with the Plans, Specifications, and Contract Documents.
3. The Contractor shall ensure that the lead abatement contractor, whether a sub-contractor or the
Contractor itself, meets the statutory standards for full-compliance abatement.
1.04: INTERIM CONTROLS
A. All lead-based paint abatement measures shall conform to Full-Compliance Standards. Do not
proceed with any methods for Interim Controls unless these were specifically addressed by the
inclusion of a "Risk Assessment" as part of the Lead Paint Report and required by the Owner as
part of the Contractor's bid.
3
1.05: LEAD PAINT REPORT
A. The property has been evaluated by licensed lead paint inspection services and both interior and
exterior surfaces have been tested. The results of these inspections and tests are set forth in the
lead paint inspection reports (together, the "Lead Paint Report") identified below:
1. The Residential Testing COm Rin0X' report dated 8/31/08— call Kevin Nestor 781-942-0188
for compliance requirements
B. The Contractor shall interpret all information and other data contained within the Lead Paint Report
as approximations and shall conduct the lead paint abatement accordingly, including as follows:
1. The Contractor shall verify all measurements and quantities in the field;
2. all work shall be completed in every detail even when not specifically called out in the Lead
Inspection Report or elsewhere in the Plans, Specifications, or Contract Documents; and
3. Where there may be a question of methods, abatement materials, and/or compliance objectives,
the Contractor shall implement, employ, or achieve the more stringent.
C. The intent of the Lead Paint Report is for the subject property is to achieve Lead Abatement
Compliance according to 105 CMR 460.000. The Contractor shall be required to perform all tasks
necessary to make the premises acceptable for the receipt of"Letter of Abatement Compliance"for
the housing units and locations defined in the Lead Paint Report.
1.06: EXTENT OF LEAD PAINT ABATEMENT
A. Unless stated otherwise in these Specifications or in the Plans, no additional lead-based paint
removal will e required
referenced herein except o for the following: NO ADDITIONS FOR THIS PROJECT— SEE LEAD
PAINT REPORT ONLY
PART 2: PRODUCTS NOT USED
PART 3: EXECUTION
3.01: RESIDENT RE-LOCATION
A. Residents occupying units to be de-leaded must be temporarily relocated during the course of the
de-leading work.
3.02: GENERAL FULL-COMPLIANCE ABATEMENT GUIDELINES
A. The Contractor shall apply the following full-compliance guidelines and methods where applicable:
LEAD-BASED PAINT COMPONENTS GENERAL METHODS FOR
PER
LEAD PAINT REPORT OR FULL-COMPLIANCE
SPECIFICATIONS LEAD PAINT ABATEMENT
WHERE APPLICABLE
1 Interior Door and Window Casings, Scrape and feather existing surfaces for
—Jambs, and Trim: Compliance with minimum requirements.
Replace treads and risers to match the
2. Interior Stairs —Treads and Risers: Existing ones.
Replace stair parts, mop boards, and other
3. Stair Parts, Mop Boards, Misc. Trim: Miscellaneous trim to match the existing ones.
4
Install new cast iron to match the existing type
. Exterior Iron Railings: and confi uration
indow Sashes —All Wood Units and All Install replacement units according to the Plans
5 Window
Components Identified as Lead And Specifications. All replacement units shall
Hazards, Including All Basement Window S match fthe existing windows unless otherwise
d.
Sashes:
Make compliant by using the most cost-
effective
6. abinets and Components: Means and methods unless otherwise
specified.
Closet Com onents — Interior: Re lace all components for full compliance.
Exterior Window Trim and 'Hot' Trim t Wrap
all w with
standard
according gauge and the colorPlan coil
and
ldstock
6. (above 6'),
II Sills and Exterior Casings: Install coverings or replace as directed
9. Porch Ceilings: according to the Plans and S ecifications.
10. Exterior Columns and Newel Posts: Replace and re aint to match existin .
Repair and repaint, wrap with aluminum, or
treat
11. Lower Trim: as needed according to the Plans and
S ecifications for full compliance.
n replacement door units— pre-hung set-up
lambs for full compliance. For historic units—
12. Exterior Door Casings and Jambs: crape, prime, and paint for minimum full-
compliance re uirements.
Stabilize, repair, and repaint with two (2) coats
[3. Interior Walls: r repair according to the Plans and
S ecifications to meet full com liance.
Replace with similar materials and paint with
Interior Railings: o (2) coats according to the Plans and
ecifications.
Remove and replace to match existing; use
15. Exterior Lattice: inyl or pressure-treated wood according to the
Plans and Specifications.
Stabilize all surfaces per the Lead Paint Report.
Prime only the entire house body with tinted
16. House Body: Primer using Alkyd primer unless otherwise
noted according to the Plans and
Specifications.
Provide and install Therma-Tru panel door with
locking handset and deadbolt, pre-hung unit
17. Standard Exterior Doors with half/lite thermal glass, match opening
size and prime all new trim.
Cover with sheetrock, mud and sand, prime
18 Other Interior components —closet one coat, replace all components to match
interiors, trim, misc. existing configuration and function.
Meet compliance standards by most-cost
effective means while retaining door. Unit may
Historic Doors & Jambs (Interior Panel- be dipped off-site or hand-stripped in place.
19
type): Treat jambs for compliance. Prime and paint all
work for complete coating of subject surfaces
and remaining components.
3.03: WASTE DISPOSAL
A. All lead-laden materials removed as part of the abatement shall be disposed off-site in accordance
with local, state, and federal regulations or ordinances.
5
3. EGRESS REPAIRS
3.1 Basement Bulkhead and Entry Door
3.2 Remove and dispose existing basement door and bulkhead
3.3 Provide and install siding to make uniform exterior of dwelling
3.4 Repair all framing and sheathing to accommodate all installation of materials
3.5 Provide and install a new footing assembly to accommodate a new steel bulkhead door
3.6 Provide and install a new bulkhead door, Bilco or equal, to enclose basement bulkhead opening
3.7 Seal and otherwise caulk base of bulkhead to new footing assembly
3.8 Repair stairs and provide new pressure-treated assembly as needed to access basement
3.9 Provide and install a pre-hung insulated door with new frame, foam-sealed to the existing stone
opening. New door to include keyed deadbolt with interior thumb-latch
3.10 Provide and install code-compliant handrails and guardrails at side egress
4. BATHROOM REPAIRS
4.1 Remove and dispose all fixtures and surfaces
4.2 Remove plumbing vent line from hallway stair stack
4.3 Remove and dispose deteriorated framing and sheetrock at partition wall between the bathroom
and adjacent bedroom
4.4 Provide framing as needed to allow placement of 5' tub perpendicular to the location of the
existing 4' tub, along the outside all.
4.5 Re-Sheetrock and complete repairs to partition wall, finish and make ready for paint by
providing a smooth, finish-ready surface.
4.6 See DELEADING scope where the work in this section may impact deleading scope
4.7 Install cementitous backer board to full ceiling height on all three tub enclosure walls
4.8 Provide and install 4" standard wall tile and light grey grout at all three tub enclosure walls
4.9 Caulk and seal tub at floor/tub seam and all other wall and tub intersects
4.10 Provide all rough plumbing for new tub, toilet, vanity where existing can not be reutilized
4.11 Drain, waste and vent to code all fixtures
4.12 Provide and install new 5' Tub with complete waste, overflow, valves and controls.
4.13 Tub Shall be Americast 5' tub or equal
4.14 Provide and install new sink and vanity with sink, faucet and laminate top with backsplash.
4.15 Allow up to $600.00 for complete vanity assembly, not including installation
4.16 Repair all floor framing and install 3/4" T & G ply decking
4.17 FLOORING: KITCHEN and BATHROOM: Provide and install new Corlon or equal sheet vinyl
for the bathroom set on underlayment per manufacturer's specifications. Set all fasteners and
flash all seams and divets with leveling compound prior to applying adhesive.
4.18 APPLY Flooring as above for KITCHEN
4.19 Install new 1.6 GPF toilet, American Standard, Kohler or equal "Cadet" model
4.20 Provide and install owner-supplied bathroom trim including towel bars, dispensers
4.21 Accommodate electrical trades in venting new fan/light unit to exterior and provide exterior vent
cap as needed.
4.22 Provide and install new 1x4 base trim with cap at all wall/floor intersects in bathroom and 1 X 6
in the adjacent room impacted by wall repairs
5. HVAC REPAIRS
a. Remove existing line from hallway stack
b. Provide a new chase in rear room 1s' floor, right corner
c. Provide and install new supply line at new chase from existing heating unit and install new riser
to 2nd floor and provide new heat location that base accommodates the existing conditions.
d. Chase shall meet all code requirements for fire blocking and finishes shall match existing
adjacent finishes grille
e. Install all finish HVAC components including g
f. Provide and install complete dryer vent kit and vent dryer to exterior; install flapper assembly
g. Re-commission heating system including provision of tune-up and balancing
h. Provide and install new 24/7 Programmable EnergyStar thermostat (see electrical per same)
6
6. . 'TREE TRIMMING
6.1 Remove and dispose overhanging tree section encroaching on roof, causing shingle damage
6.2 Cut back all limbs to approximately 4' clear from edge of dwelling
7. ROOF AND EXTERIOR REPAIRS
7.1 Provide and install up to 400 SF of roof shingle to repair section impacted by tree
7.2 _ Provide and install new exterior fascia and trim, up to 60 LF at front and rear
7.3 Prime and paint all trim or use Azec or equal cellular PVC in white
7.4 Repoint Chimney:
7.4.1 Grind out all joints and remove flashing from existing reglets
• Provide and install new mortar and replace flashing into new reglets
• Make chimney water-tight and seal as needed
7.5 Repair hole in exterior wall with materials to match the existing siding and finishes
8. OTHER REPAIRS
8.1 Patch all areas impacted by the repairs herein, with like materials and finish to match adjacent
and existing surfaces
8.2 Basement Stairs: Remove and dispose existing stairs and provide and install new stairs
including new handrail assembly. Rise and run per code or accommodate the existing
conditions
8.3 Install handrails where required by code throughout the dwelling, exterior and interior.
8.4 Plane and adjust all doors throughout that stick or are mis-aligned; restore all to provide working
handsets and latches. Adjust striker plates as needed so doors operate as intended and remain
closed.
7
�jJ¢ '�9P9JLJAdI¢!//¢d f
:oard of Building Regulations and Standards
" construction Supervisor License
y r r
• ek License: CS 70882
Birthdate
Expiration:
7/28/2009
1956
Expiration: 7128I2009 Tr# 16025
Restriction: 00
RICHARDJ SMITH
PO BOX 1769 --7—"
SALEM,NH 03079 Commissioner
Board of Building Regulat ons and Standards
One Ashburton Place - Room 1301
lug Boston. Massachusetts 02108
Construction Supervisor License
License CS: 70882
Restriction: 00
Birthdate: 7/28/1956 Tr# 16025
Expiration: 7/28/2009
RICHARD J SMITH
PO BOX 1769
SALEM, NH 03079
Update Address and return card.Mark reason for change
❑ Address 0 Renewal. [-] Lost Card
DPSCAt 0 50MA5/06PC8890 '-
91te fi o uil mg egula/ons a`�n� an ar s
_ One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: . 106603
Type: Private Corporation
Expiration: 7/24/2010 Tr# 270264
AJ WOOD CONSTRUCTION, INC.
Richard Smith
PO BOX 1769
SALEM, NH 03079
Update Address and return card.Mark reason for change.
Address 0 Renewal Employment Lost Card
BPS-CA1 0 5OM-07/07-PCM90
�J[e L/O))Nl/O%i<I/E[llLlf. Oy✓��iLO.U[[[dE�b
Board of Building Regulado(rs and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration: 106603 One Ashburton Place Rm 1301
Expiration: 7/24/2010 Tr# 270264 Boston,Ma.02108
Type: Private Corporation -
Ai WOOD CONSTRUCTION,INC.
Richard Smith /
4 RUSTIC LANE
DERRY,NH 03038 Administrator Not valid witbou gnature
l
COmmonwealth of Massachusetts
Division of Occupational Safety
Laura M Madin,Commissioner
Deleader-Contractor
RICHARD S. SMITH
Eff.Date 07/ 0
Exp.Date 07N 01 0/09, -
DC001721
Member of
00 IIII Nrypp 1 - .
IIIIII'IIO III II�II�II�O�Iu OIO u'I��Iu IIIII�I BOSTON-REN�
D00135u - C E R T I F I C A T E O F f. N, 3 N R A N C E ' Issue date: 5-06-OB
'Producer �Thia certificate is issued as a matter- of inforsiation only and
CESI Agency of New England confers no rights upon,the 'certificate holder.. -11114
10 Chastnut Drive Omit E certificate does not amend, extend or altar the nnverage
Bedford NH 03110 afforded by the policies' below. - -
COMPANIES AFFORDING COVERAGE
Insured :Company letter A Nautilus Insurance '
A J WOOD CONSTRUCTION CORP Company letter B
P.O. BOX 1769 -
SALEM NH03079-1769 Company letter C
Company letter D "
'Company letter E
COVERAGES . This is to certify that paliciea of insurAci—listed below have'bee;i aSued to the
insured;named above -for the policy period indicated, notwithstanding any reciuiremant,
term ox.conditiod of any contract or- ot, er document witb:sespect to which -Fliis.ceitificate ma
be issued or may-pertain, the insurance afforded by the policies described herein 1'a. subiect �o
all the terms, :exclusions and conditlons of such policie9:- .Llmito shown"may.,have been.ra uced
by pai&claims. '
Cc Policy "Policy
Lt Type of insurance Policy number Effective Expire ALL-LIMITS IN THOUSANDS
GENERAL LIABILITY General aggrogga'te.. . .. .$ 2,000
A X commerciai -General Liab. NC705388 5-16-0.8 ''5-1'6-09 Products-completed
Claims made operatibns aggregate..$ 1,000
% 'Occurence Per s
Owner's 's" contractors advertiainq anjury..,.$1,000
protective Each ottnYrence..:'..:.,.$ 1,000
Fire dam
one fire ... . ...... .. ..$ 50
Medical expense (any
one person) ., ... ... ..r.3 5
AUTOMOBILE LIABILITY CSL S
Any auto
All owned autos Bperlperson)y $
- Scheduled autos
Hired autos
- Non-awned autos Bodily Iniipry
Garage liability (per accidenr) . S
• Property damage, •+$'
EXCESS. LIABILITY Each'dcCuirence Aggregate
Ombrel,la form -
- Other than. umbrella form
WORKERS' COMPENSATION Statutory,
AND' S each accident)
$ (disease-policy limit)
EMPLOYERS' LIABILITY $ (disease-each.empl,)
OTHER
Description of 6perations12oeationo/ve)iicles/specialr-iteins -
CARPEHTRY d ROOFING-COMMERCIAL ,
Certificate holder CANCELLATION Should any-of the above described'"ppolicies be
cancelled before the expiration-date thereof,
' the issuin4 company. will endeavor to mail IO• days Written
notice to the certificate holder named to the left,.but failure
to mail ouch notice shall impose no obligation or liability of
any kin u the comp is agents or representatives.
"Aotho'r z se t�tiv
'..(OMM 7 CERTG*030409)aeo6a®9ae)
.4CORD .CERTIFICATE OF LIABILITY INSURANCE °"'�""ND 20
rr 02/20/2008
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Matthews Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EriTEND OR
1B2 Parker Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW_
Lawrence, MA 01043
978-601-1112 INSURERS AFFORDING COVERAGE NAICS
PoufE AJ Wood Construction, Inc WSURFRA: Liberty Mutual Ina -
INSURER B:
P.O.Box 1769 WEURERC.
Salem, NH 03079 Ra
1-603-235-7629 IN WSIR EER-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 WITH 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 REDUCEDBY PAID CLAIMS.
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
'n Ot l';:kr.Ill'DRISCw LL
�I�sv tk 12C WASHING ION SI RLET * SAL L'M,MASSAcl It SIi IISO 1970
TmI.:978-745-9595 • FAX:978-740.9S46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A ) tlicant Information r/T Please Print Le ibly
Name (BusliieWOro.anizatiorttindividuul): lJ
Address: ((�� (( -
City/Stare, J'%ip�r () 4,P,02 Phone
:arc you an 'mployer? Check the appropriate box: 'Type of project(required):
4. ❑ I am a,amoral contractor and 1
I. am a employer with 6. ❑ New construction
employees(full and,'ur part-tinge).' have hired the sub-contractors 7. etnodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet. :
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9, ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its ]0.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am it homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,ql(4), and we have no 12.[g1Loofrcpairs
insurance required.] t employees. LMo workers' 13.❑ Other
romp. insurance required.]
-Ally:,pplicnnt that chucks box HI must also till out the feclioo below showing their workus'cumpensution policy inhumation.
' Homeowner,who submit this affidavit indicating they are doing all work and then him outside contrnaton must suhmii a new afrdavit indiuuling such.
�Comrauturs that check this box must attachai an additional sheet showing Iho name of the sub-contractors and their workers'comp.policy infurmaziun.
I nor on employer that is providing workers'compensation,insurance jar my employees. Below is the policy and job site
infrnation.
Insurance Company Name: �-�r
Policy a or Seif-ins. Lie. t: (31�__..... / 1l Expiration Date: p�
Job Site Address: .yP//G��... Cityistaleizi(i(�JCf.161C/,c, , tP1970
Attach it copy of Ilse worker 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 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 S250.00 a day against the violator. Be advised that a copy of this stutcment may be lurwarded to the O ice of
Invest iga l tons ul'Lhe DIA for insurance coverage vc.ri oration.
I da hereby certify un l the pains mid penalties of perjary that the information provided above issst true
,(and correct.
SIL':1'll ltr"e'✓ // Data'
rhunc 03 —
OJJicial use only. Do toot write in this area, to be cumpleted by city or ionut ajJicial.
City or Town: Permit/License
Issuing:\ulhorily (circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector i. Plumbing Inspector
6.Other
Contact Person: __..- . _. __—. Phone q: t� .
Information and Instructions
;Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an empluree is defined as"...every person in the service of another under any contract of hire,
express or implied, oral it 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, bIGL 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(ban 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 rcunmed 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 he 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 permitilicetue 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.
I he Otf ice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do nut 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
aevi.ed 5-26-05 www.mass.gov/dia
,4 CITY OF SALLM
;( yY PUBLIC PROPRERTY
DEPAIZT'.'vIENT
constrilction Debris Disposal Allidavit
(,quired for all demolition and reno\ation \\'ork)
In accordance r\ilh the sixth edition of the State Building Code, 7S0 C'h1R section 1 11,5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it. 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
1 I L S 150A.
The debris \\'ill be transported by:
t name ul haukrlc r
The debris will be disposed of in
X.
t name ut taulny) / I
0e 2 / �
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-e
CITY OF SALEM
DEPARTMENT OF PLANNING AND
COMMUNITY DEVELOPMENT
KIMBERLEY DRISCOLL
MAYOR
120 WAsfmaGroN SY7tEEE:I'#Sgt vM MASsna-tusElTs 01970
LYNN GOONIN DuNCAN,AICP - TEI.:978-619-5685♦FAA:978-740-0404
DIRECTOR
HOUSING REHABILITATION PROGRAM
BID FORM
Property: 68 Highland Avenue,Salem,MA Owner. Amanda Cutone Case#: 09-01
WORK ITEM PRICE
1. ELECTRICAL UPGRADES&REPAIRS $ U),SW
2. LEAD PAINT ABATEMENT $ ,((4 SD d� /q
EGRESS REPAIRS—
FLOORING m.N1rCHEN&BATHROOM' $
i -B? OTHER BATHROOM REPAIRS $ \6UV
5. HVAC REPAIRS $ lout
f� 6. TREE TRIMMING $
{ ROOF&EXTERIOR REPAIRS' $ aW D
j OTHERREPAIRS
(Basement stairs,handrails,and adjust doors) / �7
f TOTAL BID $ �`{ 0 i O O U'
N I,the undersigned contractor,have inspected the above listed property and understand the extent and character
of the work to be completed as described in the Work Write-Up. The bid includes every item identified in the
Work Write-Up by the respective numbers. The bid shall remain in effect for a minimum of thirty(30)business
days after the bid opening.
4
I propose to famish all labor,materials,and equipment n ssary to accomplish all work described in the Work
Write-Up for the sum of Z i6 . Pi/d/�� 7LAu .u1 — —Dollars
I agree to begin the work with' ourteen(14)calendar days of the Notice to Proceed and complete the work
within sixty (60)calendar days of the Notice to Proceed.
I agree to fully arantee all labor and materials for one(1)year from th roject completion date.
ompany Name Signature of Authorized Re sentative
/7b UtX�19n, d630 79 yes:leer
Address Ti a of Authorized Representative
Telephone Date "�
r