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-` The Commonwealth of Massachusetts
t>v;57, Department of Industrial Accidents
,_:;;; ? Dice of Investigations
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600 Washington Street
Boston MA 02111
>�µ[. Workers' Com ensation Insurance Affidavit
Property Owner Name: !� T
I Ict �nc n iVnfaca
Job Location: a Of c�)ra,Ccj ,5+
City: Phone#c1:2g gP57 �5
❑ I am a homeowner performing all work myself.
❑ I am a sole,proprietor and have no one working in any capacity.
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I am an employer providing workers' compensation for my employees working on this job. --
Company Name: C-G11"�I I n 44 C,c n I I (h 14-, A
Address:
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City: Q. Phone#
9 977 'ii�l
Insurance Co. Policy
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❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'`
compensation polices:
Company Name:
Address:
City:
Phone#
Insurance Co. - Policy#
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Company Name: ......:....
Address:
City. Phone#
Insurance Co. Policy#
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Failure to severe coverage as required under Section 25A of MGL l S2 can lead to the imposition of cruninal 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$100.00 a day against me. l understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby certify under the pains and pen ties of perjury that the information provided above is true and correct.
Cr �ture J
Date
Print Name
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermiU El Building Department
license# ❑Licensing Board
❑Selectmen's ice
❑ Check if immediate recnnnce it rennired ❑ Health Department
Contact person: Phone#: ❑Other
09/13/2005 TOE 12:45 FAX 2003/004
ACORD CERTIFICATE OF LIABILITY INSURANCE O IN DATE(RAM/DU YYVY)
CABIN-1 09 13 05
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-S81-7200 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA PREMIER 1N8URANCE AIC
INSURER B: HARTFORD INS. GROUP
Cabinetry Unlimited Enterprise
Peter Bagarella President INSURER C'.
122 Rear Main S INSURER D:
Peabody MA 0196 ... .. ... ......._
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 MY 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,
TSRLTR NS TYPE OF INSUNANCE POLICY NUMBER DATE MWDD DATE MM/ LIMITS
GENERALLMBILITY EACH OCCURRENCE &1 ODO OQO
-DAMACETO-REl -
A X COMMERCIAL GENERAL UABILTIY I-680-4753B409-TCT 10/21/04 10/21/05 PREMISES(ER� .) B300,000
CLAIMS MADE nOCCUR MED EXP(Ar a person) $5,000
PERSONAL&AOV INJURY $1 000 000
_ GENERAL AGGREGATE S2,000,000
GERL AGGREGATELIMIT APPLIES PER PRODUCTS-COMP/OP AGG S_2,000,OOO
POLICY PD G_ LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S
ANYAUTO E.accidvd)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per pereen)
HIREDAUTOS _—
--- -
BODILYINJURY S ---- _
NON-OWNED AUTOS (Per erclaenU
_. -- PROPERTY DAMAGE S
(Pcr acciden!)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT ;
ANYAUTO
OTHER THAN FAACC S
AUTO ONLY; AGG S EXCESS/UMBRELLALIABILITY EACH OCCURRENCE 5
7.1 OCCUR CLAIMS MADE AGGREGATE S
MDUCTIOLL y
RETENTION S g
WDRKERSCOMPENSATIONAND X TORY LIMRS ER
B EMPLOYERS'LIABILITY ANV PROPRIETORIPARTNERIEXECUTIVE 6S6UB-7963A75-A-04 10/21/04 10/21/05 EL.EACHACCIDENT $100000
OFFICERMEMBER EXCLUDED?
Kyyes,deeaibe UlMer E.L DISEASE-EA EMPLOYEE S100000_—_
SPEGML PROVISIONS W. E.L.—DISEASEPOLICY LIMIT S5000OO
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION
DATETNEREOF.THEOSMNGINSURERWILLENOEAVORTOMAR. 20 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
120 WASHINGTON ST
CITY OF IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR
NGTO
SALEM MA 01970 REPRESENTATIVES.
AUTHORS Fn REPRESENTATIVE
ANTHONY BENEVENTO
ACORD 25(2001108) mACORD CORPORATION 1988
PUBLIC PROPERTY DEPARTMENT
' 120 WAiNINOTON STRasT, 3RD FLOOR
SAI M,MA 01970
T[L.(976)74B-9590 EXT.390
FAX (078) 740.9846
STANLEY J. USOV=Z, JR.
MAYOR
DISPOSAL OF DEB=AFFIDAVIT
In accordance with the provisions of MGI,c 40,S34,I acimowledge that as a condition
of Building Permit g .all debris resulting from the cmwwbm,army
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as deEaed by WIL c ID,S150A.
The debris will be disposed of at }
Location of Facility
Si __ of Permit Applicant j Date
FULLY complete the following info®ation:
(PLEASE PRINT'CLEARLY)
PQ-4,:A-7 �n ci w-, I I G
N
ame ofPamit A*liCaot
Firm Name,if
P
Address,City dt 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
f cility as defined by MR.cIlL S150A,and the building permits or licenses are to
indicate the location of the facility.
WQPlr?7jGJK�{(�(.o���c{fiQB�6 i s
fiF
BOARD OF BUILDII�fC' REG LAIMNS
1t I ..License: CONSTRUCTION SUPERVISOR
( Numb G 087554
BI _ 965
7 Tr. no: 87554
PETER BA
I
28 MARLBORO `'x y
SALEM, MA 01970
__ Actlng m oner � -
0000000
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement=C'6ntractor Registration
r - _ Registration: 131846
- Type: Private Corporation
CARPENTRY UNLIMITED ENTERPRdE.S-Ijt. Expiration: 9/26/2006
PETER BAGARELLA
122 REAR MAIN ST.
PEABODY, MA 01960
3Cn1 SOM�a-Gi0t tt6
Update Address and return card. Mark reason for change.
�
. Address ❑ Renewal 0 Employment ❑ Lost Card