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SALEM WILLOWS - BUILDING INSPECTION , ` , . ��:� C.l'I'1' i >J j �l � �.� �l/�✓ � _:�` ; ��l�i�Ll(: I'lt( )I'I � I�"i'1 �� �'�,;.:��;:�� 1�I��.I'.A IZ"C A[1 .���J � � ��,.� .���� . . � , , .� � � : � � . � -. -, , , , o , . , . �.�J --..._ -----...--- ---. . . ------ -- . . __ __ , V^ APPLICA7'IUN E012 YLAN H:X.a,�11NA Cll)N :�NU 13UII.DINC: PGI2D11'1' ,� ^ .9LL STRUCTURF.S EYCEPT / AND 2 F:9MILY DWEI_I.ING,S �V� � -- ---_--- � IAIYURT:�\'1'::� licunls must com dch ull ftcros on Ihi.r �r�c ...—, Stl'E INFORMATIO(E� W,�la � $ � F�---oor S �� . Lucution Vamc S/1 t3uildine----- —..._----- ' __.__--- Propeny Addre�s sa f .-� v lle„✓s _ . � Mnp li�� .y-a�l- � l ,� Gw� C. eC --- � I.ocatcd in: Conservntiun Arca Yi Historic dis[rict Y;� . _J �--_ --- -..._-----�- L;cc t:ruups (cheek une) Rcsidcntial(3 or more linils) R2 Type oF improvement Rcsidcntial(hotrl!motel RI - (check one) Assembly (churchcs) :\1 � Ncw f3uilding_._. Assrmbly O�ightdubs etcl .�2 Additiun r\sscmbl)'(restaw:mts. rccrcation) ;�3_ . :1ltemtion ✓ Busincss �_ Rcpuid Rcpincement.� F,ducaliomd t_ Ucmoli�ion '� Factnry(modcrate hazard) FI ,�IuvdRolocatc ___ Fac[ory (luw ha�:vJ) F2 Poundatiun Unly...__..._— I-ligh Flanvd ��_ Accussury 13uilJing___..__ Instilutinnal (residcnlial care) 11 OU�cr(dcscribe) _.. In;[itulionnl (ineapacitatzd) 12— Institutional (restrnincd) 13 �dcrcanti le ��� � Storagc Unnderate h:izard) S 1 � Sturagc(luH� hazard) S2_ U\YNF:IL51111' I\p�f1H�1:117UV(PIr.�Se typ¢ur 1'rint(7carly) � ()14'Nf.R Nam� Gi�� p � .S.&�,�c- I ;Address — � tcicphone -- ..� ur.scwrno�oF��uiis'ro itr: rr:ki•uu���H:u / � . � ,/r✓ /�io � try �„ /OD6 Sf � sf/1++ J 4c F "� I �G�G?j'fr����{'�/ �fC �.J /-Q/�` �1avl s �'�£ /'�✓��iT/ i / o /� � / ,// n " �! C�r Lr✓� / C.i�/G C r L- , /' '4 SZ� � /'�OU✓S t ��/�- . i:�ru�.crr:o co�s rut c-nu�c �icr 7�1�. �'/...°�" - �'�F"�J,._��A g/�G. �OF� � /30 oD0 ---� ��� ���� � , . f I ruv rK;�c'ruN ��r'<�e�t:�r�u� rv:,�„t iK,� h�.� l �r�ss� � �ad����s �- c,��„s�a„� �� Telephune 7rd( 5�'3 zz 9� Constructiun Supervisor's Lic # S`�'o�{� Home Impruvement Cunuactor # AHCIII7'El:'P/ENGINEF.R INPORDIA'1'lON Name Address Telephone Mass. ReQistration # _____ rH:emrr ri�:r:cnt.cu�.n r►oN Residential est. cos[ x $7/$1,000 + $5.00 = Commerci.il est. cost x $l U$1,000 + $5.00- CUMMN:NTS Tke �uidersigned does hereby nttest Utat nll infonnation s?uted ubove is trrte to Nee Ge.st of nty k�towledge ruider fhe peitalties of perjr�ry .Signed � , Dnte � 3e —� /��r���p� /�� � �/ 3�,0� 5ti /.�,., �-//dws r?�s� �� � 07/30/08 {9ED 12:09 FA% 7815996688 MASSEY CONSTRIICTION CORP �002 �AcoRD CERTIFICAT� OF LIABILITY INSURANCE OpID MS oa��movoWYYWI �sss-i o� ie oa aaooucQe THIS C�RTIFICATE IS ISSUED AS A MATTER OF INPORMATION ONLY ANP CONFERS NO 121GHT3 UPON iHE CERTIFICATE DeSanetia lRsurance AgCy, Snc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 36 Cumiuing8 Pazk AI.TER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Woburn MA 01801 Phone= 781-935-6480 Fax:781-933-5645 INSURER5AFFORpING COVERAGE NAIC# ... . _.. ..._... ..._. m9ursE� � �nSURERA: mc camn.rce x�aar,nea ee�>� INSURER B: y�zioan Nwae Asauzance co. � Massey CoABtruction Corp. c�a iHsuneRC� Colony Insurance CO da Masse $lumbing s Heatiag Co. - �� 144 5�etson 3treeb INSIIRERD: Inaueanca �; or steee er es Swampscott A9i 01907 nuSur�ne: Acadia lasuraxice Com COVERAGES TNC POLICIES OF INSURPNCE USTED BELOW MHVE 9EEN ISSOEO TO THE INSUftED NAME�ABOVE FOR TH6 PO��CY PERIOU IHDfCATEO�NOTVJfiHSTAN�ING MIY RE�UIREMENT,TER0.1 OR CONOITION OF ANYCONRiACTOR OTHER POCUMCNT WITH RESPECTTO WM�CH TflIS CEftTIF�GATE MAY BE ISSUEOOR µqY PERTAIN,THE INBl1RANCE AFFOR�EO BV THE POLICIES�ESCRI6E�HEREIN IS$UBJECTTO QL THE7ERM5,E%CLUSIONS ANO CONDITIONS OF SIICtl �OLICIES.NGGREGAT�LPAITS SHOWN MP.V NAVE BEEN REOUCE�BV PA�O CUIMS. INSft ....... � P � TIVE POLI roN .. .- LIl71TS LTR NS TYPEOFINSIIRNNCE PDLICYNUMOER pATE Mfd/DD �A7E MWOO/YV � GENEwaunaGlrr � � � EnCHOccimrznCE S1,OOO,OOO - C X conu�nFxcw�aeNersn�Gweiurc GI,183430 OB/23/07 08/23/08 PREMISES(Eeoccuimicp s100,000 , CUdMSNuoE -�OCCUR MEDEXP(AMa+eperaon) SNOtiO X Coatractual L12IJ PERSONAL&AWIWURY $S�OOO OOO X Indepead Contraet QENEftA�AGGREGIITE s2 000,000 6ENLAGGRE(',ATELIh9T/1PPLIESPER: PR�Ol1CT5-COMPlOPAGG $2 OOO OOO POLICV X jECT LOC AUTObo91LELIFIBILITY cotnameo6INGLEIi� Y1,OOO O00 ANYAUTO (E��ecimnt) � AlLO`�E�A11T03 BO�ILYINIUR� $ X SCHEOVLEOAIf�OS �P�P��� _., A X HIFE�AUTOs O�PVSBS OS�SS�O7 OH�SH�OH gO�iLYINJUR� y X NON-OWNFAAUTOS (PB�BCcidant) PROVERTYDAM1�GE y —� (Pe�OtCiCBllp � GARAGELIq&LRY AUTOONLY-EAqCGIDEM $ nrvYAUTO oTHERTHPN �ACC S — AIJTOONLY: AGG $ EXCESSNMBREUA W1�LI7V EACH OCCuttRENCE E OCCUR � G.aMSM1�DE AGGftEGATE 4 S DEOUcnBLE ., s .__ f� 2ETENTION S 5 WO��COMPENSATIONANO R TOR`:LIM�TS p2 EMPLOYEft51J����1Y E.L FACH ACC�OENT S.ri,0��OOD ANYPROPRIE70RIPARTNEWIXECUTIVE ' ..'" . D O��CERIMEfJ�EREXC4UOEOi �'687rj893 08/15/07 OB/15/OS E.LUISEASE-EAF.�LOY T500 ��� Ifyeo.CaecrlCeu�r E.LOIS�SE-POLICYIIMIT SSOO 0�0 SPEC�AL PftOVISIONS bebx 0'IM1iER OESGwP710N OF OP�nONS/LOCATION$I VEHICI.ES I kXCLUwON3 AObED BY ENOORSEmENT/SPFC�1.rROV1510N5 PROJECT: Renovat.i.ona to the Public RestY00ms at Salem Willowa Park� Salem� MA CERTIFICATE HOLOER CANCELLA710N SALEM-3 �OIILpANYOFTHEA80VEOE9CW9EDP0�1qESBECANCELIEOBEFORETHEEXPIRATION OFTEiHFREOF,THEI$SUINGINSURERWILI.ENOFJMORTOMA9_ 3� OA`BWRrtTEH � Noi10E70THECERTIFlCAiEHOLDERNAmEOTOYNELER,BUTFALL.URETODOSOSNALL C1tY Of SA�01a phppsENOOBLIGA110NORW1BILINOFANYIUNnuPON7HEINSURQt,R3AC�ENTSOR A , 93 9Pashiugton St. Salem 2@1 01970 ftEPRESENTATNE9. Al1THORIZEP PRESENTATNE ACORD 25(2001108) ACORO CORPORATION 1988 � 07/JO/08 WED 12:09 FAX 7815898688 MASSEY CONSTRUCTION CORP I�j001 Massey Construction Corporation 144 Stetson Avenue Swampscott, MA 01907 PH-(781)/593-2299 FX-(781)/593-6688 Date: 7/30/08 To: Sally,Salem Bld. Dept_ F'com: John Corcor�n Re: MCC lns. Cert. Dump Info.(Trans River MKTG. Co. 247 Commercial st. Lynn Ma. Ph.#781-593-8106) Tot�l Pages Including Cover: 2 Thanks John C. . ` �':'`���� CITY OF SALEM PUBLIC 1 ROPRERTY . � N �' �' _,,; -�� •_ a;;ir''� DEPARTMENT `.,n�VF .I V C:N:Il':)NISCn�I.1 � \I�`'��N I���Wr\1H1\dIU.\S�R/E@T � �:\lli\I.M.111.\CIIIiP'I'ItiJ197.�, 'Cr.i.:)78-.'�ti�Ji`)5 � P�s. `l7%-'iC�'�SiG Workers' Cumpensation Insurunce :�t'fidnvir. Liuildcrs/ContractorslElectricians/Plumbers � � ih�rnt Infunnrtion Plcase Print Leeihtv V:1117C lBu<iutsv��rgani�ztirnt�lndioiduall: ,� Q C6�sh'✓�f?or� C�r ��id���,,: /yy sG-�sa � �� � - c<<yrs�:�«;r��. �u/Rµ"i°Scv{-�- �'1/f� O��D I'hune ;�_ 7g�- s�3 ��-� 9� :\r.�ou nn.mploycr? Chcck thc apprupri•rte bux: � 'Pypc uf prujcct(rcquireJ): I 1.❑ I ;un n cmpluycr wiih 4. ❑ I om a ecncral cauiractor and 1 C> � ^•w construction employec�(full �neUur pan-tmu).• have hircd thc sub-conirrctors 7. RtrtoJeling �.Q 1 :mi a sole proprie[or or partner• lis�td un rF.e ;�ttachcd shect. � - ship�and have no empiuyces These sub-contrac[ors have K. ❑ Demoli�ion . workzi's' comp. �nsurance. 9. � puiWing addiiiun working liir m¢ in any capac�ty. 5. ❑ We are a coiporution und its �Ko worken' cump. ii�surance ,�fticers havic eserciseJ thcir 10�❑ E1O�trical repairs ur addi[ions rcquircd.] I I. Plumbin� rc .�irs or�dditinnv 3.Q I am a hnmcuwncr duing�II work righ[uf exemption ptr MGL b P' mysclE �Ko workera' umip. c. 152. j t(4),and we h:ive no 12.0 Ruul'repairs in,uranco reyuired.J ' cmployccs. �Ko worktrs' 13.❑ Othnr comp. in,urance rci�uircd.J •niry appLcaut�hu[cl:<cks box RI musi:Jsu lill uw Ihe ticlianlxluw slwwin�{�heir auhcu'cumpenv�im��iulicy infurmaiiun. . . ' I lumcuw�w:n��'hu x�Lmil lhis at7idnvi�indicuing Ihcy a�e doing ull\Wf�01W IIICII AIR UYKI(IC l'WIIfM10l3 OID51 auhmi�a new al'f:davil inJiuong.ueh. �(' � a rt�ihal chcck thif box mun�atlxhttl dn addiiimal sha:l.huwing Ih¢nanu of Ilu sub<onirxWn and�hcir wuhen'comp.poGry in(ormariun. I a�n �u� r���plu�•er lhat is pruriJii{K rvorkers'rumpenuuinn insurai�re fw•n�y eu�ployees. Be/mv is IGe po/i�y und job.��ifn � :� injunnutiva Imuraucc (:umpauy V;uae: ._. . ._.......__...._...------ . Policv�t ur Sclf-ins. Lic. h: . . ._ ..---.ExpiraUun Date: � lob Si[¢ Address: -- - City;5tate/"Lip: .�tt•rch n copy of ttie workcrt' cumpcns•rtion policy dcclaralion pay;e (showin�; tl�c policy numbcr•rnd cxpiratiun drtc). Pailuro to +ecure cocerage�s rcquircd under Sectiun 25:\�f`tGL a 152 ean lwd to the iroposition of eriminal penalties of a IIOd ll�l fU SI.SnO.OQ�RIUOf OIIOYC.If IlllPl'1\UIIIPCfIf� JS \YCII :11 LI\'II �A:f1:lIIlC]111 IFIC 1'ur�n of� STOP WURK URDER and a fine ni up to�2�0.00 a Jay agui�ut �he violo�or. 13c advivcd thut a copy uf ihis;iutcmen� may be CurwarJcd,io ihc OOice�F Inc:augau�nu of dic UI:\ tor in,ur:utoc tnocn�c �eritic.rtiun. /Jo hrrrby rcr�ijV ui�de�rl+e!'(II�t+''r,��Prmdtics uf prrjury thut dm i��furinullon pruvideJ uGa`'3O Irr/eee��correcl. f l��� i���--r� ;��_:�:������: _ ri, �:, 7 � ( - s''�t"3 a-1-� !)[/iciul use mdy. Do nnt �vri�e iu d�is ureu. ro he cun,yferrd by cirp w�o�un o/Jiriul. . C'itv or�fmrn: ---. .. Pcrmit/l.iccnse x.- - ... � . . I..uing.�W hurily (cirdc onc): � I. ISuarJ uf Ifcald� 2. Iluildiu� Dcparancnl .S.Cil�;?o��u Clc�k J. L•'Iccfricnl Inspertor j. Plmnbin�; Inspcctor � 6. O�her _ __. - . ('uulucl Pcnon: ._ . . ._. I'honc q: Information and Instructions � - \1:tv:iihusetts Gcneral La�vs chapttr 1�2 reyuirrs all einpluyers ro provide workers' coinpensatiun tix thcir cmployees. � � Punu:me ro �his��atwe, an rmplu��e� ia defineJ as"..xvary pei:son in rht scrvice uf�noihtr undtr any tonn'�ct of hire, � r�prtss or implicd. oral or writttn,.. . . .\n r�nployer is defined as"an individual, partnrrship, associatiuu, corpuratiun ur uther Icgal tntiry, or�iiy two or more � � oi�F.c (J[CLJlflb' CII��J'Ct� Ill 8 JUIRI CRICfpf15C, 3I7(I IfICIIIILiI�f11C ICb'ilI CCPf25B11l:3[IVCS OI�(I@l'PJS2tI ampluyar,or the (CItlIVCf Jf INSICC UI :tll 111(IIVI(IOBI, pwincnhip, association or oeher leg�i entiry,empluying tmployees. Howcvcr the � uwner of.a dwelling house having not more than three �pamnrnLa an1 who resides therein,or ihe occupant uf the dwrlling hou.e of anod�zr who empluys persons w do mainecnance,con+truction or rcpair work on such dwclling house � or on rhe erounds or building apputten:uit thereto shall not becaust of such employment be deemed w ba an rmpluyer." � .\1GL chaptcr 152, §��C(6) also stacts that"every state or local licensing agency shall w•ithhold the issuunce or rene�val uf u licttnse or pennit tu uperate a business or to construct buildings in the communweulth for any � applic•rnt NLo has not produced�cceptable evidence of cumplirnce wi[h [he insur�nce coveru�e required:' Additionalty, MGL ch.�pter 152, §25C(7)sr:ites"Neither the conunonweslch not any of its political subdivisions,hall enter into any wntract for the perfomtan�e ul pu6lic work witil accepcible evidence ol'cu�upliunce with the insurancc requirzments uf�his chapmr h�vz been pro�enteJ W the contrac[ing authority." � Applicants � . Plaise fill out the workers' cumpeivation atiidavit completely,by checking die boxes cha[apply tu yuur siwaiion and, if necessary, supply sub-contracwr(s) name(sj, address(es)and phona nwnber(s)along with their certifica[e(s)of � insw�ance. LimiieJ Liability Companies(LLC)or Limited Liability Partnerships (LLI')with no employces other than the membzrs ur purtners, are nut requireJ to carry workzrs' compensation iiuurance. If ao LLC or LLP does have � employaes,a policy is required. Be advised that this aftidavit may be submitted to the Deparvnent of Industrial � .Accidtnts f'or contimialion of insuranee rnvarage. Also be sure lu sign unJ dute ihe •rl'tidavit. The al'lielavit should i�e rcwmed to die ciry or town that the application for thc permit or license is bcing requested, not the Ucpartment of . InJus[riul Accidcnu. ShouW you have any yuestions rtgarding [he law or if yuu are rcyuimd tu obWin a workers' cumpen,ation policy,piease call the Dep:utment at tlie nwnber lisred brlow. Self-insucod cumpanies shouW enter their � self-insurance license number on ehe appropri•rte line. - . City or Town Offlc{als Ple�tic be wrc thac the affiduvit is complete and printed Iegibly. The Department has provided a sp�c�at the botWm � uF tha aftidavit fur you W fill out in the event the 011ice of(nvestigations has to conWct you regarding the applicant. Pl.ase bt surc to till in thc pormiVlicensz number which will bz used as a retercncc numbcc [n adJition, an applicant � ihat mu.t submit multiple pannic'liceivcc applica[ions in auy given yexr,need only submit one.(ftidavie indicaiing current poiicy information (if necessary):uid undtr'7ob Site Address'� [Flt 8(1OIll'�II[,houW writc "all lucatiuns in �city ur town)."A copy nf the aftiduvit that h�s baen officially stampeJ or marked by cha city or town may be prooided w�he ��pplicant as proof diat a valid a(fidavit is on filn f'or futura pz�mits or licenses. A new at'tid�vit iuu,t be tilled out�ach ytar. Where a home owner or citizen is obtaining a licenst or parmit not related to any business or commercial venture '� �i.e. a dug licanse or permit to burn leavts etc.)said person is VOT requirzd ro complctc this affidavit. � l�h,; �)I�IICL•UI IOVtlf1;�:140115 \YOUIIJ IIRB IU [I7:IIlIC �'OU 111 :l(IV:IIIIC fUI yJll!COUPCf�ttOf] JI1lI tiI]OIIW }'UU I1JVC :llly(�LLC54011>, plea�e du not hesicate f0�IVI' US �C:III. ' Thc D�p;�runent',�ddress, telcphune and fax numbtc The Commonwealth of Massachusztts Deparanent of Indusuial Accidents Otflce of InvesUgaHons 600 Washington Street Boston, MA 021 l 1 Tel, t! 617-727-4900 ext 406 or 1-8'77-MASSAFE ti:�;.�a s-zv-us Fax # 617-727-7749 www.mass.gov/dia ~'' -" �� CITY (�F SALLM ' ��j��- PLrBLIC PRc�PRERTY ;,..js ,,^ ,`.� , ; ''•a:,� DEP:�IZ"I'�IENT �. . , � �',I ,. �. I_: U ��.�i:•�.�..����i.;iif � �.�ii �t. \I.�..�� . ,. i . • :I�� -: I I � 9'3.'J;.�1;:K � I ��: 'i'8.•J: ��iJi, C'onstrurtion Debris Disposal .affidavit (rri�uircJ liu all �anulition an� rcnu�:ui�in ��vrk) In ac�urdancr ��ith th� sixth rJition oFthc Statc DuilJing Co�r, 7S0 Cb1R s�ctiun I I l.� DcUris, and thc provisiuns uf 1�iGL c 30, S 54; DuilJiny Permit r� is issucd with the ca�dition that thc dcbris resultin� from this ��urk shall be �li,posed ot in a prop�rly licensrd waste ilisposal lacility �s defineJ by MCiL c ltl. S ISUA. Thc dcbris will bc tr:�n;portcJ by: Inomc uf huJcr) - Y hc �rbris will bc dis��used uf'in : (uamr o(lacility) � �,iddre<�u1�I�ctliiv� ,�gna�uic of prnnrt.y,phcant 7�3G�6 � ���ir . . . „ . � , . . . . . . . o`���pED Aqc�r�� . c DAVIO F. '' JA�UITH No.2853 � Beverty, MA ,� . . � . . . . . . . � � �� Jy 4 � ' � � � � � O~�F�(iNOFy'SS,� . David F. 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