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7 75-o 0073
APPLICATION
�r TO FOiI
LOCATION
PEFPNT GRANTED
INSP of
_
Fr&w Dan Healey InsUantx To:Balking Inspector Date:6212D05 TLRe:11:DT:18 AM Page 2 of 7
ACORNOLt,TH36 06 21 O5
D CERTIFICATE OF LIABILITY INSURANCE OP ID °A0('/21/05
�
R10°UCIER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dan Hurley Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Chestnut Green, Suite 24 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Seven Federal Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers HA 01923-3620
Phone:978-777-9394 Fax:978-777-3306 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: Granite State Insurance
INSURER B:
North Shore Window 6 siding IwsIRERc
James shields DBA
40 Preston Road IIRSIRER D,
Somerville NA 02143
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 BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE POUCYNUMBER DATEAMID DATE UNITS
GENERAL LIABILITY EACH OCCURRENCE S
CfR.WERCNPI GEN:AfC LIABILITY PREMISES(Ee ocarercel $
CLAIMS WDE ❑OCCUR NED EW(".�) $
PERSONO AADV INARY $
GENERAL AGGREGATE S
GENL AGGREGATE LIMB APPLIES PER PROOLICM-CONPIOP AGG S
POLICY JER LOC
AUTOMOBILE LNB4RY
[Es eCwdED SINGLE LIMIT $
PI NY AUTO [Es tleN)
ALL WJNED AUrOS
BODILY INJL6RY S
SCIIECULEDAUTOS IPer Person)
MRED AUTOS
BODILY INUURY
S
NOI.ypINTgp AUTOS (Per ecUdat)Aeltl
PROPERTY DAMAGE S
(PeracU j
GARAGEIWNILRY AUTOONLY-EAACCIDENr S
AIN AUTO OTHER THAN EA ACC S
AUTO ONLY: AOG S
EXCESSAAIBRELIA LIABUPY EACH OCCURRENCE $
OCCUR El CLAIMS AfADE AGGREGATE S
F
CEDUCTIBLE S
RETCNRION S S
WORKERS COMPENSATION AND TORY LIMNS I I ER
A ENL°vEaLUBartv Alry PROPRIETOR E)�CURVE WC2313281 05/18/05 05/18/06 E.L.EACHACCIDEW $500000
XCUJO/
CFFICERHET.eER EXCWDE°° S68 Ammnrf® NOTE E.L.DISFnsE-En ErwLO 5500000
SPECIAL PROVISIONS Oebv E.L.DISEASE-POLICY LIMB $SOOOOO
DESCRRRON OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS
As per policy.
CERTIFICATE HOLDER CANCELLATION
$WFSMPSc SHOULD ANYOFTHEABOVEDEBCRBED POIJCIES BE CANCELLED BEFORET E)O`MTXMN
NORTHSHORE WINDOW& SIDING DATETEREOF,THE59UMGINSIRi8NN1 EAVORTOM 10 DAYSWRnTEN
40 PRESTON RD. NOTICE TO THE CERT*=TE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SMALL.
SOMERVILLE, MA.02143 BI'DSENOOBl1GATNINDRWIBILISYOFANYKMUPONDREIRSURHr. AGEfrS°R
j 1-617-628-7204 REPRESENTATIVES.
AUTHORIZED I-800 439-7205 ��A�
Daniel J Hurley
ACORD 25(2001108) ®ACORD CORPORATION tt188
The Commonwealth ofMassechuself ,
Department of Indusirid Accidents
Qfflee of])svestigadons
600 Washington Sired
Boston,MA 02111
www mess goulad
Workers'Compensation Insurance Affidavit Boilders/Contractors/Electridans/Ptnmbers
Ampficant Inkruistion PleasebpWe
Name Masaosa�orp�nizauJIIH (�d
Address: 1
City/State/ P: Phone#., �.
Are y a employer?Cheek tki PPr'op�e bow-' Type of project(rtgdre d):
1. I am a I it
eVbyar with 4. 0 I am a general contractor and I 6. []New construction
employees(8311 and/or part time).• bave hired the ealxeormaclms
2.❑ I am a sole proprietor or partnu- listed on the attached sheet i 7. ❑ Remodeling
ship and have no employees These sub-contracims have 8. ❑ Demolidon
wodit for me in air,capacity, w'orkc0'co p•insurance. 9. Building addidon
[No worker' ,insurance . 5. C1 We ar'e a corpoatioa and its, 10 Electrical sus or additions
reported.).I ii_ officers have "exeiprsed t>eir
3. I am a bomeowna.doing all work right ofexemptf per MGL, 11.0 Plumbing repairs or additions
c. 152,11A and we have no myself [No workets'.comp; 12.0 Roofrepaut
insarance.ngoireQ t. employet:t. (No t�orken' 13.E] Other
comp.iasurancerequvcd j
'Any applicmt then checks box,Ml uM also fill outih¢section below showing itseir.,wodpps'oomeaagoo p polky iosom�tlon
+Homeowners who submit th allude rit isdicRioj they etc dobg all work and then hft a"Uih do cmdroctore niostsubmmt sinew aff aevit indicating such
=ContrxbnthatebeektbbboximasnschediissM sbeashcwigdsemnetitlDrmb000dngafmd dab wmken
I oar ad employerthw it provWx vb sPascompspsdon i drtrancuf for sty eiiipl6yyeEs Bdow Is dwpdfry aid job slay
injormoNon. / I,L/.�Imsuurance Company Name:
`7
Policy b or Self-ins.Lie.A n/�- .2d' _ Expiration Date
Job Stu Address City/Staw&ip•
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)..,-
Fah to same coverage as requlaed under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
rate up to S1,500.00 and/or oneyear iriprisonment,as well as civil penalties in tie form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the valttur. Be advised that a copy of this statement may be forwarded to the Office of
Imesdgationa of the DIA for insurance coverage verification.
I.de henbyeeA*rarderdbpabor mrdpenaMn ofped&7 do the btfwmadoa pmvidad above is&W and correct
Siumat re: Date
Phone#:
O•alekl sus only: Do nd wdM in fhb ame,to be compktod by cLy orapwa QBIekL
City or Town: PermWLlcense N
Issuing Authority(circle one):
1.Board of Heakk 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
' n for their employees.
Massachusetts Geoeral Laws chapter 152 requires all employers 101 ov of ano�th�er under too contract of hire,
Pursuant
to this statute, an employee is defined u"...every_Person
express or implied,oral or writtea."
IMM entity,or any two or rom
An emplew i5 defined as an individual,Partnership,association,le alr epresen or odsof s dectasad employer,Of the
of the foregoing imaged.in a joint enterP�.and including the association or o
of a byem Howevq the
receiver or trustee an individual,pmmershiiP. other legal entity,employing r the
house having not more than three aputments and who resides theists,or te occupantof'1
owner of a dwelling ns to do maintenance,construction or repair work on such dwelling house
dwelling hoots of another who ps terse be deemed to be an employer."
or on the grounds or building apptuturr enant thereto shall not because of such employment
MGL chapter 152,425C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a Hcense or Permit to operate a business or to construct beildiagg is the eomunoaweakh for any
applicant who bag not produced aaeptabie evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 15Z 12SC(7)states"Neither the commonwealth tin any of its political sid&visiom SW
ofpublic work until acceptable evidence of compliance with the insurance
enter into any contract for the performance�tOd In contracting=tho*-
requirements of this chapter have beeapres
Appllcaats
lion affidavit oomPletoly,by checking the boxes that apply to Your situation and,if
Please fill,ont thesub_cOrs'compeona
necessary,snPP1Y my_contractor(s)nasae(s),address(ea)and Phone simnber(s)along with their ceruH�s oo�fer than the
nintance. Limited Liability COmpanieg(LW C)Or Limited Li�ihty Yatmecshipa(LLP)
sera or partners,are not requiredto carry workers'kers'compensation msuranoe' If an LLC or LLp does have
employees,a policy,is required. b
insuranc Be advised that this affidavit may be submitted to the Department of Indnslrid
Accidents confirmatroa of e coverage. Also e cure to sign and date the affidavit. The affidavit should
or town that the application for the permit or license a being requested.ad the Dgpumment of
be returned to the city the law or if you are re9nired m obtain a woriters'
Iddn 'Accidems Should You have any questions regardmB below. Self-insured'oocs should enter dick
compensation puff please.call the Department at the numberljsted
self-insurance license ttmnbet on dte line
City or Town Offaclab
Incase be sun 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 hag m contact you regarding the applicant
Please be sun to fin in the permidticense number which will be used as a reference number. In addition,an applicant
that swat submit multiple permit/license applicenons in any given yea'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
ofthe affidavit ilist has been offieWly stamped or marked by the city or town may be provided to the
town}"A copy or yip. A new affidavit must be 1r'lled out each
applicant as proof that a valid affidavit is on fib far fhuue P"rs not related.m any business or co ial venire
year.Where a home owner or citim is obtaining a license or permit fete this affidavit
(ie. a dog license or permit to burn leaves etc.)said person is NOT required in comp
TheOtf ere of Investigation would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate 0 give n a call:
The Deparmient's address.telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEMj MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ. JR. TELEPHONE: 978-743-9598 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 resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
Tle debris will a dispose of in: (l/4fcV,
(iCJ 0 dispose
vV
(Location of Facility) r�
ign, e o p licant
Date