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21 SALTONSTALL PKWY - BUILDING INSPECTION (2) CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBEKLEY DRISCOLI. MAYOR 120 WASHING'1'ON STREET ♦ SALEM,MASSACHUSE'ITS 01970 TEL:978-745-9595 * FAX: 978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizatiom/Individual): (n ��AN.C/ Address: .34 #V(i S41&�l /VL 4SS City/State/Zip: C) Cl Phone#: G«" �-/ Z— 77443 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction ployees(full and/or part-time).* have hired the sub-contractors ❑ Remodeling 2. 1 am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub-contractors have 8. ❑ Demolition working for the in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its l0.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.[0Other f clt-iij°`L 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 most submit a new affidavit indicating such. �Contracmrs that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy #or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 S 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 certify under the pains and penalties of perjury that the information provided above is true and correct. St a uure V ""-'�_p. 1 Date JCS�GO Phone# G 1 7— D 11 — -7 7 t'C 3 Official use only. Do not write in 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 5. Plumbing Inspector 6.Other Contact Person: Phone#: ' Y 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 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 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 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 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. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office 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 Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID DATE(MM/OD/YYYY) BE 03 05 08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ,. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Benesvento,T Ins. Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 497 Humphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Swampscott, MA 01907- Phone: 781-599-3411 Fax:781-581-7200 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: NORFOLK 6 DEDHAM INS. CO. INSURER B. Matthew Beane dba Matthew Beane Construction INSURER C: 34 Bellview Avenue INSURER D' Salem MA 01970 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 NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY E PDATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE s500,000 A X COMMERCIAL GENERAL LIABILITY R0403682A 09/20/07 09/20/08 pREMISES(Eaoecurence) $ 50,000 CLAIMS MADE � OCCUR MED EXP(Any one person) $ 5 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PRO- AUTOMOBILE ECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS Eft EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $. OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ Syes tlescriba untler SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1 $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS PERMIT ADDRESS: 21 SALTANSTALL PARKWAY, SALEM, MA 01970 D �D CERTIFICATE HOLDER CANCELLATION CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN CITY OF SALEM NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL BUILDING DEPT IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR WASHINGTON ST SALEM MA 01970 REPRESENTATIVES. AUTHORIZED EPRESENT TVE ACORD 25(2001108) ( ©ACORD CORPORATION 1988 a� � - -7Uo - a �� � _� Board of Building Regulalio S gt' girds Construction Su rV, License: Pervisor License CS 88370 Expiration: 10/25/2009 Tr# 9021 ResMetlon: 00' MAT-THEW BEANE ' 34 BELLEVIEW AVE 1 SALE M, MA 01970 4 - Commissi— onc����J i I SECTION 5: CONSTRUCTION SERVICES 5.P Licensed Construction Supervisor(CSL) C15 995 70 I D�asl v°1 U r-VL(,t'- 5tM/1C/ License Number Expiration Date Name of CSL- Holder A� fist CSL Type LKLiG✓ RVL .Sylat''7 (serbelow) T Description A dress ^ U Unrestricted(up to 35,000Cu. Ft.) LL/ R Restricted I&2 Family Dwelling Si nature 7 —77V RCR Masonry de al Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Impl�overnent ontractor(HIC) y u�' —.peF�4K� r zro fic'k'tsl HI Company Name or HIC Registrant Name Registration Number y �tiNlrict,/ )jl/L SIw1L-41 6"47o Address tg 1)-6' e ('j'Z7t? Expiration Dale Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... fir— No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, TUkh {;ask raft' as Owner of the subject property hereby authorize A" L'. -- to act on my behalf, in all mutters relative to work authorized by this building permit application. 3 Slo�i Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION /1, (M btu— & , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. wtti?T 6LSvl.c_ Print Name )s, fU Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of r'u NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively. 2. When substantial work is planned,provide the information below: Total Floors area(Sq. Ft.) (including garage, finished basement/attics.decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for"Total Project Cost" The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code. 780 CMR. T°edition MUNIt'IP;\LI'Il - USE Building Permit Application To Construct, Repair. Renovate Or Demolish a Revised Amitai' One- or Two-Family Dwelling /. 2Q)8 This Section For Official Use Only Building Permit Nu r: Date Applied: Signature: '3• i v' a8 Building Commissioner/ Inspector of Buildings - Date SECTION 1: SITE INFORMATION 1.1)Property I+aw51! Slrnll P k 1.2 Assessors Map& Parcel Numbers kr 4 ti� 1.1a Is this an accepted street?yes_ no Map Number Parcel Nutnher 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq @) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑ Public❑ Private❑ Check if yes❑ P y SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner[of Record: l ar Lq H L rfS 7 1 S4 �� G nu1 Sltif( Name (Print Address for Service: /-- 07- fl7- 7- 443 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) mrt Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': &u e(ol ✓l Lw wr r t4 fl o L� } 1 A✓ 'fi K V )( WAU' .01 OLN `1FT o SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 7J00 u 1. Building Permit Fee: $ Indicate huger tgA�temmed.: ❑Standard City/Town Application Fee ,/ �/ 2. Electrical $ ❑Total Project Cost(Item 6) x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ S oppression) Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ - 0 Paid in Full 0 Outstanding Balance Due: The Commonwealth of Massachusetts 4 i Board of Building Regulations and Standards FOR MUNIC'IP:\LI'I'1' Massachusetts State Building Cafe, 780 CMR, T"edition tiSF Building Permit Application To Construct, Repair. Renovate Or Demolish a Rvi Acd Jammn One- or Two-Frnnily Dwelling ) ](x 3 This Section For Official Use Only Building Permit Nu r: Date Applied: G� Signature: Buif ng Commissioner/ Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property Address: p 1.2 Assessors Map & Parcel Numbers �-1 SL1 if r,t� 'Elll Pfr It 4i4�. I.la Is this an accepted street'?yes_ no_ Map Number Parcel Numtx:r 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq IU Frontage ol) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.I,c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Public❑ Private[3 Check if yesE3 SECTION 2: PROPERTY OWNERSHIP' 21 Ownes of Record: ! I a,-�� ��—I4 i 3 _ I l J 4 l�}-' G N ul Kamen€'_ Address for Service: 07- tr7- 77�43 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': I f4 ✓t c ✓ I.vr r u f l G rr } 1 ArL vt V io SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Ofrtcial Use Only (Labor and Materials) 1. Building $ .1�GU u L Building Permit Fee: $ Indicate ho free is termined: ❑Standard City/Town Application Fee (`//��// 2. Electrical $ ❑Total Project Cost(Item 6) x multiplier x 3. Plumbing $ 3. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount Cash Amount: 6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: l SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) V r-A(,t1T )J LKn v License Number Expiration Date Name of CSL- Holder ;3 L4 &A;- G✓ �L(� Sy�Lt"► List CSL Type(set below) 4 dress Type I Description ` � f U Unrestricted(up to 35.000 Cu. Ft.) R Restricted 1&2 Family Dwcllin Signature -t M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Bunung .Apliliancc hi tallauun D Residential Demolition 5.2 Re�gLgst�ered Home'JiIm ovement6ontractor(HIC) 4 fl (7 HI C mpany NQ:,orHC Registrant Name Registration Number Adress/ ✓ Mi s 70 / rVt;A­ P� U,) -k(7—I jqi Expiration Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 2506)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... tt3� No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, TUkh Ixr+�k nca as Owner of the subject property hereby authorize 1't9. — A"n Ci to act on my behalf, in all matters relative to work authorized by this building permit application. . ,C n 3 l Sl/,p Signature of Owner - Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION p ), V"4 Gtti— /, , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. PvtkTI- 6�4wr_ Print NtuneV"____�,�— fi 3 }S I Lfr- Signature of Owner or Authorized Agent Date (Signed under the pains and penalties ofperjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program), will iA have access to the arbitration program or guaranty fund under M.O.L.c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 1 IO.RS. respectively. 2. When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) (including garage, finished basemendattics.decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for"Total Project Cost"