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6 NICHOLS ST - BUILDING INSPECTION (2) CrIA, OI. S.A1."1:JI 1,I)A \•Illm 1, jl21I I • �'d ! 'I.\I \..\ III .I u19t, ll I.'1-8,-�li Oi'li q I �\ 9-4.-.I11 '18.10 APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS IMPORTANT: Applicants must complete all items on this page SITE IN'FORDIAT1.9N Location Name � tyt G'It wk S — Building Property Address Located in: Conservation Area Y/N Historic district APPLICATION DATE Use Groups (check one) Group Homes R3 124_ Residential Q or more Units) R2_ Type ol"improvement Residential (hotel/motel) Rl _ (check one) Assembly(Theaters) Al _ New Building_ Assembly(restaurants & clubs) %2r_A2nc_ Addition Assembly (churches) Al Alteration Business B Repair/Replacement Educational E_ Demolition_ Factory (moderate hazard) Fl Move/Relocate Factory(low hazard) F2 Foundation Only High Hazard H_ Accessory Building Institutional (residential care) 11 _ Institutional (incapacitated) 12_ Institutional (restrained) 13 Mercantile NT_ Storage _SI _Mndcrale I-lazard Storage S2_Lnw I lizard ON NERSI IIP INFORMATION(Please it Print Clearly) 0WNER Name ,lUC.t 13drhSfe.l >1 Address jV .CLpjS Si, SaA . YhA 0177D Telephone vv Signature D FSC It I PTION OF %%0RK TO BE PE RFORDI E1) W1 I R� rt�l d� Iv s✓ ;��— y ')-!iG -�rSer�o,S w'ndy.�i/ Lh 9a►.�yTr_ Fs ITNIA t'ED CONSTRUCTION COST CUNT RAC'FOR INFORNIA'r1UN Name WLvF Grlyt/ � 8 Address 24 13tYj yf ow uK Telephone 617"k17-1743 Ls Construction Supervisor's Lic # Home Improvement Contractor# ARCI11'rhCT/1iNU1NE'ER INFURIATION Name Address Telephone Mass. Registration # PERMIT FEE CALCULATION Estimated Cost x $ll/$1,000 + $5.00= COMINIENTS The u ndersigtted applicant does hereby attest that all infortnatiott stated above is trite to the best of my knoivledge under the penaltiesTof perjury Signed �&t I (owner) (agent) APPROVED BY : DATE' APPROVED: 407/—A-�r CITY OF SALEM ; i PUBLIC PROPRERTY DEPARTMENT hl]I It:ktl1Y:)K IX:s n.l. \I�tt'a 12C WASHING I ON S LKEET • SALC\3,MAssA(l it st.i'i s 0197.^, 'fist.,978-745.9595 • F.kX: 978-740.9846 Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name ll3usincssi0r aniratinn/Individuap: C sly;Stale Zip: U�q 2(/ Phone is �`7`0 �7— 77415 :\re you an employer?Check the appropriate box: 'Type of project(required): 4. ❑ 1 am a general contractor and I I.❑ 1 am a employer with G. ❑ New construction _ Kiployces(full and/or part-tints).' have hired the sub-contractors 2 1 am a sole proprietor or partner- listed on the attached sheet. : �- Remodeling ship and have no employees 'these sub-contractors have S. ❑ Demolition ,working for me in any capacity, workers' comp. insurance. 9, ❑ Building addition (No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] of itters have exercised their 3.❑ 1 wn it homcuwner doing all work right of exemption per NIGL 1 1.❑ Plumbing repairs or additions myself. LNo workers' swop. C. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t cmployces. (No workers' 13.[j Other comp. insurance required.] Any,i,l licant that checks box of muss also fill out the.section iwluw showing(heir worku3 cumircmatio,policy information. - 'I lumcowrlen who submit this affidavit indicating they are doing all work and then hire outside cwuructom must submit a new at'fdavit indicting.such. �C'omneun that check this box mtul attached:m additional shut showing the vote of the subcontractors and their workers'comp.policy information, l um air employer that is providing workers'compensation insurance for my employees. Belary is the pulfry and job site infonnution. Insurance Company Name: --......._.-.... . I'olicv it or Self-ins. Lie. r,'; - _. _. Expiration Date: Job Site Address: City/Slateizip: Attach it copy of life workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ul':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 a STOP WORK ORDER and a fine of up to S250.00 a day against file violator. lie advised that a copy of this statement may be forwarded to the Office of I❑v .miga tions ul the DI for insurance covcrago veri beat ion. l do hereby certify a�n/dJer a pains and penalties of perjury that the information provided abovee is true mrd correct Sicnaulre: l'l, t CI-7- Official use only. Do not write its this area, to be completed by city or town official. City or'fown: __---. _ Permit/License X.- - Issuing Authurily (circle one): 1. hoard of health 2. 13uildiny Department 3.Cilyi fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other __..._. . _ Contact Penou: _. . .. _--- Phone #: t Information and Instructions ,,lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuarht to this statute,an emphgyee 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"an individual,partnership,associatiou,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." that"ever state or local licensing agency shall withhold the issuance or chapter 152 _SC 6 also states 6 R Y �1GL chap , s OY 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, rvIGL chapter 152, 325C(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 time 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 line. City or Town Offlelals 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. I'kase be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permiu'license 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 ahome owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. it clog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he of lice of Investigations would like to thank you in advance for your cooperation and should you have:my questions, please do not hesitate to give us a call The Department's address, telephone and fax number: 'The Commonwealth of Massachusetts t 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 Revised i-26-05 www.mass.gov/dia ` .4CUD BEANMA2 12 16 O8 CERTIFICATE OF LIABILITY INSURANCE OPID CM DATE(MMIDD/YYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Benevento Ins. Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 497 Humphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Swampscott, MA 01907- Phone: 781-599-3411 Fax:781-581-7200 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A. NORFOLK 6 DEDHAM INS. CO. 23965 INSURER B: Matthew Beane INSURER C: dba Matthew Beane Construction 34 Bellview Avenue INSURER 0. Salem MA 01970 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 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 REDUCED BY PAID CLAIMS. POLICY NUMBER P LI Y EFFE T E POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE DATE MM/DOM DATE MM/DD/YY GENERAL LIABILITY EACH OCCURRENCE $ 500,000 A X COMMERCIAL GENERAL LIABILITY R0403682A 12/03/08 12/03/09 pREMISES(Eaocoarence) s50,000 CLAIMS MADE [j] OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY F PECROT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—ICLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORV LIMITS ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE It If yes,tlescriba untler SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS REPLACEMENT WINDOWS CERTIFICATE HOLDER CANCELLATION CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN CITY OF SALEM NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL BUILDING DEPT IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 93 WASHINGTON ST SALEM MA 01970 REPRESENTATIVES. AUTH ED R ESENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER j The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 26(2001108)