34 PRINCE ST - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Tht_97g.745.959S a FAX:974-740-9846
Worken' Compensation Insurance Aff)davIC Builder/Contnctors/Electridans[PMmben
AM11cant InformationPrintease L
eelbly
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Address:_ �
City/Stazeizip:S�'. �^ ./n19- d 1g70 in wx N: q �'����/•S�—t�
Are you an employer?Cheek the appropriate bons J�F,
pe of project(required):
1.M"a employer with� 4. Q 1 am a general contractor and 1 ❑New construction
cntpioyces(full and/or p rt-tine)•' have hired the sub-comractors
2.Q tam a sole proprietor or partner- lined on the attached sheet t ❑ Remodeling
ship and have no employees Then subcontractors have Q Demolition
working for me in any capacity. workers'comp. insurance ❑ Building addition
f No workers'comp, insurance 5. ❑ We are a corporation and its Electrical
mquircdJ ot�cers have exercise!their repairs or additions
3.Q I am a homeowner doing all work right of exemption per MOIL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,41(4),and we have no 12.Q Roof repairs
insurance required.] t cmployecs.[No workers' 13.Q Other
comp. insurance required.]
-A)q'Pishcaul the checks boa/1 mot also R11 uu dw wl,"below Amine tMit wakes'cumPmwduw Ddiry iobunmtir6
ilunwatunrn wha submit this aJlldwk indicating fty am tWiry d1 work and 140e him oaftws camraawe anal.uhnit a new alltdavh indiading uroh.
:(',uttrxmts the disk as*hm mart adaolrd an addaketal.pert.howing Me agar ores mseansism and their wurkete'comp•policy inbtrmadus.
/am on earployer that G providing workers'compearadan Laurance jar/ny employees Below is the pa/lay.and fob a114
....,.r........�iujwaratirAaw.»»r..as.w.«r.r....+.,� tow,..+—rrr..r.n.•e«.. �,�[� --- _.
Insurance Company Name:
Policy B or Solf--ins. Lie.`q:LJ C V 6 0 G 09 L_7d .. _ Expiration Date:
Jub Site .address: _ 3 7 0 If• CityiStatuZip:S;de,)A MA. 0/p'7d
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Pori lure to secure coverage as required under Section 25A tit'.1GL c. 152 can lead to the imposition of eriminal penalties of a
tine up to S 1.500.00 andiar one-year imprismtncnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Ile a4vi.4ed that a copy of this statement may be forwarded to the Utlice of
Im•.,ngaumts of tlic DIA for insurance cover it vcriftcation. .
/do Lereby certify trader the a der a N-7747Y7.1 /he inferaralloo provided uboo is
me and correct
1i,•um,ro _, �j '/ �•�—/! �• Date �j/6/(/�
70/flflkcidliwx�rowk owk /b nor wr//ein/his area,to lotevesp/etedbydryortown ofjit•lai
n: _-. Permit/l.lcema rthority (circle one):llealth I. Building Ocpartincut 3. City/fown Clerk 4. Electrical Inspector S. Plumbing Inspector
rson: _ _ Phone p:
Information and Instructions
♦lassachuscus General Laws chapter l52 requites all employ t provide
a workers
service f' other under compensation for heir et hire.
pursuanif to this statute,an emPtAY'fe is defined as"...every person
express or implied,oral at written"
r aaoeiatiM corporation of other legal amity,or any two or more
,.\a erwpfoyn O defined Y"an io�vidud.partnership,. to r seatativa of a deceased employer.of the
Of the foregoing engaged in a lotto enterprise.and including gal en to des. However the
association or other legal catity,employing tp Y
receiver or tcururs of an individual,partnership.magthe and who raider therein,err the oatrpant of dw
owner of a dwelling haws having ant mite roan dude maapartmentstenon
dwelling house of another who employs Pew to d°mainrenance,c�rastraction or repair work oa such dwelling house
or on the grounds of building apptrtena
thereto shall nag because of such employment be deemed to be an employer."
NIGL chapter 132. ¢2SC(6)also states that"every state or bead licensing agency shag withheld tb issutaee or
rertevrel of a Ikea or perut to oper
ate a business at to cosntraet buildings in the commonwealth for any
applkas>t wM Iwo trot ProdKod acceptable evidence of cooptlana with the ItsuraKt coverage required."
of its political subdivisions shall
Additiaeally.MGL chapter ke p forma )states"Neither the commonwealth evidence of compliance with the insurance
enter into any contract far the performance of public work until acceptable
requirements of this chapter have bier presented to the conawting authority..
Applkaote
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation and.if
necessary.supply,sub eonractor(s)name(s),addresses)and Phone awnber(s)along with their cerifttate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)with no employees other than the
members or parsers,one 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 die Department of Industrial
Accidents for confirmation of insurance coverage. Also M sort or licettse to sign ants being requested not the Da affidavit date the aillidavit. The should
be returned to the city or town that the application for the permit
t of
InJustial Accidents. Should you have any questions regarding the law or if you are required w obtain a worker'
compensation Policy.Please call the Department at the number listed below. Self-insured companies should enter their
salt-insurance license number on the line'
City or Town Officials
.. ....._-
pr
please he sure that the affidavit is complete and inted IJgibly. The Department has provided a space at the to•_,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 till in the parmivlicense number which will be used as a reference number. In addition,an applicant
t must submit multiple Permitilicettse applications in any given year,need only submit one affidavit indicating current
th
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
to cy marked b the city or town may be provided to the
or m tY
town)."'A of the affidavit th:u has been officially stamped Y use be tilled out each
to ) copy
applicant as proof that a valid affidavit is on file for future permit or licenses. Anew affidavit m
year. What 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 bum leaves etc.)said person is NOT required to complete this affidavit
fhc 01 iix of Investigations would like to thank you in advance for your cooperation and should you have any questions,
pieube do not hesitate to give us •a call.
The Department's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
On%*of lavatlpdeas
600 Washingtaa Street
Boston, MA 02111
Tel. li 617-7274900 ext 406 or 1-977-MASSAFE
Fax N 617-727-7749
2cviacd i-26-05 www.mLw.gov/dia
CrrY of SALEm
PUBLIC PROPRERTY
DEPARTMENT
..yam u.t•'�..�u
IMP—
at.�.. t�C 7.�N::Jt:f taaT•iu:�1QvtK:u.a�ls:.9
Construedon Debris Di bud Affidavit
(requirwl roc an dMolition aid reaovatios work)
laaecontsttet w ith tht siudt edition of do Stun Building Cody.730 aUk section i l 1.S
oebriar and the provisions of M. GL t:406$ S*
Building Few _ . _ is iswted with the eoodtios drat the debris rtesult ns ftm
po a t
this watt shall be disposed of in ilesnsed wuw disposal &dUty as dented by MGL o
The debris will be transported by:
of hariM
rho:kb�riis will be disposed of in :
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BOARD OF BUILDING REGULATIONS•-
C .License: CONSTRUCTI
4% ONSUPERVI_SOR,
.
t Number: CS'r,� 064786 # .
k. Birthdate:-10/01y1966, '
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'Expires 1pl01/2008 Tr.no: 3488.0
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Restricted OQ
# ;PETERA SHEPPARDr�Cr*=
25 OSGOOO ST Gk 44 1
SALEM MA.01970� ,s' •tG" ,�t,
e�•`r.. t Commissioner
10/31/2007 11:20 AM FROM: 781-321-2414 Supino Insurance Company TO: 19787454577 PAGE: 002 OF 002
AC-ORD. CERTIFICATE OF LIABILITY INSURANCE DATE(M�D""""
AFFIN-1 10 31 07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Supino Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
1012 Eastern Ave/Rt 60 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Malden NA 02148
Phone: 781-322-2800 Fax:781-321-2414 INSURERS AFFORDING COVERAGE NAIC9
INSURED INSURERA_ Atlantic Charter Ins
INSURER 8 Western World Insurance
Affinity Construction, Inc. INSURERC,
25 O obd Street
Salem VIA 01970 INSURER D'
INSURER F.
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
MY 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
POLICES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSRE TYPE OF INSURANCE POLICY NUMBER OA D FEWD LIMITS
GENERAL LIABILITY EACH OCCURRENCE $500000
B X COMMERCIPLGENERALLIABILITY UPP973143 11/10/06 11/10/07 PREMISES(Eaowvrance) $
CLAIMS MADE X❑OCCUR MED EXP(Any one pwwn) $50000
PERSONAL S ADV INJURY $500000
GENERAL AGGREGATE $1000000
GENT AGGREGATE LIMB APPLIES PER: PRODUCTS-COMP/OP AGG $500000
X I POLICY P JECTRO-
LOC
AUTOMOBILE LIAEILRY COM81NED SINGLE LIMIT
ANY AUTO (Eaascldani) $
ALL OWNED AUTOS BODILY NJURY
SCHEDULED AUTOS (Par Peraen) $
HIREDADTOS BODILY NJURY
NON-OWNEDAUTOS (Perawdeni) $
PROPERTY DAMAGE $
(PeraccidaM)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN FA ACC $
AUTO ONLY AGG $
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR F-ICLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND X TORV LIMBS ER
A EMPLOYERS'LIABILITY NCVO0609701 02/07/07 02/07/08 EL EACH ACCIDENT $100000
A AFFIPRWMEEETOWARRTNERRD ECUTIVE
OWNERS NOT EXCLDD 02/07/07 02/07/08 E.L.DISEASE-EA EMPLOYEE $100000
It yes,describe under
SPECIAL PROVISIONSbelow E L.DISEASE-POLICY LIMIT $500000
OTHER
DESCRIPRON OF OPERATIONS/LOCATIONS/VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
sALEMHI SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYSVM4RTEN
Salem Harbor Comunity NOTICE TO THE CERTIFICATE HOLDER NAMED TOTHE LEFT,BUT FAILURE TO DO SO SHALL
Development Corp. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND IRON THE INSURER,RSAGENTS OR
102 XaFayette St
Salem MA 01970 REPRESENTATIVES. D'
ACORD 25(2001/08) w AL.vnu�vnrvRATON 1988
EPIY�' OF�i;LEl�
y PUBLIC PROPERTY
DEPARTME►�IT
Vn�ae 130 WADIDIM,r Site•
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A_*PLC TION FOR THE )I*AIL g12OVAn _ rnN"a?rtCr g
DEMOL'1'IO .OR CAANGE 01[TSE O1R OCC[7! CY FOB ANY ZxUMG
74 an INFORMATION 91
Loeadon Names
R"wV In kxwtsd In a;C4nmva*n Arse YM ArA_WAft b Dkdrtot YM
2.0 OWNERWP INFORMATION
11 Owsw of Land _
Na"W D A r mP
Addrum /40 oZ ZGy%�Y&-•�' 57%
S,c -e • D/ 7d
Telsptlorw. `17 P— j OQ
3.0 COMPLeTE THIS SECTION FOR WORK IN ouSllelo BU LCINOS ONLY
Addwon Existing
Renovadon Number of stories Renovated
Change in Use Now
DemoUdon ExisWV
Approximate year of Area per Hoot(at) Renovated
construcdon or renovation .
of existing building New
adat Description of Proposed Work:
,4ee, ✓2 eSCi 5�,�� s �� ��( a r`�
'A 777T-7
--- - ----Mail Permit to; O spa a -C* • SG qj V M,4. (J I 4;1 - -
What A tM QwWd use of dw ?
d 9u�7dindt �lp_tc C— k dws&q,how nwMF Larne?
We t1MIM a+�q��b Lao -
Arddlads NanM
Adbnaa and PhOW
0,Aacha Ves NanM
,
_ f sa
can tn+ naa i /� ►+tc RmgWraWon r / 7
EstYndad Cod d Pr�ojaot Parmr Faa Calaitlon
PamUt Faa i o� i O Es*naud Coat X SWSI >DO Rosklw W
Es*rmftd coat X i„/i,009 canm+.raW --- -
An Addltlond S&OO Is added as an
AdmkdWs"ehwga.
Make an that aY fladda era lxoPwfY and ebb wrfthn to avoid delays In pro-
TM undanigned do"hwe"apply for a Building Permit to above stated
specocadom Signed under penalty of PWJLO
Date
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