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175 MARLBOROUGH RD - BUILDING INSPECTION (2)
li CITY OF SALEM PUBLIC PROPRERTY \4a. DEPARTMENT s 1slflF RtF.Y URIK:ULL MAYsat I=WAsttL\CrON STREhT•SAIFN,MAS,ACI11%N:'1lS G197: Till 978-745.9595 •FAX:978.7469846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADDiicant Information Please Print Leeibly NaMC lf;umocss/Organizatiotulndivtdual): /p t!//R-6 t-AOS (4AI-7 z_ Address: 2S g-7 - CitylStare/zip: L4tA✓v , /V0r-= of 9 o'Z— Phone Al: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 ant a employer with 4. ❑ 1 am a general contractor and 1 6, ❑ New construction employees(full and/ur part-time).* have hired the sub-contractors 2. I am a sole proprietor or paMer- listed on the attached sheet. t 7• Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. workers' comp. insurance. q, ❑ Building addition ,No workers'comp. insurance S. ❑ We are a corporation and its 10.[1 Electrical repairs or additions required.] officers have exercised their 3.❑ I ant a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. (No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. (No workers' 13.❑ Other comp. insurance required.] •Any applicam Itua checks box 01 most also fill am the seceian below dtowiag their worimis eompansution policy inrunnati'm 'I1 m wwmcm who submit this affidavit indicating they are doing all work and then hire outside cunirnam must.utmttl a new andavit indicaing Mich. :Contmmois flat chalk this boa mug attached an additional Awd showing the namo of the cub-comracim and their workan'comp.policy information. lain an employer that is providing ivarkers'compensndon hisurance jot tnry employees. Below is the policy and job site injormdtion. n A Insurance Company Name: PP(-,,VAr /YJ,1142- — L/A =4 /?AC W16 1 SSC-s.3 Expiration I olicy q ur Self-ins. Lic. ti: / ^ Z 7 portion Date: Job Site Address: i7S /YjA7LL o W4 y M. City/Stan/zip: .lids t 4134- e Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure w secure coverage as required under Section 25A of.vIGL 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 STOP WORK ORDER and a fine Of up to 5250.00 it day against the violator, lie advised that a copy of this statement may be forwarded to the 011ice of Invesngatiuns of*the DIA for insurance coverage verification. /da hereby certify under the pains and penalties of perjury that the information provided above is true and correct Vex, %/ Dare .6-0 a Phonco UJfcial use only. Do not write in this area.to be completed by city or town oJJic is t city or'rown: _-_ Permit/Licenseq Issuing Authority (circle one): 1. Board of Ilealth 2. Building Department 3.Cit)/town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other contact Person: -- - > __ I hone q: 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"tat 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 itustee 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,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 number(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 returned 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 litre. 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 perinidlicense number which will be used as a reference number. In addition,an applicant that must submit multiple pennitflicense 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 t i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. the Otiicc or 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 Office of 1ovesdgadens 600 Washington street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE Fax #617-727-7749 Revised 5-26-05 www.m&w.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT l2CW.\9"".:JNS;AEET •S.\t u,St.\u\(:at .H:1"15]19IC TF.I:978-7454599 •FAX:978.74G9846 Construction Debris Disposal Atridavit (required fur all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5 Debris, and the provisions of vtGL 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 v1GL c 111. S 150A. The debris will be transported by: _t) AW A-6S -4-, 72i S (lame of hauler) I'lie debris will be disposed of in : N0�8�QCr c�A>�-7i� (name of(aclLty) ia.A:res. of tS.il,t;i) ACORD CERTIFICATE OF LIABILITY INSURANCE 01/12/2007 THIS CERTIFICAJE IS MUED AS A MATTER OF INI'UKANKIR Richard Bertolino Sr Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1200 Salem St N121 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Lynnfield, MA 01940 INSURERS AFFORDING COVERAGE NAIC M RJs1Ass RNamERA Penn Millers Hikolas 8antz:i5 eeR .& Zurich Insurance 35 Harvest St w mC: Lynn Mass 01902Rrslr+al D: _ O anER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 POUGES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. ma PONCY IXRRAIIOx DLfIS LTR mSRD IVPEOFNSYRANDE DATEIMamMY) pAIE A OAERALLYImYiY PAC 6613047 08/01/2006 08/01/2007 EACNGCCINRIauCE $1,000,000 X •wMMERCW.cEIBL.lLUBWTV FREMafS(4 RmeaRel $1,000,000 % f X cWN6 RA0E ❑GCCIm MEOFYPwwRee l+�Fl] 55,000 PENaoNALS HYY WIRY _ $1,000,000 ae1FAAL AGGREGATE s1,OD0,000 GFNLABGRLfiStEDNT ApRIES pet �HiODUCTS-COAT b AGO S1,000,000 R%LY71 LOL AVIOYOBAEMASRl1Y COlmREDSNGIE LIMD S IEa eecNRq MIV/NTO ALL OBTmADT05 BOdLY WLRY i seREDlAmwvras (Pe,weml I AWOS BOLYLY RM i NONONIAED AUTOS (PN-dd-f) AiD1EERRt'Y OIaFLE i InR eetiOe,Q awAaELwm.ITy AUTOOALY-EAACCIOBi! S ANYMRO 017ER TNAN IEA O S AUTO ONLY: , S ��yyygygBury EADHOCCIRRFNCE S OCCUR ❑CUa5MADE AOOREGATE S S oElA1CTeLE i i I REIeVTbN S ( i ' 8 iwDRltaa cONPeaATDNAND 5563c95706 08/19/2006 08/29/2007 TORv uMrrs ER EATLOYERS'VAWTY EL EACIIACCIDEM a100,000 �AW PROPRETQiNARMER.FJIECUfNE OFFCER NSER EWIA0607 E.L DISIA—EA 19,1 E $500,000 WECNL�PNOVIS�IONSb E.L 0I9EASE-POLICY UNIT $ 100,000 OMEN OESCRPtONOP OPBIMTnN1110CAlIONSlVB11ClE31IXCWSnH4/IODEO BYBnORSEIE]R/SPfWlN10NE101E Seperate cart has been ordered for holder from Zurich and Mass Workers Comp Rating Bureau 175 Marlborough Rd Salem Mass CERTIFICATE HOLDER CANCELLATION City Of Sales saoms ANY of THE AswE oESCNIEm POLICIEA m R Cs_ BEFORE TIIE EImaILT70N Attn Building Department DATE TNeEOF. THE g511N0 NNUREA Pml ENDEAVOR TO MA0._DAYS zYmRB1 C9M 120 Washington St NORCE 10 AIR W No.OEN NAMED TO 1ME IJ3f, T FAIJ RE W OO SO SNALL RAeOSE ND OmmsllON OR LM®JP/ OF ANY NIS UPON T7E MINTER, RS AGEIPS OR Salem Mass 01970 REPREseTmmEm A V RIONRED pFPRE9ENmTNE Richard Bertolino ACORD 25(20011AOB) ACORD CORMOMRMATION T93B T 'd BTLOTES8L6 817 01-11101.IBH p-Jeyotb eSS =OT LO 81 TIC it ✓7e '(iomnnaruiea.�Go ✓L�aaaac .uae�ld . BOARD OF BUILDIN G REGULATIONSr License CONSTRUCTION SUPERVISOR Numb4r:CS 090806 Birthdate:'06/29/1967 F ' 'A Explrss. 06M/2008 Tr. no: 90806, Restj.Fted 100. _ = NIKOLAO SI HANT�ISi 35 HARVEST ST ``i`i ./_.� / ,4 LYNN, Mq 01902` C-^�^ /J � x� _ --Commissloner :1 �iie iJamvnwn.I4e¢/,f� o� aael�d Board of Budding Regulations and Standards ` HOME IMMOVEMENT CONTRACTOR 41 . Registration 143891 ` Expiration 8/10/2008 ' , Type Individual p NIKOLAOS.I HANTZIS ~ � _ a " NIKOLAOS HANTZIS - 35 HARVEST ST ` LYNN,MA 01902 Deputy Administrator i GITIC©F��E,t PUBLIC PROPERTY DEPARTNI&NT ►umF�r o•�•+. %Gros t 30 WARGNG on STN"T•uLW4 yk-1,n 01970 M.r$-74i9S"•FAX 976-74&M6 APPLICATION FOR TAR REPAIR RENOYATI N CONSTRUCTION DErIOLI'TION, OR CAANGE OF USp R OCf'rrp,—CY FOR ANY VULI M STRUCTURE OR BUILDING 1.0 SITE INFORMATION " Location Name: i3uilding Property.Addrew - - 11S i'y1AIZI- 3ozau,�,- H Rog Rroperty Is loeaW In a:Conservation Arse Y/N 0 Hlstorlc t]Istrld Y/N 2.0 OWNERSHIP INFORMATION 7.1 Owner of Land Name: 2 —11 Address: �7� l�F2L42pi?Uuy�l Vv� . Teleptane: - 9a _ d 7/ 3.0 COMPLETE THIS SECTION FOR WORK IN EYISIINtz BUILDINGS ONLY Addition Existing Renovation �(J Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (so Renovated construction or renovation I of existing building New Brief Description of Proposed Work: A'11/*C" // .j //V 66L,J Wi7N t/YnuI. iced�krCC-r-�C� �,r,�Da c.u5 c�1 .0 ' 7 / ah1 � �/ASS, �P✓+a� /d^�7 -- -- Mail Permit to: -tfw� /75' i1//�!4 oRO / - -- p 6 S nD C..n v1 What is the current use of the Building? many units?�— Material of Building? a cX> J If dwelling.how Asbestos? A-I a will the Building conform 10 Law? Architeds Name Address and Photo Mechank's Name Address and Photo (fS Az c9coc HIC Registration Conatniction Supervisors License 0 Estimated Cost of Projed S 5�--C6. OO Permit Fee Cak ulatlon permit Fee= �J Estimated Cost X:7/s1000 Residential- - -- - . Estimated Cost X S111S100Q Cammrtmercla! —-- -- An AddWonW $5.00 is added as an Administrative charge• Make sure that all fields are properly and legibly written to avoid delays in proceasing- The undersigned does hereby apply for a Building Permit to build to the above stated specifkations. Signed under penalty of Perjury Date -3d_p � o 3 a `d x a 9 V r ... 7 1