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3 ROPES ST - BUILDING INSPECTION 443%"SIdUST13EfiL£ilRdtliD APPROVED BY T+IE JMBAJF.CIl]B.PBIDR TD.A.PERW=NO GRANTED y� CITY OF_SALEM No. ca?d(�2--eJ �' Deteg: Is Property Located in Location of io S-�i�� tM Historic Dls W? Yes_No_ B0_1 A+� o �S 9 is Property Located in Bte CaraervaWn Area? Yee No_ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) /ReplaceMReroof, Install, Siding, Construct Deck, Shed, Pool, Repai Other: PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications- Owner's Name y Address & Phone :5 •��C,�� s . _ f,7.f-1 9-rd - o 79 6 Architect's Name S U4-1,f�l�l // Address & Phone T'S'E A l St Mechanics Name ' Address & Phone ( 1 What is ft purpose of buiWft? Material of WIldhV? 41-11�lk if a dweding,for how many families? � WW budding conform to law? Asbestos? EsIlmated coat Cfty License« N P' state wane« /3 3 S3 Don Iaproveaant � � - n e-(Z Lic. 1"�u 7' Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE (//J MAIL PERMIT TO: No. �� /CPPLICATION FOR PERMIT TO LOCATION PERMIT GRANTED 2.0 APAOV D INSPECTOR OF BUILDINGS A 1_ 1 ' y t ' I Pusue POonan►OSPAWMCUT ao Vbmawm smut/ FLOOM sly w►ou�ie .- Tv a�7Ng7sb.sss oR aw ►/ut/sue s�s.slto stANLsvMJ- s JIL D1�OW.Gf DffiI�Ai�AYI'! d�eeaalro.rtA�!.piartier of�I�.s�!�1 a�elr�Nd�A�a.es�(os �r r dsdli� eiY aiwtiy a�so�doa ��sett•e�e.a�!r nrci.�plea I.aados a[!�I(4 d Dow PU[i.Y oae0lds tes�OsMlo�ie6dlost OgAAU PRW Cb1ARLY) Naar offamit A#pAmd Fi�Nam�ds4► 6r lb AM ON*toOm dw daswelM r.% A&a odw >Ilhslo�al�ildi�a moeen�m4o�ia.po�l�nBaoM/�odLa�w df>gopl '>r ss�dest�r m.v4 SUM&ao1�t6uldfeiDs�iti a gaoNs aR 1 daM dr badas dit haft .9CORD.. CERTIFICATE OF LIABILITY INSURANCE 3�T-1 cos 0M s o PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Richard Soo Hoo Insurance HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 1148 Washington St, Suite 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Boston MA 02118-2108 Phone: 617-338-8168 Fax:617-338-1148 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER Penn America INSURER B: I.Lperty IM l Insurance co. Sunshine Windows COmpan Inc. INSURER C: 147 East BerkQQley Street INsuRERD Boston MA 02118 INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTVATHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO NMICH 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 1�EXPIRATION S TYPE OF INSURANCE POLICY NUMBER DATE�IMWDDFM DATE Y LIMITS GENERAL LIABILITY EACH OCCURRENCE s300,000 A X COMMERCIAL GENERAL LIABILITY PAC 6414651 09/08/05 09/08/06 PREMISES Eaomwarxe $100 000 CLAWS MADE ®OCCUR MED EXP(Am one ps ) $5,000 PERSONAL S ADV INJURY $300,000 R Add CG 2011 GENERAL AGGREGATE i 300 000 GERL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $30O 000 POLICY M JECT LOC . AUTOMOBILE LIABILITY ANY AUTO (Ea COMBINED ISINGLE LIMIT S ALL OWNEDAUTOS BODILY INJURY S SCHEDULED AUTOS IPer Patel HIRED AUTOS BODa mdW) S NON-0WTIED AUTOS (PuraaltlaM) PROPERTY DAMAGE $ (Per a[Ci w) GARAGE LIABLITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGO f EXCESSNMBRELLA LIABILITY EACH OCCURRENCE f OCCUR CLAIMS MADE AGGREGATE $ f DEDUCTIBLE S RETENTION f S WORKERS COMPENSATION AND TORYLIMRS ER B ANY PR EasLwmLln WC2-31S-311884-025 09/11/05 09/11/06 E.LEACHACCIDENT $100 000 ANYPROPRIMBER EXCLUDED? CUTNE OyFyeeFaaI�C�ERIMEMBEREXCLUDED7 E.L.DISEASE-EA EMPLOYE S10O 000 SPECIAL�PROs ONS below E.L.DISEASE-POLICY LIMIT s500 000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IEXCLUSIONS ADDED BY ENDORSEMEMfSPECIALI, Door, window or assembled millwork installation i Tloatd'o(BDtIdInERt&platlaee,R4Standar4s HOME IY(pROVEMENT CONTRACTOR it ��f�Dn\. CERTIFICATE HOLDER CANCELLA CITY OB LDANY SUNSHINE WI T City of Boston DATETI SENDAI CHEN ` Boston City Hall NOTICE TO Building Dept. 146 EASTAft 1 City Hall Plaza IMPOSE NO BOSTON MA02118 __ Y. Boston MA 02201 REPRPSEHrAjr AUTgRMED00 Richard OO 00 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Elects icians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): S Gam/? W 4,, G U ' Address: C4-r City/State/Zip: 6e4!! '1_)ZGQ. fS�l ee2f- Phone#: 15" Are you an employer?Check the appropriate boa: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t T 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. I J We are a corporation and its 10. Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions c. 152,§1(4),and we have no 12. Roof myself. [No workers comp• repairs insurance required.]t employees. [No workers' 13 El Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must subrnit a new affidavit indicating such tContractots that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy in£orrnation. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:� -tii VYV Policy#or Self-ins.Lic.#: L L)C 2- — 3 t S— 31 I��'¢%-��/'s^ Expiration Date: Job Site Address: :5r"c°�-�� sl` �e L� City/State/Zip: b IF 7 eJ 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 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 well 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 Investigations of the DIA for insurance coverage verification. I do hereby Gerd under the pains aannd penalties of perjury that the information provided above is true and correct. Sienature• � d oA � Date ��" �8— Phone#: e5"( 7-3 ° — Ojjieial use only. Do not write in this area,to be completed by city or town offWal. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• information ana 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 any two or more of the foregoing engaged in a joint 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 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 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting 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)name(s), address(es)and phone number(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 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 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 lime. 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 the 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 permit/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 valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each applicant as roof that a P PP P year.Where 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. The Office of Investigations would lilre 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