9 RIVERBANK RD - BUILDING INSPECTION fL irucKfis#Ao APPAOVGD sY T46
*mM=9 P4WR XDAP=W A9lNG GRANTED
CITY OF_SALEM pp
Romb Loomm a L.o.do. of
"Lroloraowdw Yak _No_ �atLitaa
is ftwy Lamm in
QowaAao Awd Yet.No_
WYLOM PERW APPUCATWN FOR:
PGWA UK
(QwW MlLi Mm apply) lmw $wft comma D" Shad. Pod,
Roodupbw cow.
PI.E M PULL Ot/T UlOWLY i COYPLt ULY TO AVOW DELAYS W PROCESSWG
TO THE U46PECTOR OF&A DING&
urLdwsi WIAw - hot* sop" for a pw" to bum aoo No* to ow fam"Op
Orrwrs Nmw Pa-
Afteu 4 Phm 9
Amhkods Name
Aft"s t Phorw L
MYChi OU NMI 1 10
Addr"s l Pho w 4 1 o-a Pi,- 0 J(2,
LrL.r.i a Lorirlap9 r.olral�q,Lor now mil►Samna.? /
vm 01 ae aura.Lo w? /�O
twaaaq am a, CIV uowm r N A sum uoaw a
xSWiftm of ApWoU I
So= UNDER TH9 PENALTY
of PERJURY
DESCBWTwN OF WORK TO U DONE
Pmff Ta.-2�zjQ� ,
_ d0 dO •
ZLZ777
Q31N11l� 1NrH3d
""to�
NOuvool
Oi AWQGd
vcm Ndtlr37d IV
7p- -ON
Board of Building Reguladoas and Standards'
HOME�11,TROVEMENTCONTRACTOR-
Re91at&aBo t143977-
Ekp7taBoB-j.�1412006` .
�e
RMICHAELA RIL_rIY �ONST.
MICHAEL RILEY�� -
46BEDFORDST
BILLERICA,MA 01821 Administrator
` BOARD OF BUILDING REGULATIONS
License:-gCONSTRUCTION,SUPERVISOR
I ' Numhec�C$ 070494 • 'i
Birtbdate it/l)ZI7969 '
Expires�411/0212006 Tr.no: 6980.0
Restricted ,00q
MICHAEL.A R1LEY� �
46 BEDFOP D ST
BILLERICA, MA 01821--''f Commissioner
1
i
� ]N- 2006 10:01 Grant F.'I?-'il'1.
'-GKo:Du� CERTIFICATE OF LIABILCCY INSURANCE
' GATE IMMIO^Jryyyl
61
3/06
Ambrose & Grant Insurance en PR TICERTIFICATEISISS DASAMATTEROFINFORMATION 1
A9 ONLY AND CONFERS NO RIGHTS UPON THECERTRICATE
1500 Providence Highway HOL0 THIS CERTIFlCATEDDESNOTAMENO,E%TEND OR
I N6rwood, MA 02062 ALTER THE COVERAGE APMROm BY THE POLICIES BH_OW.
INSDRr� IN`•LlRg7SAFFORDINGCOVgt4GE NAIL#
Michael A Riley INSURER A: HERMI TAG$ INSURANCE CO ---
66 Redford St INSURERB_ - ----
Billerica, MA 01821 INSURERc:
INSURER O: ---J
C VER INGE. INSURER S ---
I
THE POLICIES OF INSURANCE LISTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT,TERM pR CONDITION OF ANV CONTRACTOR OTHER DOCUMENT WITH RESPECT Tp WHICH THIS CERTIFICATE MAY BE ISSUED OR
j MAY PERTAIN,AN,THE INSURANCE 1OWN MAY
BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
PULICIE@.AGGREGATE LIMITS SHOWN MqV WgVE BEEN REDUCED BY PAID CLAIMS.INSRADO'L� --__
I'Y@$EL F R POLICYNUMBER FOIJCY EFFECTIIE .U. PIRA N --
'GENERAL LIABILITY b M r LIMBS —
A X COMMERCIALGENERAL UASIUTY EACH OCCURRENCE a 1 OOO DOD
HGL/503952-05 11/22/05 11/22/061ER�EMS� �i—
.]CIAM6 MPDE C]OCCUR _�P�cIre ) a 100,000
_ ---- I MEDEXPIA 11000
PERSDNAL&ADVINJURV
__ -- a 500 000
GEN'LAGGREOATE41MMAPPLIESPER: I GENERALACGREGATE a P ��D�
rPOLICY ECT LOC ftODUCTS•COMPK)PAGG S 1 ODD DDD
AU TOMOBILELIASILITY
�ANYAOTG COMBINED SINGLE LIMIT ---
�ALLOWNEDAUT03 (Ee�CGUMt) a
SCHEDULED AUTOS BODILY INJURY
HIRED AUTOS $ --
�NON•OVrNEDAUTOS �P&Ie,I Ry —�a --
PROPERTY DAMAGE $
GPRAGE LU1BILiTY
IP&mde'd
ANYAUTO AUTO ONLY EAACCIDENT $
AV ON HAN
EA ACC a
AV ONLY,
EXCES$AIMBRELLA LIABILITY AGO a
'OCCUR CUIMSMA➢E I EACH OCCURRENCE S
AOGREGATE_ $ —
DEDUCTIBLE IF $
_ . I RETENTION a I I a
W OW M$COMPENEATION AND $
EI111PIR RB'LMBI4RY I !TORY LIMR61 ?R 2"LO H?IETr IT TNER/E(ECUTI�E
0 FICER/MEMBER EXCLUDED7 EL EACH ACCIDENT
Yppss deadbe�
SPE6ALPPOVISCN6beb 1 I ELOISEASE•Eq EMPLOYEE a
OTHER El.DISEASE•POLICY LIMIT �8
I i-,LTION OP OPERATICNS/LOCATIONS/VEH CLEF/EXCL USIONS ApDEp BY ENp DRSEMENT/SPECIAL PROVIWONa
l
att buili•dng dept.120 wash at
FA30979-790-9866
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIESBE CANCELLED BEFORE THE EXPIRATION
9 RIVERRANK RD DATE THEREOF,THE LRSUING INSURER WILL ENDEAVOR TO MAIL —DAYSINRRTEN
SALEM, MA 01970 NOACETOTHECERTIFICATE HOLDER NAMEDTOTHELEPT,BUTPAILURETODOSO SHALL
IMP�O��/SSE��NO OBLIGATION OR L"JUTY OF ANY KINQ UPON THE INSURER,ITS AGENTS OR
REP/{E5•NT EB
AI1A7HbR R93ENTATI
'I acoRD zs 12Davoal L
®ACCRD CORPORATION T 9BS
TOTAL P.O1
CIT1/ OF SALildr MASSACHUSICTT!
10 va"IMtfOQ lroaif, Sao rim"
lALaM. IWaACMYaRI'a Otarf0
Tft"""ft as►. 2"
PAM 070.146""
Is aooasdmm with die provieloes Of MM 040 S A a caadidos atyow
Haiidlal t'btmit is did dW deb&ta#Ol ft=tbls warts ball be dbpow d
offs a peiopedy llceaeed mild wars'dbPmd hdft sr ddlaed by MM
Choptet t$d ISO A.
IU debris will be dlapossd Ot ta:
/L�fCIrO l��Ut, � ocadoorot
P,,,W
�178' 670 .fay
$4121M OIAppHcmt
(o C - o C.
i�ar.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBF.R11Y DRIsCOLL
MAYOR 120 WASHI\GfONSTREET♦SALEM,MASSAC11uSl:.1 rS01970
TEL:978-7459595 0 PAX:978.740•-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information y r7�-R I Please Print Leeibiv
Narne(Hu<roesWOreanizatioonn/lndii�vidual)/ / 9e.I A,
Address: '( & (� (JPCV Fn A S4' /
City/State/Zip: /S IIQr/Gyr ' Phone N: 27,r a 7
Are you an employer?Check the appropriate box: 'Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and I 6 ❑New construction
employees(full and/or part-time).` have hired the sub-contractors
2.41 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
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
[No workers'comp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME] Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. [No}porkers'comp. c. 152,§1(4),and we have no 12. Roof repairs
insurance required.] t employees.[No workers 13. Other
comp. insurance required.]
'Any applicant that checks box ill must also fill out the section below slowing their workers'cumpensation policy information.
f homeowners who submit this affidavit indicating They,are doing an work and then him outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy informi ion.
I art air employer that is providing workers'compensation insurance for uty employees. Below is the policy and job site
information. �,q._
Insurance Company Name: 4M ��n J{ r''1 _-...__---.—
Policy#or Sell'-ins. Lic.#: ____-__ Expiration Date:
Job Site Address: I tin f,Ue2 to,,A City/State/Zip: 3*1,e r
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 ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it day against the violator. Be advised thut a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert=uuderses aidpenedtie�perjury that the information provided above is true and correct.
Sieaanrrer Date:
Phone#: ? 9
Official rise only. Do trot write itt 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. Electrical Inspector S.Plumbing Inspector
6.O(her _
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 entphyee is defined as"...every person in the service of another tinder 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 ajoint 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 oil 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
with the insurance
enter into an contract for the erfomhance of public work.until acceptable evidence of compliance
Y P
requirements of this chapter have been presented to the contracting authority." „
Applicants
Please fill out the workers' compensation affidavit completely,by checking tine boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone nunnber(s)along with their certificate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
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 Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and(late 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 tine 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 pertnit/license 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
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Officc 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
Revised 5-26-05
www.mass.gov/dia