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400 HIGHLAND AVE - BUILDING INSPECTION (8) CITY OF SALEM PUBLIC PROPRERTY o DEPARTMENT wtarnratF.r uat4t:tru MAY(* 12C VA-%&%GTM SntmT a Surat,l�4SAC7n.�TrsOt97II 'rtl--9711-743.9593 a FAX:97s-740.9846 Workers' Compensation Insurance Affidavit: Builden/Contractors/Electridansn%mbe» .applicant Information Please Print Legibly dame CV - Address: 3 �✓Y �r S1. 78 VOL! —(73 R3-- City/Starcizip:_ )Qv cj Phone Are you an emptayert Cheek the appropriate host: rojeet(required): 1.❑ 1 am a empbyar with 4. ❑ 1 am a general contractor'"]� F w construction L tmpluy�Ys(full uul/w part-time)-' have hired the sub eotunc 2 (fit am a sok proprietor or partner- Listed on,the attached ahceodelinship and have no omploy°as Them cob-ccemsciors havolirioaworking for me in any capacity. workers' comp. insurancelding addition►(No waken•comp, insurance 5 ❑ We arc a corporation and i . triea! required.] ofcers have exercised then repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MOL 1 I.❑ Plumbing repairs or additions myself.(No workers'comp. c. 152,¢1(4),and we have no 12.0 Ruorrepairs insurance required.) t .:mpjoycc&(No workers' , comp. insumnarequiretLi 13.0 Other .niq;kVbcmt thu eRccks ben e1 map also Mum dw uaiun bcbw,sharing their wwkom'cuntg'u+rMLm D•tky intrwmWieq I Iwwrwrwra cob tubaril rAia aAtdavii maintains they am fniati os work anti thm Ake owsida emkrocrms mrrar.ukrnk a row afRdavd indioeing oohs :C' t xvn one check dos bm mud a°aehd to all irionat Am%Mwing roe none arms tobcouraclon,and(heir wurkers'comp•pdKy ur/o mmane. /one on mttp/oyer that Is providing workers'compensation,huuranee for iffy employees Below is the polity and job We iryoretrus" // Insurance Company `V-7V--C t Policy 4 or Sclf-ins. L/ic.0: W GC! n�S7 . 2 O or�� Expiration Date: y ' Ft� Job Site Address: `7W CityiStatuZip_�_I��-_ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratlua date). Failure to secure coverage as required under Scclion 25A of.N4GL c. 152 can lead to the imposition of criminal penalties oft finor op at S1.M0.00 and/or one-year imprisomncnt,as well as civil pcnallics in the forth of a STOP WORK ORDER and a fine a(up to$230.00 a day against the violator. lie advised that a copy of this slatcinent may be lurwarded to the Office uf Inr,an;;aumu of the DIA for imuraree covcra.,e verification. /do hereby t.rtijy on, r her pai m no/ties ajperjory that 11trt/njarmadoff provided above is true arid correct. Ki,.nthtr� �� Mite. /0122- r: i)Pcid lWOnly. DON*(write/at/lair area,to be rampletet/by Myer/own Ofj&-/ai City or'rown: Pcrmidl.leease M Issuing Authority (circle orlc): -- 1. Ituard of health 2. Building Dcpartincot 3.City/romn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Gnalaci Person: _ Phone 4. Information and Instructions ,%lassachusetis General Laws chapter l52 requires all employerss tprovide ervw.workers' aof another undo compensation or onn'rtheir�O� Pursuant to this statute,an raWkyee is defined as"...every person eapresa or implied.Oral or written." ,.,,.�,,...,.n...� tines ar other Irgnl entity.«nay two or more An copy q u1 detised Y"im IndlvidrMi.r�""""'�� a Or the of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer- association or other legal entity.employing omploycea. However the receiver or trustee of as individual.nt mot aht a ' and who resides theteie.a the ooeuptm Of" owner of a dwelling haws having not more than throe aparEmaalt work oo such dwelling house dwelling house of another who employs persons re do maintenance.construction reou P� or on the groun ds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter I32.42S(6)aim states that"*very stab or local lid0using agency shall withheld the Issuuee or me a business or to construct buildings In the commosweskh fir tray renewal of a urea w or permit b operate with the insurance coverage required." appUeant wbe ban act ptrodneed aeeeptablo evideae*of eomptlanu nor any of its political VAdWilitten Additionally.MGL chapter 152.423CM states Neither the conirrtomvethvtdience compliance withinsurance enter into any comsat for the perfrtnnaace of public wont until acceptable ry requirements of this chapter have been presented m the contracting Appllraars if Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation and. necessary.supply sub-contractor(s)name(s),addhesa(es)and Phone number(a)along with their cenificato(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 Induenisl Accidents for confirmation re insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city a it or license is being town that the application for the perm requested, not the pepratment of ladustriul Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy.please all the Department at the number listed below. Self-insured companies should enter their .elf-insurance license number on the line. City or Town Oft" Please be surd that the affidavit is complete and printed legibly. The Department has provided a space at the bottom. of the affidrvit for you to fill out in the event the Office of Investigations has to contact you regarding the applicanL Pleases be we to 17,11 in the Permit/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"•Oil location*fa (city or tuwnl."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 titled out each year, Whore a ham 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 etc.)said person is- requuad to complete this affli vit l'he Ofticc of Investigations would like to thank you in advance for your cooperation and should you have any questions, lease du not hesitate no give us a call. The Department's address, telephone and fora number: The Commonwealth of Massachusetts Depaftzaent of Industrial Accidents OAlat of Iavadpttoeg 600 Worthington Strati Boston,MA 02111 Tel, 0 617-7274900 ext 406 or 1-977-MASWF Fax 0 617-727-7749 2cviscd 5-26-05 www.inass.gov/dia Lynch Construction 31 Seven Star Road Groveland, MA 01834 (978)373-1918 Construction Supervisor#: 065505 HIC #: 131266 Agreement for Construction Services October 15, 2007 Parties: Client: Arthur Velonis Contractor: Lynch Construction 5 Agawam Lane 31 Seven Star Road Andover, MA 01810 Groveland, MA 01834 Phone: (978) 470-2977 Phone: (978) 373-1918 Location of Work: 400 Highland Avenue, Unit#19, Salem, MA Description of Work: Interior build-out for Bob's Famous Fried Clams Demolition of existing partitions per plan. Slab cut, excavation and repair of disturbed areas to accommodate plumbing trenches. Ref-ame with metal studs per architect's drawings. Installation of electrical wiring per plans. Supply and install drywall. Supply and install acrylic paneling in kitchen and prep areas. Supply and install cabinets and countertops at sales area. Repair and replace acoustical ceiling as necessary. Painting of all wall and trim surfaces. Install pre-hung masonite doors per plan. Install bead board and crown molding per discussion with owner. Supply and install tile flooring per discussion with owner. Supply and install walk-in refrigerator/freezer combination—not including refrigeration equipment. Not included in this Quote: Plumbing and HVAC Vestibule Total Cost: $89,920 r Ly9rh C-gnstruction 31 Seveq Star Rgad Grovelapo,MA 01834 (978)173-1918 permits: By this agreement, Client acknowledges its authority and authorizes the Contractor to apply for and acquire all necessary construction-related permits. Client acknowledges that no work can begin until all necessary permits are in hand and that Contractor will use good and reasonable efforts to acquire the necessary permits, but Contractor does not control the timely issuance of said permits. Client agrees to endorse all applications as required to facilitate permitting. All work and schedules, as well as that of any subcontractors, will be subject to all applicable permits being available on a timely basis, and will be performed by licensed whenever r uired. and insured professionals Prequired. General Conditions and Definitions: 1. Any changes are to be documented in writing and signed by all parties. Any changes will be paid for at the time of the change request,prior to the changed work being undertaken. Contractor reserves the right to not accept specific requests for changes if and when acceptance of those change requests adversely affects'integrity of work product or schedule. 2. Additional work will be billed at the rate of$50 per hour for licensed labor, $30 per hour for common labor unless otherwise agreed. 3. World sites will be left in equivalent condition to those existing prior to contracted work. 4. All reasonable efforts will be made to protect the existing structure from weather. In the event of extreme weather conditions, the cost of any damages will be the responsibility of the owner. 5. Contract will be considered substantially complete when all work has been initially completed; repairs and warranty are beyond the scope of substantial completion and final payment will not be withheld due to repairs and warranty items. 6. Non-payment or delayed payment according the payment schedule will result in work stoppage for the duration of any payment delays, and completion time extended accordingly. 7. sate payment will result in a finanep change applied to the etltire balance 4 e at ap annual rate of 18%. 8. ()My those work items specified in the"Scope of Work" and"Plans" are included in this contract, and this specifically excludes any items not specified, such as upgrades to electric service, water service, fumace/boiler, or other unspecified systems. Lynch Construction 31 Seven Star Road Groveland, MA 01834 (978) 373-1918 Additional Conditions for Residential/Home Improvement Contracts: 1. All home improvement contractors and subcontractors shall be registered, and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration One Ashburton Place, Room 1301 Boston, MA 02108 617-727-8598 2. Client is entitled to a three-day right of cancellation under MGL c.93, ss48; MGL c. 140D, ss10 or MGL c. 255D ssl4 as may be applicable. 3. Client is entitled to owner's rights and warranties under the provisions of 780 CMR R6 and MGL c. 142 A. 4. Unless otherwise specified or notified, there is no lien or security interest given on the residence as a consequence of this contract. 5. Any and all necessary construction-related permits are necessary for work to commence. 6. It is the obligation of the contractor to obtain such permits as the owner's agent. 7. Any owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guaranty Fund. 8. The contractor and 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 Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in MGL. c. 142 A. ij�Owner: Date: Lda Contracto . `� . Date: 2 Z CITY of SALEm 4Z PUBLIC PROPRERTY DEPARTMENT aLaa lS 7.�IN::awf�raT�iutal,aQvGwu.►ns;:a TUjw4p)9ts f.�t:97iJ�6lW Construction Debris Disposst Affidavit (reyuird for all denutwon and renovadom work) to aoeordinca with the six&edition atfis State Building Cods,DSO MIR soction It 1-5 Debris,and dw provisions o(M. CL a 40.S Sk gWlditg Pe N _ . _ is issud with dw eonditim fiat the debris resulting foss this wart shall be disposed of in a property licensed wasa disposal facility as dented by%lGL e II1.S15" The debris will be transported by: .�"'� Itwmeot'1,autM��� fhb&--bris wilt be disposed of in : _ lzq ZIZ77 _ e , .5 �/ee �nmson�seea/� o�./j�.aeoadu<ae�A `� Y ",s BOARD OF BUILDING RERULATIONS a L�Ce45B ° j4rUU('T)ON_3'Uk `,RYISQR w ' Number C9 ' �065005 � 'Birth i/15f797D x a �ti "'row t/15/ R1.0513 BRIAN A LYNCH 31 SEVEN STARG-- �` GROVELAND, } a Comminlow "k :AR OFPPDTME,�1T t+e:+Ts•7+besss.1<,�s:s».s«laps A_ppLiCATION FOR THE REPA_UL RJMO ATION. CONDUCT " DEHOLTI UM OR CRANGZ OF USZ Olt OCCUPA_xry_ FoR ♦Ny >trSIvZWG BTRUCTURZ OR BUII.DIri(� 10 SITE INFORMATION Location Nam ffokj 1-�" enerf C6s.&� Iluildlrg; ProMIV Is locWl*d in a;COnWWAdon AM Y HWAft DMM YM 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ NarrW ,I-+— Address.T w- 7�I 3I-392© OCOMPLETE THIS SECTION FOR WORK IN�is?1N0 BUILDINas ONLY Addition Exisdrg Renovatkin Number of Stories Renovated Change in Use New [Approximets moGtlon ��g Yew of Area per noon (sf) Renovated nstructlon or renovation existing building New add Description of Proposed Work: ,1�U• ICk' O-�� ' --- -----Mail Permit to: - - - IMnwj is!M current use at 00 StWdkV? 1/zx �l mat eriai of Buitdn0? / � K a vMM now nmM uMft? Will the&ddit CarAwm to LMW? `�`S Asbes"? Nd !f fh' Mcv f 1 fir, �, y Adddreew ArdONWsar d�PhOAS emgdwi Sr l ) +s Name r hcrt Addnm and Photo Cau4talion &VWviaors Licenses �L.:tx) Hlc R.gWWon to Eswnaosd Cost a Project `9 Pennk Fee CaM_MM n Permit Fes$ EoWnsted Cost X$7/$1000 Residential -- -.- - - Estlmatad Cost X$11/:1000 Ccmrmrds4 An Addff "S&OO is added as an Adminisbative c mg& Make sun that an flelda are propsdy and legibly written to avoid delays in prooaNnp. he T undanipned do"hereby a"far a SuildhV Pan*to build to f,above TM spg&as ons. Signed under PAY Of PwPAV Date J. NI s y