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DOMINICK PANGALLO MAYOR TOM DANIEL, AICP DIRECTOR CITY OF SALEM, MASSACHUSETTS DEPARTMENT OF PLANNING AND COMMUNITY DEVELOPMENT 98 WASHINGTON STREET, 2ND FLOOR ♦ SALEM, MASSACHUSETTS 01970 TELE: [PHONE REDACTED] HOUSING REHABILITATION LOAN PROGRAM APPLICATION FOR PLACEMENT ON QUALIFIED CONTRACTORS LIST COMPANY INFORMATION: Company Name: Company Address: City: State: Zip: Contact Person: Title: Telephone Number: Cell Phone: ❑ n/a Email Address: ❑ n/a Website Address: ❑ n/a Federal Employer ID # MBE/WBE: YES / NO Number of Full-Time Employees: Part-Time: MAJOR TRADE PERFORMED BY BUSINESS: ❑ General Carpentry ❑ Deleading ❑ Electrical ❑ Plumbing ❑ Painting ❑ Masonry ❑ Other MAJOR TRADES NORMALLY SUBCONTRACTED: ❑ General Carpentry ❑ Deleading ❑ Electrical ❑ Plumbing ❑ Painting ❑ Masonry ❑ Other LICENSE INFORMATION: Contractor’s License Title: HIC License Deleader Contractors License ---PAGE BREAK--- INSURANCE COVERAGE: INSURANCE TYPE POLICY NUMBER LIMITS CARRIER Property Damage Liability Workers’ Compensation PLEASE LIST THREE REFERENCES FROM JOBS RECENTLY COMPLETED: Name: Address: Type of work: Estimated cost: $ Contact person: Telephone Name: Address: Type of work: Estimated cost: $ Contact person: Telephone Name: Address: Type of work: Estimated cost: $ Contact person: Telephone ---PAGE BREAK--- COMPANY HISTORY: Number of years in business: Has your contractor’s license ever been revoked? ❑ No ❑ Yes (explain) Are you presently, or have you ever been debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal debarment or agency? ❑ No ❑ Yes Are you a member of a trade or civic association? ❑ No ❑ Yes (Please List) PLEASE READ BEFORE SIGNING: AUTHORITY TO OBTAIN VERIFICATION: I understand that signing this application gives the City of Salem’s Housing Rehabilitation Loan Program Staff the authority to obtain verification from any source provided herein. The undersigned certifies that all information provided on this application is true and correct to the best of his or her knowledge and belief and that no information has been excluded, which might reasonably affect a judgment regarding eligibility. Signature Date Name (please print) Title ---PAGE BREAK--- PLEASE SUBMIT APPLICATION AND COPIES OF REQUIRED DOCUMENTS TO: CITY OF SALEM HOUSING REHABILITATION LOAN PROGRAM DEPARTMENT OF PLANNING AND COMMUNITY DEVELOPMENT (DPCD) 98 WASHINGTON STREET, 2nd FLOOR SALEM, MA 01970 TEL: (978) 619-5685 DOCUMENT CHECKLIST: Copies of the following documents must accompany this application: ❑ H.I.C. License ❑ Construction Supervisor’s License ❑ Liability Insurance Certificate ❑ Workers’ Compensation Insurance Certificate If applicable, the following documents must also accompany this application: ❑ Electrical License ❑ Plumber’s License ❑ Certificate of Completion from U.S. Department of Housing and Urban Development sponsored course Lead-Based Paint Hazards Course ❑ Deleader Contractor’s License from the Massachusetts Division of Occupational Safety