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..� Llcense:CONSTRUCTION SUPERVISOR `
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ExPt a: 10l4 06 Tr.no:.2626.Q°
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' DAMES J SHIELDS
40-PRESTON RD
- SOMERVILLE;
Commissioner
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NORTHSHORE W INDOW&SIDING
James Shields
40PrestonRoad tS
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cram:Dan Hmtey ITHUIBncIa To:Belding Inspector Date:6212005 Time:11:07:18 AM Pap 2 of
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NORTHSIS 06 21 O5
PP.ODuaER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dan Hurlev Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Chastnut Gzeen, Suite 2A HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Sevan T ederal Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers MA 01923-3620
2hon2:976-777-939,L, is:c:978-777-3306 INSURERS AFFORDING COVERAGE NAIC-'
wwT2ED INSURERA Granite State Insurance
INSURER B:
Noi:R SL102e Nlinu'yLl v SiGL;_„ INSURERC
JaaS Shield Da33.
40 Preston _�,OZC'. INSURER D'
SCmerville 22a 021113
(SURER E.
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY RECUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
7.WY 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 BEEP]REDUCED BY PAID CLAIMS.
POLICY PNMBER TOUCTIn-FECITV O.d�
:I TR P� TYPE OF INSURANCE DATE(M.`+NDO DATE MMO
GEEiT umIILNY RICH OCCURRENCE
f_ r' EENEPAL LIABILIT!C ERi1A1 PREMISES
(E.TJt I£
omvcoae)
rL:.IMS MADE 0CC-CUR MED EXP(Any"persanl I£ .
IT� PERSONAL S ALA`INJURY $
l i GENERAL AGGREGATE f
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ISr�?LLLED AUTOS (Perpersanl $
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1:`Tr FF.GPP,IEicR,7ARIDERI'uEcurmE WC2 3.L2282. 05/18/05 05/18/06 rL.EACHACCima $500000
r--IrfRA,a:EERIXCLUDEDi
SEP, 2LTITACr."�-T NOTE EL.DISF�sE-Fa EMPLOYEE $SOOOOO
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aer policv.
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CERTIFICATE HOLDER CANCELLATION
Sb AIL,Wsc SHOULD ANY UFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPMTION
NORII-ISHORE WINDOW & SIDING DATE THEREOF,THE SSURiGP9URERYYAlENDEAVORTOMAIL 10 DAYSWPoTTEi
40 PRESTON RD. NOTICE TO THE CERTIFICATE HOLDER NWED TO THE LEFT.BUT FAILURE TO DO SO SHALL
SOMERVILLE. MA. 02143 DOSE NO OBLIGATION OR LIABILITY OF ANY WIND UPON THE INSURER ITS AGENTS OR
1-617-628-7204 REPRESENTATIVES.
AUTHOR®REPRESENTATIVE
1-800-439-7205
Daniel IT Hurley"CORD 25(2001lOB) O ACORD CORPORATION law
l/
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVIC2, JR. TELEPHONE: 978-745-9395 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resultingfrom
this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
cation of Facility)
=
Si a e f Applicant
Date
The Commonwealth of Massachusetts_
Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AVVIiC2nt Information Plftse P ' t Le 'bl
Name (Basiness!oiganiza 'on/Indivi ) /v
Address: x/
City/StateJZip: GUUI' " 116 Phone#: 2 2� ( D
1A. o u ployer -sippriateboa
mo Type of project(required):
aem with 4'. ❑ I am a general contractor and I 6
employees(fun and/or part-time)•
• have hired the suV-contracrors El New coos Wcuon
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
,for me in any capacity. workers comp. insurance.
working ' 9. ❑ Building addition
[No workers'comp.insurance 5. El we area corporation aril its, -
requimd.];i officers have exeictsed their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL' I LEI Plumbing repairs or additions
myself. [Noworkers'.comp: c. 152,§1(41andwe64110 . 12.[j Roo'frepairs
insurance required.]t. employees [No workers' ;
comp.insurance requred]i`„ 13.❑ other
*Any applicant that checks box#1 must also fill out the section below showing their workers compensation policy infommtion
t Homeowmera who submit this�'affidavit indicating they me doing all work and then lib outside coatigetors niust submit anew affidavit indicating such
tContractors that check this box`nmst attached an additional sheet showing the name of the sub contiactors and them workms'comp.policy information.
I am an'employer that is providing leers'compe sation insu rice r my employees,Below is the policy and Job site
information.
Insurance Company Name: /d/(/.
Policy#or Self-ins.Lic. #: (f — c 3 / Expiration Date: U.10
Job Site Address: Sr%�( City/State/Zip:
Attach a copy of the wor rs' compensation policy declaration page(showing the policy number and expiration date).
Failure to segue 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 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
Investi ' ns of the DIA for insurance erage verification
I do ce r the en rlury that the injrmaton provided above and correct
Si tore: Date:
Phone#: C/
Offld l use only. Do not write in this area,to be completed by city or town official
City or Town: PermWIAcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 3.Plumbing Inspector
6.Other
Contact Person: Phone#:
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 to er,or thny two or e
d
o%
of the foregoing engaged in a joint enterprise,and including the legal representatives of a eceased enaQ Y
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 e p §25�states f blic work until acceptabl"Neither the e evidence of nor any ofits
wrm'subdivisions
enter into any contract for the performance P
requirements of this dinpter have been presented In the contacting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)namc(s),address(es)and phone number(s)along with their certificate(s)of
ili Partnerships LP)with no employees other than the
Limited Liability h>P (L
insurance Emoted Liability Companies carry or L IY
members or partners,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 In
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 Deparunent of
IndustiW Accidens, 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 Ofliciais
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 fin out in the event the office of Investigations has to contact you regarding the applicant
Please be sure to fin in the permi0icense number which will be used as a reference number. In addition,an applicant
that must submit multiple permiWicense applications in any given year;need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."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
to an business'orcomttercial venture
license or permit not related y
year.Where a home owner or citizen is obtaining a P.
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would lure 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
Revised 5-26-05 www.mass.gov/dia