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CITY OF SALEM
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The Commonwealth ojMassachusetts
Department of Industrial Accidents
Office of investigations
Woo
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: C 0-�Oi OQ, :f_ bn�i m'ArL .
Address: 7 gQ Q Mc t n -
City/State/Zip: O 1 1i o Phone #:
Are you an employer? Check the 6ppropriate box: Business Type(required):
1.el am a employer with 14 employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establisbment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl.real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. El Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] l2.FZ(Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
--if the cotpomte officen have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I an an employer that is providing workers'compensation insurance for nny employees. Below is the policy information.
Insurance Company Name: IV)Ct_
Insurer's Address: Q-14 aa0 LcNA Q_Mn Ct:- A YQ_
City/State/Zip: QC (>,n >n 3r�81 N
Policy#or Self-ins. Lic. # l 5/ 0 P�i 79 A - Oy Expiration Date: Q-01—C6
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a,copy ofGthis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification. S
I do hereby certify,under the pains and penalties ofperjury that the informaton provided above is true and correct.
Phone#: 97 � 5 i
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4. Licensing Board 5.Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee 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, association, 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."
MGL chapter 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 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 the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC) or Limited Liability Partnerships (LLP)with no employees other than the members
or parmers, 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 Officials
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.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition. an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). 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 filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
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
www.mass.gov/dia
Form Revised 5-26-05
08/10/2006 THU 10:03 FAX 781 581 7200 BENEVENTO INS AGENCY 10001/001
ACORQ CERTIFICATE OF LIABILITY INSURANCE OPID DATE(MMIDOMT'Y)
CAEIIN-1 OB 10 06
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, Imo. 01907-
Phone: 781-599-3411 Fax:761-581-7200 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA PREMIER INSURANCE Al
Cabinetry Unlimited Ent INSURER B! RTFORD INS. GROUP
e INSURERC:Pater Bagarella president EA
rise _
122 Resr Mayy n SIE INSURER D:
Peabody MA p1960
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 SEEN REDUCED BY PAID CLAIMS.
V.
-IrE
LTR NS TYPE OF INSURANCE POLICYNUMBER DATE mMlDDm) GATE IMAVIOIM LIMITS
GENERALLNBILITY EACHEMUM OCCURRENCE $ 1,GOO,QQQ
A X COMMERCIAL GENERALLIABILRY 1-680-4753B409-TCT 10/21/OS 10/21/06 PREMISES IEe acauence) $300 QOQ _
CLAIMS MADE � OCCUR MED EXP(Any one pBraord 1 $5 000
—, PERSONALAADV INJURY S 1,000,000
GENERALAGGREGATE §2,000 000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCT§-COMP/OP AGG $2 000 000
JPRO-
POLICY LOC
AUTOMOBILE UABRITY
COMBINED
ANY AUTO Ea accident)ANGLE LIMIT S
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Perpytsm) $
HIRED AUTOS
NON-OWNED AUTOS (PefL sve nt) $
TO
•---_ PROPERTY DAMAGE §
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANYAUTO
OTHER THAN EA ACC $
AUTO ONLY: ACC $
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS WOE AGGREGATE $
S
DEDUCTIBLE
a
RETENTION $ $
WORKERS COMPENSATION AND X
TORV
EMPLOYERS'LIABILITY LIAll MITS ER
B ANY PROPRIETORR'ARTNER/EXECUTNE 6SGUB-7963A75-A-04 10/21/05 10/21/06 E,L•EACH ACCIDENT _ $ 100000
OFFICERIMEM13ER EXCLUDED? E.L.DISEASE-EA EMPLOYEE § SOOOOO
11 yaCIALPe8aROVISder EL DISEASE-POLICY LIMIT $ SQQQQQ
SPECIAL PROVISIONS Ielaai
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIN
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVORTO MAIL 20 DAYS WRITTEN
City Salem
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO BO SKAL
120 Washington St IMPOSE NOOSLIGATION OR LIABILfTYOF ANY KIND UPON THE INSURER ITS AGENTS OR
Salem NA 01970 REPRESENTATIVIRL
AUTHORD:ED REPRESENTATIVE
ANTHONY BENEVENTO
ACORD 25(2001108) 0 ACORD CORPORATION 194
PUBUO PROPERTY DEPARTMENT
120 WASHINGTON STRZWn $no FLOOR .
SALaM,MA OI&70
TCL(276)74"595 EST.380
FAx (976) 740-964s
STANLa:Y J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In aceoidance with the pmvisiona of MGL c 40,S34,I
of BmldinS Permit 0 .all debris ac dw cadge thiat as a &jty, iaa
Sm caned by this BWk&g Permit shaft be . posed gin a the ��disposed of in a pr+opaly licensed solid-aaaft
disposal fsci7i'ty.,as defined by MC$,a I>;SISOA.
The debris will be disposed of atIJc, A
n / LacaIIon of Fammy � m
r— '—
atrir�
eDsLe,
(PLEASE PRINT CLEARLY)
,p-N(-.�o r-cl 110�
Name of Panait Agplrica�
Firm Name, ifany
Addexs,G�ty&State
The above statute requires that debti fi»m the demolition, renovation,rehab or other
alteration of building or atr wtum be disposed in a
facility as defined by MQ p rilitg or soli Mare disposal
indica the location of the facihci 'tyl SOA, and the building permits or licenses are to
' 4a • "� � �Q�ytOa! i
t s 60AD OF �Uq,Dll ION$
I V PC"": CONSTRUCTION SUPERVISOR
NumbtLCI\ 087554
L BI 965 1
I 7 Tr. no: 87554
fi
PETER BA- -
28 MARLBORO
SALEM, MA 01970 Addsw
m oner I .
f
�e a
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement .Contractor Registration
�..- Registration: 131846
R Type: Private Corporation
CARPENTRY UNLIMITED ENTERPR(SESI1't- Expiration: s/zs/zoos
PETER BAGARELLA ?:
122 REAR
MAIN ST.
P EABODY, MA 01960
Update Address and return card. Mark reason for change.
Address Renewal C Employment , Lost Card
zl9Y- __._ 363p��60
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`"36A107 35-�O-9
EXTERIOR INFORMATION BATH FEATURES COMMENTS SKETCH
13 -Multi-Garden 1 1, a INSPECTED FFL ONLY. 27
3 3 Story I I Oki,— Retin
3 94—84k,T— Rafn Aves a SFI-
f6dridebod 3 BdcVStone ;A30Bth R Is FFL
4_ p me 1 Wood rn.-B-Al RaBn 9hdT
Piltakwall 08 -Brick Veneer— ;WHBta (480)
'Sec Wall 1 1% RESIDENTIAL GRID
Food 02 -Hip OTHER FEATURES
01 -Asphalt Shgl 1 w -a n ryTWOR b1offt
.1 1 :3 Rating.jAverage
f BRICK erg'
gge Ratln§'Average
A 2 01
GENERAL INFORMATION IWSFN lRatind
ix�C -Averse ORMATION ouet
CONDO INIF
TFL
Y *.'1806 NEff-W-01ii. u 5FL
kxbuc�— .AfrAt*11 �TRIVI�JQ �,Bk!�13 36 FFL 32
j K 1 0 1 166 REMODELING RES BREAKDOWN BMT
%OW& No UmIF JRMS S! -��FIJ,I
LUmWAO Indo(&, 1 3 41 1� M
, OS ,f,,' -Name
INTERIOR INFORMATION DEPRECIATION Addition',
P�Conf;AV - %
TFL
Ift-,irrin(Wel 02 -Plaster a % 7 -
SFL
4 IT
S 'Jilt I I %FEco 21 7 C28)
V! Psirli�T Typica % 4 Electric:
I Special: —
Pdrinflofti 03 Hardwood Override; % !Hi 31 121 3 SUB AREA SUB AREA DETAIL
See Floors'14 Carpet 1 351- %prrpanwpl:
a a] Code
12 Concrete I CALC SUMMARY COMPARABLE SALES - P, D
wdr�9g SFI- Second Floor 1,494 100.4401 150,058 1 1 ype.
BMT Basement 1,41613 25.110 36,811
3 Typical 9 0.75 W,,,&Size Aj,
FFL First Floor 1,466 100.440 147,246
46d0oristAdl, 1.01586 TFL Third Floor 1,008 100.440 101,244,
SO:100.441
1 Oil *-Goi t 1.00
03 -Forced HM Featimas;69000— Nka77 �Jrvi]Val]0
"1.00 w
100 C Facitb� NJ6($WoWAFew15A34 �- Tvoial] 435,359!
a Su Fin;86.44 3968[Grosskeal 5434[f,mAreal 1969
Derdratvk MT.MW Adj Tata(504360 A
nq,'I.� epreclation�161395 Spacial ---tdresjo VaYSu Ne 63.12
�De_a_p_ =41M Vo IMAGE Patriot Properties,Inc
prectaled Total:342965 W@?AFma1 d8b343000 VaVSIj Wit 86.44 ess
-nnA7.n
TIR % RPoIRCEL ID
C*�W�Dapod*n,.g&jiy/S C [:tfePT11'L0CffFaoi�,NB�Mry ME k� RIM wimlyycpoa�.Ky uJift%*wDfS ftJuds.VaIue,.W,
03 Garage 0 Y 1-40011. AV FR. 1945, 1 14.88 T 50, 105 3,000! 3,0001
35 0067 0 1 of 1 Residential TOTAL ASSESSED:483,800
Map Lot Suffix CARD Salem 14035!
PROPERTY LOCATION IN PROCESS APPRAISAL SUMMARY
T • Nb011 r:ia�t piredtivnBtre.el/Ci np p;:Use Code, Builtl' 'Vafue " 1'aM Items iE= :Land Size'^ "e nd Value= -";.�7ofa4Vaht9 .. >t 91Le IDeBCriptiO
4 PICKMAN STREET,SALEM v 105 - 343,000 3000 0159 137,800 483,800 v
I` OWNERSHIP _TG�SRef' `v
,0inert:GASTON UAYMREGINA --- --- --- - --- ---
343,000 3,000 AS m `3' Y� "__,'� ... 5q �SourceMarketAdl34C3o0s0t 0 .:++io3fa0l0V0a lueperS I
gI S
0159 137,800 483,800
,800 483,8000159 3 OR
t Patriot
�
0� n / ad
Properfleshw.
SALEM 05/10/00
USER DEFINED
PREVIOUS ASSESSMENT Parcel ID 3500670
W MA d-... flwn iTex;YrBUse CaT ld Value: 1,La- LendVaNe=TbtelVafue}t4ss'addValue:F':" N Q : `'-m0aten�... PrW4d v
P�01970 2006 105 FV .. 343000 3000 .159 137800 483800 483800 year end 1212812005 'Pdotld# '.
PREVIOUS OWNER 2005 105 FV 328,900 3000 159 12760 1.0 459,500 459,SOO year end roll 11612005 PRINTa �•Prier!d 3;
2004 105 FV 305 200 3000 1te " T[p1e p
ON41�`1,3 159 118200 426400 426400ro11 1I2012004 Pr10fId#1S
2003 105 CV 305 200 3000 08/07/06 11:57:37
i7wmef3i .159 118200 426400 426400conversion - 1(/12004 Prior ld#2
Strpett 2003 105 FV 172,700 3000 .159 133200 308,900 308,900 Year End 17712003 LAST REV Prior,ld.#3:
m
T �• 2002 105 FV 159,200_ 3000 .159 104000 _. 11412002 d2tei .Tlroe,Y.Frior,01
ff SUPrdv' Ctl 2002- 105 T8 159 200-3000--- 59 104,000 266,200 121412001 10/26/00 13:41:16 ,PnOr Id#21
2001 105� 10''. 0 .14400 LA10 11/2012000-
t?t sfial; 59 24 apro Pnor Id#3'
NARRATIVE DESCRIPTION SA ES INFOWCAlal, PAT ACCT. 4035 ASR Map;
t'u�iV 1,�'` T ,L al SN a 1?t;.. 0at6 n' SeleCode:'1" SaIEPIfiCe '�V' iaf'.`.VHir ASs4CP1JL° aIUA a ram' x�" NOkea -4 _;.
This Parcel contains.159 Acres of land mainly classified Fgc1 Dtsi
Three Fam.with a(n)Multi-Garden Building Built ab t 1806 OCONNOR I E 3121421 111/1900 No No
Having Primarily Brick Veneer Exterior and Asph t Shgl Root
Cover,with 3 Units,3 Baths,0 HalfBaths,13/4 aths,l2\
Rooms,and 3 Bdrms. _ �I:andtteason
OTHER ASSESSMENTS zBldReasw
o?<:_. ':Amamm:.'.
r�
BUILDING PERMITS ACTIVITY INFORMATION
DakB ar' Oases r t"`C70t .LastVstEedCotle 'F. I .`°' mneM =x Oats = T }� =''Res_q _ :.,
Iferd-"Code re CIAB$ ' \ ' 5110I2000 Measllnspect .. 283
esd �'�, 9G�'?tterci°.;Cdde .o'ixl - -- -
2 ..R2 RES TWO F 100 S!1r=< __. _.. .. __. .......... _. ... _.
u, Exml>il
t0: 1 T -1 Level
.r1 Sfree ....... ._ _. ....... .._ _..
N
Use OC cri .„LSIOa bEU •, apt ` ilnftT aj kT ELT'_.i$dsej::United `rAd'Ti� i a4e5h'N* °ti' 'sa''4.t�"'"w°: "-'x. .;+' u.'A... ISed C, NL u '$pec� -",L a J. �-5„r.-
Faa „ua�PriceUMs= d.ype 1 Nelgh, in81 % --.1n172 h,%�Irdl3 '% ,s„ .% xFact Use Value �. -"rNoles
r
4k+t.a. .,,,n: , n,u„ .�. FaCfefYaklB�,a,,, e..=V „ ' .' IDflu Mod:�{ u;, : �.f-' .`�tr
�,. .. e VaN1e'"' ' Ctassa
105 Three Fam 6920 !,Sq.Ft Site 0 10.96 1.817 FA 11.00 004: 137,833 `n137,800',
105 Three Fam. 140I '.Front Ft Site 0 EA1.00 004:
ToYaIAC%t{A•0.158861 6920.00 Par'--- 105 Three Fam. ,Prime N DDesc EA R 4 Tofa1: 137,833 Credit 1rNa 137,800
Disclaimer:This Information is believed to be correct but is subject to change and is not warranteed. Database:FY2006 apro 2007