6C NIMITZ WAY - BUILDING INSPECTION (3) WARM TRADITIONS
STOVE SHOPPE
/y A Division Of
AQUA TERRA PROPERTY MANAGEMENT, INC.
Contractors License # 0.32756
Edward A. Ferguson, Jr. uo 46 ef�ottmr atu{( e an�ff ">
Construction Supervisor License
License: CS 32756
Birthdate: 10/15/1954
Expiration: 10/15/2009 TO 5454
Restriction: 00
EDWARD A FERGUSON
15 PICKERING ST
DANVERS, MA 01923 Commissioner
Home Improvement Contractors License # 134399
Aqua Terra Property Management, Inc.
Edward Ferguson
R�ilri(1Pn r r r "KrgilfifliriTs�R�nr ar s
HOME IMPROVEMENT CONTRACTOR
Registration: 134399
Expi ration: 1 1/132007
Type: Private Corporation
AQUA TERRA PROPERTY MANA
€bKNT)"rERGUSON.
144 PINE ST.
DANVERS, MA 01923'
A dininistramr
144 Pine Street, P. O. Box 2081 Danvers, MA 01923 978-777-5562 1-800-286-5662
_. ci.OJ !J:✓JO 'tGM.Ir+. IiUI_L lean/J�}I y :/I�-f(d'i`l�rJ:7C� hl)."q° 0�j_'
The Commonwealth ofMassaehuseffs
Department of In4uHal Accidents
OfJlee of lnvemestrions
600 Waahinglon Street
Boston, MA 02111
www.massgov/dia
Workers' Compeosation Insurance AflMdavit; Builders/Contractors/Electr'ic(ana/Plumbera
Applicant 1plform tt on Please Prim t-yzioly
FAQ Terra rope�it} f`kAnGt t'n1Pf1 Inu
Name (3us=V0rpniz4noWndJviduap; A7bft _u
Addlcss:— 1 `+ 4 `f7,1C' Stye+- `P. O. bOA L�04ESI
Ciry'Sute/ZiF: t����e Phone hl q7� --
Art you ov employer? Check the appropriate base Type of project (requlred):
1. 1 am a atlpL:ya with _$_ 4. ❑ I am a general cantracmr and 1
rmpioyut (tull aod/ol pan•timc) • have hired the sub-cootraama 6. Q New consbtcdon
1. 1 um a sole proprietor of parmer- 0stod on the attached sheet t 7. ❑ RemCdding
ship and bat a oo employees These sub-contractors have g ❑ Demolition
working fol me in any"Pack. si'orksls' corny, instuance
(No worknn' ooaV insurance 5. Q We are a corporadoaits and 9' Q Building additiCo
req-ainW j officers have exercised their 1,0.❑ Electrical rt7airs or additions
1 1 _ 1 am a homeowner doing all work rigbt of exemption pet MQL 11.0 Plumbtog repass or additions i
mYWCtu 'No workers' comp. c. 152, 41(4), and we have no 12.❑ Roof repabs c'-
ineance roluired.j r employees. (No workers' 17 0 Other
comp. ma MDCC required.)
nny ggncted Jwi cb" lox aI moo w'ao all ow it,motion blow sWwina their vore,60'uontpmrtaoon puller mforrnnon
t n,mwowo�rho wbmt ant rNidavit mdmlina they on doing NJl rmt snd Ihso Mr,outride oonmston muse rwyrult a No,ef5durt oA,&rina wed
L one.cton J..i thmc No>ua oua ntxched an eddid mA thni showhta M nanz of tit wt*oanmaxa end than worsen'wntP, poled :net, "%imw
1 an ae employer that is provldlny worker"rosaprnsarled/nSwronce fpr my employers Beiaav is sba policy and job site
in fd rm town
InsuraoaCompan) Ntttse._ ft l•Cl1f) nC�_� .
PClin' a or Sclf its. Lic. H _ 1,L)(" loE 6 73 y( _ Pxpiradoa Date:
JobSitcAddrest._�C ifY)i� �Ciryistateaip &
Anacb a copy of the workers' compehaatlod policy eclarutio» page(Showing the policy number and eaplration date(Lt-v+ c InS
Failure Ice saws =eetage as required under Secdon 25A of MCL c. 152 can lead to the imposition orcrimjnal peaaltic5 of a
ftnc up re 51-500.00 and/or one-year hnprisoameat, as well as civil penaWes in the form of a STOP WORK ORDER and a fine
of w w SIS0.00 a day against the violstor. Be advised that s copy orthis statement may be forwarded to the Office or
I0vr3deadotu of the 01A for inswanee coverage vorilicatian.
1 do Aercby tees r the pal that the fnforsnar proltiQtQ above Is ftr aAdd crrrccz
Sienaanc /_�_p �1 _ Da /O`Ic� •O/
?hope a
OffIrial uur edly. Do nae wr4e in rms area,to be ro,nptarad by add or rows offlc's'dr
City or Town: _ Permh/I.lcease a
Isselgy Authority (drrJe one);
I. Board of Health 2. Balldlog Department ;, City/Towa Clerk 4, BAecirical Inspector S. Plumbing Inspector
6 Other
Cn Rigel Person; Phone M:
Information and lnstructions
Massacbusetrs General laws chapter 152 requires all employcs•to provideworkers' compensation for their employees.
Pursuant to this statute, an employes is defined as "...everypersen in the service of anotber tinder any contract ofbire,
express or implied.oral or wrrtte0." -
An employer is defined as"an individual,partnership, association,poa;=o ;on ar other legal entity,or any two or more
of the foregoing eugagod in a joint eaterprisy and including the legal representatives of a deceased emplgya,qT the
receives or trustee of an individual,partnership, association or other legalentiry, employing employees. llowr:&the
owner of a dwelling house having not more than three spartments and who resides thereic6 or the occupant of the
dwelling house of another who employs persons to,do mainumanee,construction or repair work on such dwelling house
or.wo.rbc.gmltnds.wrbu lidg _ tbeoaussofanebcmy7eYrneeutbedeearedtobeaa• q,
MGL cbapter 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 perform=cq of public work until acceptable Mdeoco of compliance with the insurance
requirements of this chapter have been presented to the contracting autbority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boraces that apply to your situation end,if
necessary, supply sub-contractors)uame(s),address(es) and phone amabc*)along with their ocrtibeako(s)of
insurance Limited Liability Companies(LL4C)or Limited Liability Partnerships QJ.P)with no employees other than the
members or partners,an not required to carry workers' tomopexsation insurmce. If an LLC or LLP does have
employees, a policy is required. Be adyised.that ibis affidavit may be submitted ttf•the Department of bndastrial
Accidents for confirmation ofinsunance ebverage. Also be,apre to stgp•and.da}eih'e,afa�syit The affidavit should
be returned to the city or town that.the application for tha permit to license is being requested,not U Department of
Industrial Accidems. Should you have any questions regarding.the law-or ifyou are required to obtain a workers,
compensation policy,please call the De pmltncnt at the number r listed below. Self-mitred Companies should enter then
self-insurance license mumber em the appropriate lino. .
City or Town Ofllcials
Please be sure that the affidavit is complac and printed legibly. The Dcparhaeut has provided a space at the bottom
o f the affidavit for you to fill out in the event the Offiee ofInvestigations has to contact you regarding the applicant
Please be sure to fill in the peranidlicense rumba wblch will be used as a reference==obcr. In addition,an applicant
that mist submit maltipldpermiUlicegse applications in any given year,need only submit.one affidavit indicating current
policy information(if necessary)and undo"Job Site Aft="the applicant sbould write"all locations in (city or
town)."A copy of the affidavit tbat bas been officially stamped or marlced.by the city or town may bepuvided to the
applicant as proof that a valid affidavit is an free for futurepemats orSecuses. A meow afUxvit m stDc acd out each
year.where•a home owner or citizen is obtaining a license or permit not related to any business or commercial vexuae
(i e a dog license or permit to burn leaves etc)said person.is NOT rex e d to complete ibis aWdrdt
The Office oflavextigations would bike to•thank you in advance for your cooperation and should you have any questions,
please do Dotlpsitateto giveus a call.
The Department's address,tole pbone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfIIee of Investigations
600 Washington Street
Boston,MA 02111
Tel.# 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-os Fait# 617-727-7749
www.mass.gov/dia
Department of Code Enforcement
Debris Disposal Affidavit
In accordance with the prooisions of GL,C. 40, sec. 564, a condition of permit 0 is that the debris
resulting from this work shall be disposed of in a properly licensed solid waste disposal facility a; delingd by
4L, c. l 11, sec. 150A.
The debr;s will,or has been disposed of at:
�, ��tio "Pr oigd3
Location of Facility
1,
Location faction/jobsite (Street Address) —"—"
Signoture ofapplican ' ontracto PDate
r
CITY OF &U.&M
PUBLIC PROPERTY
DEPARTMENT
a�n��ossoou
NAroa 130 wA9aNGTON SrMW•JMEK M. &UM =M 01970
T&--978.745-9M•FAY:978-740.98"
HOMEOWNER LICENSE EXEMPTION
Pkrw Print
Data
Job Location P,e Pa.g
Home Owner Address d e ti itn,ra w,4 Y
Home Owner Telephone -_ 91 F, 7 �. 6 >i
Present Mailing Address 6 e 2r,M„7- w a y
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she reside@ or intends to reside, on
which there is, or is intended to be,a one or two family dwelling. attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATIJFRE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
q
EITY~OF
PUBLIC PROPERTY '
DEPARTMENT
w►raa
i3oev►wu+�,,, 7+s+sssUL esn Own
ONSTRUCn
IMMOLMON,OR CHMGZ Olf Usk OR Wffi n;" i..R .
1.0 an INFORMATION
London Namst tluYd4 w.
--
-- -- -- -- --- -
F Property is locaMd in a;Conrsrvatlon Area yM Hlslor(p t>NYlot
a
° 2.0 OWNERSHIP INFORMATIOL—Aoc
M Owner of Load
° Nam.: i Buis` SAddrsas: G c N i . y7o
TeNhorw
3.000MPLETt3 THIS SECTION FOR WORK IN EXLM3NQ BUILOINOS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition
Existing
Approximate year of IArea per ROM (sf) Renovated
constn+ctlon or renovation
of existing building New
Roe!Description of Proposed Work:
r 95tAcy /ef- S�o41e
11 b e r�sal/e� A)
Mail Permit to: �� rrs� SE,
`• use d tM guibinp?
What is the uxrot M dw how many units?___-------�
tutatarifl d dt
Bu� np? �jDP`F y S Aab*WM? 0
auilav Confam to Law?
AP*Asd*Name t
Address and PtwM
Madwies Nano
Address and Phone o 7 AHtC ROOWSWn d su
Constn+dlon 3— j
Pov�llunse d
pamr< CakuMli
Fee a ,.,,�O�-
F-sanded d Project meted Cost X:71SIOW R*@WwWl
vc+
PW"Fs+_ 5 Eatln+atadd Cost X Si usio0o c4nw r�--_.
-- An A dO"S6A0 is added as an
Administradvc chwg&
lUaw qua that aY ttelds am Propel" and leytbiy vKitten to avald delays in P ^4'
The wWws +*d do"hweby app*for a SuUd"Pwnd to WN to the above stated
epococgftw Sip"under Pence Of Perry
Date
3
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