20 OLIVER ST - BUILDING INSPECTION �w+s eEon APPROVeD sr INE
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CITY OF SALEM
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PLEASE PLL OUr LIMISI.Y a CONPLUMY TO AVOID OKAYS N PROCUSM
TO THE INSPECTOR OF OWLDIN08: '.
hsnby sppbs for a pork to build a000rdbtp.to Mtfr.folwaN
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DESCRIPRION OF WORK TO N DONE
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CITY OP SALIMq MASSACHUSMrTS
Pusuc Pwaramw DarARTMENT
120 WRS"lNOTON STIIaaT. 340 R R
SAL-M.MA OI S7O i
M (07017411-001915 CU. 360
PAR (9170) 740.00"
STANL6V A UG VIC& JIL
DISPOSAL OF DEBRIS AFMAM
Is mO daees WA(be psOvidm Q(UM O 44 U4 I aebaowledge do m a cood dom
ofB1ift Peak if all debris numb*fins as oaassudim adiviyr
Sovemed by this Bwl ft Permit dmA be digm d offs a pope*Ikamed SOH64vu"
dLpoed Baft,as defined by UM a 1%SIJQA.
Mis debris wM be disposed atme?a�1 /� �f �/,urrrb4,'
Ldeadm ofPadlity
S Afty of Pau#4AVpncw Dale
FULLY Casopleta Ibe iblloari%MhM a"
(PLBASB PRIM?CLRAnY)
Naas@ of Ponait AppHcsd
c /sue. .
Fire Nacm if say
.37f 7ieeac Nc� Swb�
Add mes.City A State
Dw above statute regw m(bat debris bm(be dnohdM rmovsw% rehab or odw
akaldw ofbWUbl or sttlrcoae be disposed in a properly-S med so"Waets disposal
haft err defined by M(X caL SISQ& mad the hdWiq permits or fieeases m to
iadiab the locadon of the hah't.
ueparrerenr of[naasrrra.9ccuun13
O,aiae of lXWsdlgdlons
600 Washington Stud
Boston.MA 011ll
www:nrass gow✓ad
Workers'Compensation Insurance Affidavit: BWMen/Contractors/Elect ickns/Plumbels
Applicant Information Please Print Legibly
Name -1;%e� /3-wx
Ads : & 44e hnwk- A,r,/
City/State/Zip: .r " Phone 0: FJ�
Are you an employer?Cheek tke wropriste box Type of project(required):
1 s employer with T 4. ❑ I am a general contractor and I
employes(62 and/or part dm4o have hued me won 6. ❑New conahnction
2.❑ I aim a sole proprietor or partner- listed on the attached sbeet t 7. ❑
Remodcling
ship and have no employees These sub-contracton have S. ❑ Demolition
for me ID ��' imurensG 9 ❑ Build in addition
wotxltios enY rol�Y• comp.
(No workers'comp-insurance 5. ❑ We are a corporation add its
offers have eaacised their 10.0 Electrical repairs or additions
3.❑ I am a homwwner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself [No workers' comp. c. 152,)1(41 and we have no i
iePairz
iucoramce required.)t aPbycu• [No workers' 13.0 Other
comp.imm anc a mquued)
'Auy eppticmt duns ehecas box e1 scud WO an out less Raise sta below wl"unk warm' policy iofosetrd�
t Homeowwn who su1 1 min*M&vit WCOM dray m dams sir wok and men bue aeside mubactas mud submit a mw ae36vk mdwasfna suck
rConereton dM cheek rots boa not ditcbW an ddit mW sbwt showing mo name of der msowemtoe and dw wmkm'conq.poVq ndbrrnetkmL
law or employer that is provldbW awdwrs'compemsados hunre eefor dry employees detow h ikepoiiry and job sits
Insurance Company Name:
Policy 0 or Self-im.Lic.l: Expiration Date:
lob Site Address:__ 26 G/vtr s City/State/lip: syee� /W
Attach a copy of the workers'compensation policy declaration page(showing the policy number and ezplratiou date).
Fail=to segue coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year inVrisosment,as wen as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigation of the DIA far insurance coverage verification.
I As bairbyeero under rice polar sal ps 00RIary that Me brfwmdioa provided abo►w is ono and eorreex
Sismattue: Date•
O,oldd ass only. Do erns write in this area,to be cowpldd by cly or town o,Qlelet
City or Town: PermWLeeme 0
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Persom Phone 0:
Massachusetts General Laws chapter 152 requires all employen to provide workers'�ansation for tbetr enrproyc'Pennant a this stem% an earp/oya is defined as"...every person in the service of another user any contract of ltbei
,xprM or implied,oral or wntoea." .
"offer it defined as"an i�idmviaiial,partnership,as�aatwn'corporation or other legal entity.or any two or rrrorAn e
of the foregoing m!loot etiterptisr,and including the legal representatives of a deceased employs
receiver or tranus of an mdrvtdt A pareaas>>ip,association or otha legal entity,�PhoY emPloYea
WCVCW
owner of a dwelling bonne laving riot mene than three and who resides lherem,Or the ocatpant of the
who employs persons a do mamtensuM construction OF wort on such dwelti g house
dwelling boast of atiother thereto sban not bets of such employ mut be damed to be a employer."
a an the grounds or buildingappurtenant
MGL chapter 1s2,425C(�also states that"every state err,WW liceo t agesey slat wkbMM the haaatsa or
reaewd of a license or Perm to aP"c a basism or to construct buildings V the eommoaweaki fa see
who has mat produced acceptable a deer of compilance with tbs,iasaraaoe coverage required.»
APPKCWA Additionally.MGL chapter 152,125CM staid"Neither the eo>mnonaveai®rem any of its polideal so Iona sbaIl
enter into any eontrnet fbr the perfotmate of public we*until acceptable evidence of OOUVVanee wi&the m W"W
requirements of this chapter have been presented a fe contracting atiodly."
Appikaub
please fill out tee workers'comPmsation affidavit comph tely,by checking the boxes that apply a your situation and,if
necessary,supply sab-eon °r(s)wnw(sN address(en)and phone ambers)along with their cabficate(s)of
insaraoce. United Liabft Companies(LLCM or Limited Liability partnerships W)with no employees other the the
member or Partners, an not�ed to care,workcn'compensation bsmaoe. If a LLC or L1.P does bavo
membe o a policy is inquired Be advised that this at6davit may be submitted to the Department of b&WUial
Accidents for confirmation of insurance coverage. Also be sure to dui sad date the aQldsvk !ter affidavht should
be manned a the city or town that the application for the permit or license is being requested,not the DelmontOf
lndustrial Accidents Should you have any Vernon regarding the law of if you an required a obtain s woricnte
compensatioapolicy,pkM call the Depa UDW at the Fr listed below. Sclf-insured compaoia should enter they self-insurance litetise tnmrber on ihe liDL
CHY or Town Officials
please be sure that the affidavit is complete and printed legibly. The Deparmuent has provided a space at the bottom
of the affidavit for you to fill out is the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fib in the perimtjceme number wbich will be used as a reference IN In addition..an applicant
that must submit multiple pM=0iCcM aPD>ications in any given year,need only submit one affidavit indicating currene
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations is (city or
town}"A copy of the affidavit riot has been otBnsily ataeyed or marked by the city or awn may be provrdod to the
applicant se proof that a valid affidavit is on file for fhtme permits or licenses. A new affidavit must be frilled out each
year.whore a bome owns Qf citaea is obtaitiusg a license or permit not related to any business oremomercial veakm
(ie.a dog license or permit a burn leaves ere.)said Aaron is NOT mqu6ed a complex this affidaviL
The Office of Investigations would hte to thank you in advance for your cooperation and should you have any question+,
please do not hesitate a give us a tags.
The Departmont's address,telephone and fax numbs:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigatlona
600 Washington Strut
Bostan,MA 021 It
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax,#617-727-7749
Revised 5-26A5 www,mass.gov/dia
i
j 8/8/2005 12:52 PM FROM: Fax O'Keefe Brothers Construction Inc. TO: 19787409846 PAGE: 001 OF 002
F
• O'Keefe Brothers Construction Inc.
• 397 Linebrook Road
• Ipswich, Ma 01938
•
•
•
To: City of Salem Building Inspector
Fax number: 19787409846
From: Kevin M. O'Keefe
Fax number: 978-312-1065
Business phone: 978-836-8026
Home phone:
Date &Time: 8/8/2005 12:52:33 PM
Pages: 2
Re: Roof Permit 20 Oliver Street
;i AUG-04-2005 THU 03:01' PM INLAND UNDERWRITERS INS FAX N0, 18009326717 P. 04/04
..... .......
t
t
r
I
I
I
Obligee Name
# City of Salem
Qbligee Ma Ming Address
120 Washington Street
u
Salem, MA 01970
f Policy Number
08BSBD09S13
IMPORTANT NOTICE TO OBLIGEESIPOLICYHIOLDERS -
'I TERRORISM RISK INSURANCE ACT OF :2002
You are hereby notified that, under the Terrorism Risk Insurance Act of 2002, effective
November 26, 2002, we must make terrorism coverage available in your bond/policy.
However, the actual coverage provided by your bond/policy for acts of terrorism, as is true for
all coverages, is limited by the terms, conditions, exclusions, limits, other provisions of your
bond/policy, any endorsements to the bond/policy and generally applicable rules of law.
Any terrorism coverage provided by this bond/policy is partially reinsured by the United States
of America under.a formula established by Federal Law. Under this formula, the United States
will pay 90% of covered terrorism losses exceeding a statutorily -established deductible paid by
sureties/insurers until such time as insured losses under the program reach $100 billion. If that
occurs, Congress will determine the procedures for, and the source of, any payments for
losses in excess or$100 billion.
The premium charge that has been established for terrorism coverage under this bond/policy is
either shown on this form or elsewhere in the bond/policy. If there is no premium shown for
terrorism on this form or elsewhere in the band/policy, there is no premium for the coverage
Terrorism premium: $0
Form 04333-0 Page 1 of 1
0 2002.The Hartford
R
8/8/2005 12:52 PM FROM: Fax O'Keefe Brothers Construction Inc. TO: 19787409846 PAGE: 002 OF 002
I '
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r CLJTV -.7$1}729-z522 FAST (781)7ZR-41)83 THIS GERTIMATE 15 ISSUFD ASA MATTER OF INFOPMATION
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