16 NICHOLS ST - BUILDING INSPECTION (2) OQ
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CITY OF SALEM
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PLUM NLL OIR L mmy a CoYP1.ETt:LY TO AVOW DELAIfs N PROCEay
TO THE INSPECTOR OF BUILDINGS:
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The Commonwealth of Massachusetts
= Department of Industrial Accidents
At
office 911n agadOns
600 Washington Street, 7rh Floor
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit: Building/Plumbin lectrical Contractors
PlePJNTatut
121 - aan�-� ��p *• -�_./°-' �
name: 4421E.2ilnh
address > 'eyg1�>�L1/�
c� ./v9f✓2(� ��/�' state ////mil �+ zip: 641d1Q1 phone# 2//-!✓7 A15� '
work site location(full addresA /VW o IS J r ;lem ///r/
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ I am an employer providing workers compensation for my employees working on this job g y company name: - c,Y*.3.�'
rt ^gam " Ntb "R •G" '� ``3� #Si � ���
address.
=.Y+r a- ryµ "4 3
city: S.
insurance co.
' am a sole proprietor,general contractor,or omeowne'r(Circle one)and have hired the contractors listed below who have
the following workers' coin nsation olices:
comuanv name:
-'� 4 x
address: �/. /1/ /L Lae
city: 0"lAalul4,0 2 .. bone M: X l JO..,./6u,
insurance co. ¢11211/tl�L"zy; j # -
. .
coin an name• � � � ��"'"� ' � '�d, �t�
Yr
address• -.>e.�a,.,<
city: obone#
insurance co. ' nolicvff s�
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f+
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties perjury at the i
nformation provided above is true and tarred.
signature Date 37 Zh,S
Print name 6AAr Ne- y2/L .f e4 /.0 Phone# 7�1 �/. 3 ��
rED]
use only do not write in this area to be completed by city or town official
own: permit/license# ❑Building Department
❑Licensing Board
k if immediate response is required ❑Selectmen's Once❑health Department person: phone#; ❑Other
pi.203)
FROM RoBERTS INSURANCE FAX NO. :9786833147 May. 05 2005 11:30AM Pl
Ra DATE(MMIDDIYYYY)
ACO
CERTIFICATE OF LIABILITY INSURANCE o 5
Pµnnllr.r.R A, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
HEATS INS AGENCY INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
M.P. I}O HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1060 -OSGOOD STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
NORTH ANDOVER, MA 01845
978-683-8073 INSURERS AFFORDING COVERAGE NAICN
INSIIRED S R S DEVELOPMENT CORP. INSURCRA
19 MARKED TREE ROAD INSURFR R
SUDBURY, MA 01776 INSURtNC
INSURER D GUARD INSURANCE GROUP
INSURER E
COVERAGE8
THE POLICIES OF INSURANCL LISTED RELOW HAVE GLEN ISSUF_D TO THE INSURED NAMNO AROVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING
ANY RCOUIRF.MENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMI N(WITH RESPECT TO WHICH THIS CERTIFICATE MAY OC ISSUrD OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED Hf_RFIN IS SUBJECT TO ALL TI IL I LAMS,CXCLUSIONS AND CONDITIONS OF SUCH
POLICIES AGGREGATE.LIMITS SHOWN MAY HAVE BEEN REDUCED MY PAID CLAIMS
MDA OD ... __. ..._ ru-ucyeFFPullv� POI ILYCXPIRATION
LM NDAD TYrE S fC POLICY NUMBER DATE MMIDDIYT DAIt MMlnnlYy LIMITS
nrNrRAL LIASILI I EACH OCCUHHENCt i
COMMr.RCIALGENCnAL LIAHII nY r",ISES(Ea occuranceL—._ i
_ LLAIWWnr r JULUK MFn FXNAn,n prn....) Y
rmn (JNAL 6 AUV IN)UNY 4
— frNrFAI. AGMIlGAIt
DEVIL AOOHEAATr LIMIT APPLIES Ptli I'mooUr,IS.COMPIOP AfiO
POI.ICv jItcj Ina
AU I OMOMI.0 LIADILITY COMBINED SINIII.L I.IMI I 5
ANYAI Rn IEe ecClVenD
ALL O WNFn AI ITnS Ilflnll Y IN.II MY
SCHEDULED AU I OS —
HIRED AUTO' nn DIL Y INJURY
NCN.UWNtUAU(OS IYRI ArejtlngD i
— PROPLRTY DAMAGE i
' (PPr RnridnnQ
rOARAGr:LIADILITY - AIITOONLY EAACCiDCNT i
ANYAUTU OTIiCn THAN FAAfG #
AUTOONLY AUG 1;
CXCCSS)UMBREI I A LIADR.ITY - - - - - -"Arm OCCURRENCE
_ I
uCOUR CLAIMS MAPF A,CRECATE _ i—
nc DUCTISU, i
RFTr:N I ION f t
TATI'G oTH-
WORHERSCOMPFNSATIONAND TORYIjmTb_ X GT
EMPLOYEHS'I IARII.ITv SRWC631527 04/01/05 04/O1/06 _ 500 000
ANY PAOPAIETowPARIw I E L EACH ACGDFNT S IIfXPf.UTNE
D OFFICERIMEMDLM LM IIinm) tL UI$bASF FAEMPIOYr. j .SOD,DDD
IIyyBJ,QOHAIDuunWl
SPEUTAL PROVISIONS below _ rL DISCASE PULICY LIMA 8 5 DDD
OTHER
DESCRIPTION OF OPF.RATION.".)LUCAUUN$I VGHICI GA/CXCLUSIrJNS ALII IFn nY f.NDOnSEMENI I$HCCIAI PROVISION.^•
ATTN; KAY DURKIN
781-937-5416
CERTIFICATE HOLDER CANCELLATION
NHUUUU ANY OF THE ABnvr❑r:;(nmr.D MaICILS Bt CANCELLED B FR RE THE FAPIRATInN
NORTHERN HANK S TRUST COMPANY PAfP IHFRr.OF, TIIC ISSUING INSURER WILL ENPPAVnR I(I MAII lU DAYS WRITTEN
215 LEXINGTON STREET Nonce IO IRE CFNTIFICATr.IIOLDEP NAMCD TU THE Ltl'I,nor FAII DHP. IU u)an SHAI.I.
WOBURN, MA 01BD1 WrOSE NU OBLIUAT10N nR I IAnu ITY nr ANY KIND uruN IHt INSUHtN,IIS AGFNTS(A
RFPPFSr.NTATIVCS.
AUI HORIZED RFPPFrr.NTATNC
ACORD25(2001100) / A O ION 1988
CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM,MA 01970
TEL. (978)745-9595 ExT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aclmowledge that as a condition
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in miy licensed solid-waste
disposal facility,as defined by MGL c III,S1SPA.
�Pq�ipMW�fJ(i24/lPs ,.�.� , ref •:
The debris will be disposed of at: 'f
Location of Facility
� Fy� �ss�a�HufFr1
Signature ofPamitApplibantill• rla ti fS Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
�S/ Gt�� d/ �' //�//7 .�Q'/CK/i/ Lin � JG//GC/✓1/ ��1(��/'l
Name of Permit Applicant
Firm Name,iff any
Address,City& State
The above statute requires that debris from the demolition, renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII,S 150A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SALEM
BUILDING DEPARTMW
Ii0ME0WM LICENSE VMdTION
Pkm Pdd
DA oS
•HOIv1E0�Vi� �///" /�✓ �'�/ • ( ArHFa�i�f Gl q �°
"Z53iff MAn 40ADDRUI ('�b A6 n <dl lush ,l/5oi l
The eurtesa.aemptioo d-bmmownas'was exaaded a brchde owwet-9;XuPl" d77Y0
Uaks a ko and w allow soeh homeowswss a es�sde an htdivida�llor hats Arlo does as ptw t, .
iiocase,.yrwided tEathe wwma ad as
aqwvbm
DEF24nOHOFHCmEQ tm
F.-now 0)who owns s rmwJ cf Lod on wbleh behhc asides a bftaft to reside.eo"Addt k 6r k
intended w br,s m a two!tuft dwc2n&ovadad a dwdtad Mucemes mmcuM 10 FxAl be t 9=ON
firm sovcwm A peen w•Lo wnstrucm mom thm me boat in a two-ym pow sbaE
addaw
s boawrowW. Suds-n meow•nd'sb&Frabn*w the BuDdbg O>ScK oats to*s
Bw'1d6K Odteiai.thn belslrc b<tespomtbk w aD tuft wak perfamad raft dse pestafi. '.
Tht wOcrsipW-bvmt aaumes tespotwibDity im mmylbmec`+igh the State Batt Code ad '
other aWc2bk`ocs by-bm,rain and n%ob iom
The wAmip od-bomaowm f ecrtiLn ti>a1 lrJshe wtdasutds*t CjW of S hm MW A D�.
p
mi=two bdpwdcm umduas sad ngtaremetas and that blahs wig=wV
HONMOWWR'S SIGNATURE
APPROVAL OF BtWING WSPECI Olt � '
$a other side for state code
HOMEOWNER'S EXEMPTION
- The code sssta dj-t'arq)wttteoarncr performias wvrk to srhicb s bdildirrg yamftb da M • - -
cxcroptfro®tla pavbiom of thb accdon (Scene 2tp u-IJccoslog d Goatrnttioa Septs ibm
provided*a b a lemeowner ergases 0 pcsco(l)for Mm to do.such W=k to Fad bomeowa-daif oei
mM lwroeo mean vbo we tbb cmurlm are itrawatc that tbey an aaam ixg to papoentbWw do
supervisor(see Appodc Q.Roks and Regoblloa for IJacoslog Coswrwcdm Sgwvlor a,Saeda.
L24 Thb Ldt of awareness atkn rcaula in sofas pobkms. n'be>.do, - * R wa bb
urdk=wd persona In this cast yom Bald saomot pocc d&Saba fie muxa-O popn at k i c va
lkeaecd Supovbw. The bom"weer acting as sopervbatr b abinsl*resrod fly .
To cusac dm�homeowner b folly awne otbUher•reepoo*Sblstla.map ooma�dde�:r pet .
of am pcnrrJi appliadm that da!tea czat An b&Ww I the rarpasl DO Rai do
mpervbm Yoe nay can to amcod and adopt raM a formlkofllllotias Sot ttaa is rate commod%