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I I& PUBUG PROPERTY DEPARTMENT
r20 WA2HJHaTON VMff T, 3RD FLoD11
6ALEM.MA Ot 970
TEL.(976)745-9595 EXT.360
FAX (976) 740.9846
STANLEY J. Usovlcz, JR.
MAYOR
DISPOSAL OF DEBRL4 AFFIDAVIT
In awadaoce with the prvviaioas ofMOL c 40,S34,I
of BWIding Permit 1trmdft am dw CMEWICdon adge that as a dvity ion
governed by this Building Permit aball b� � aar�'
disposal facaity.as defined by MOL e�S of is a Pr'oP�Y licensed soNd-waste
The debris wiU be disposed of at
Location OfFacitity
r S ire of Pemart Applicant r Date
(PLEASE PRINT CLEARLY)
Name ofpenzdt cant
�S�k]1nQ r, n i m i n
Fain N dame.my
Addrw,City�State
The above statute requires that debns from the demolition, r=vation,rehab or other
alteration of Wilding or structure be dim is a poly-ham solid-waate facility as defined by MQ clA S 150A,and the building permits or licc=w oo pow indicate the location of the facility, are t
I
=. The Commonwealth of Massachusetts
3 w Department of Industrial Accidents
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4: '�: � OfceofInvestigations
600 Washington Street
Boston MA 02111
Workers' Co m ensation Insurance Affidavit
Property Owner Name:
Job Location: ,5 Pi` K cn c�� 54
G City: QI1 n , Phone# R 1// 9
❑ 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 providmg workers' compensation for my employees working on thrs)ob.
Company Name:
Cahina rr , llAM4n
Address: 'a Q R . m n.,,n
City: d Phone# q7
Insurance Co. 11G f �� 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 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$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the ice of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties oIpp�erjury that the information provided above is true and correct.
t Signature? � � e r Dates
Print Name RA- 0. iii,� ICA Phone# - 15
Official use only. Do not write in this area,to be completed by city or town official
❑ Building Department
City or Town: Permit/license# ❑ Licensing Board
❑ Selectmen's Office
❑ Check if immediate n=.,onnce is rmuired ❑Health Department
Contact person: Phone#: ❑Other
it
09/15/2005 THU 14:12 FAX 781 581 7200 BENEVENTO ,INS._AGENCY Z001/001
-Ago v CERTIFICATE OF LIABILITY INSURANCE OP ID DATE(NWDM'wv)
CABIN-1 09 15 D$
vRooucER 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 NOTAMEND,EXTEND OR
497 Humphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Swampscott, MA 01907-
Phone: 781-599-3411 Fax:781-581-7200 INSURERS AFFORDING COVERAGE NAIC#
INSURED
INSURER A. PREMIER INSURANCE A1C
Cabinetry Unlimited Ente rise
INSURER B: HARTFORD INS. GROUP
_.-
Peter Bagarella PresidsidellLRrp INSURER C: —
122 Rear Mal INSURER D;
Peabody MA 19 ,
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 WfTH 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,E(CLUS IONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NQ TYPE OF INSURANCE POUCYNUMBE0.^ pA E M D DATE(MIMR)DIM LIMITS
GENERAL LIABILITY EACH OCCURRENCE Sl 000 OOO
A X COMMERCIAL GENERAL LABILITY I-680-4753B409-TCT 10/21/04 10/21/0$ "IS REM ISES(Eo--,- S300,000
CLAIMS MADE X❑ OCCUR MED EXP(Any me person) g$ 000
r
- PERSONAL 6 ADV INJURY 81 000,000
GENERAL AGGREGATE 52 000 Q00
GENL AGGREGATE LqIMpIT�APPLIES PER: PRODUCTS"COMP/OP AGG 62,000,000
POLICY JECT LOC - - -
AUTOMOBL-E LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(@e awidenl) S
ALLOWNEDAUTOS
SCHEDULED AUTOS BODILY S
(Per persQn)onl
HIRED AUTOS
NON BODILYINJURY 6 NON-OWNED AUTOS (Pere dent)
PROPERTY DAMAGE g
We�� lGARAGE LABILITY
-EA ACCIDENT 3ANY AUTO " '-
N EAACC s AGG SE%CE C UMBRBLL4 LIABILITY RRENCE 6OCCUR GWMS MADE gDEDUCTIBLE .--
RETENTION SS 8
WORKERS COMPENSATION AND
B EMPLOYERS'I ABILITY x TORY LIMBS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE 6S6M-7963A75-A-04 10/21/04 10/21/05 E.L.EACHACCIOENT 6100000
OFFICER/MEMSER EXCLUDED? —
Ifyyee.Ee8c ewor E.L DISEASE-EA EMPLOYEE_ 5100000
SPEGIALPROVISIDNSDeIuw E.L.DISEASE-POLICY LIMIT $$OQQQQ
OTHER
DESCRIPTION OF OPERATON9/LOCgTI0N5!VEHICLE$/IXCLUSKINS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
CITYOFS SHOULD ANYOF THE ABOVE DESCRIBED POLICIES SECANCELLED BEFORE THE EXPIRATIOe
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN
CITY OF SAI.EM NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
120 Washington St IMPOSE NO OBLIGATION OR LABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Salem MA 01970 REPRESENTATIVES.
AUTHORIZED REPRESENTA7IYE
ANTxoxY BzxaveNTo `
ACORD 26(2001108) 0 ACORD CORPORATION 198E
s" C71 w2orr�� ,uaeal o/�/�fggoaaFuaedla
1 E: pOA 'OF BUILDIW.,, REG�JLA+FION$
t .License: CONSTRUCTION SUPERVISOR
I Numb 087554
BI 965 i
7 Tr, no: 87554
I � 1 �•
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PETER BA • ,
28 MARLBORO
SALEMr MA 01970 '`"` "'
if� .F S`.% �.
Acting m oner
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement-Contractor Registration
Registration: 131846
Type: Private Corporation
Expiration: 9/26/2006
CARPENTRY UNLIMITED ENTERPRISES 11
PETER BAGARELLA
122 REAR MAIN ST.
PEABODY. MA 01960
`,
Update Address and return card. Mark reason for change.
Address Renewal
Employment Fj Lost Card
I,.