14 SHILLABER ST - BUILDING INSPECTION Crry of SALEw
PUBLIC PROPRERTY
DEPARTSOM
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Construction Debrb Disposal Affldsvit
(rayttimd let all danolitioa and rotovadatt want)
to manlattre with the dxdl ad dais o(the Sam Duddias Codsi11S0 C 1A saotioa 111.!
Debris,ud dte provisions of M. GL a 406 S 54
Suihiall Pon tit A _ is Wo d whk the aoadidam drat the debris txndtitts Am
,his watt shalt be disposed of in s property lieaosed*taste disposol facility as defined by MOL a
1t1.S15" ,
The debris will be transported by:
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_. ,nom...rtrort.r)
fheckbris will be disposed ofin :
re�„r t�:dltyl
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CITY OF SALEM
PUBLIC PROPRERTY
`o DEPARTMENT
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Workers' Compeasadoa Insurance Affidavit•. SaildentContractorwElectrfdanWp%mbers
Ana(Icant Information / /V 1"
Please Print Legibly
Name tauaincss/OrganirarkiwI hvKW): AV V M
Address:
City/sulwZip: (fix p;
Are yaw an employer?Check the appropriate bow
1.0 1 am a employer with 4. 0 1 am a Scmual conisusc a and 1 . New consect(r construction
employvros(full and/or piutAime).' have hired the sub-comractora 6 New corunru¢tion
2.0 1 am a sok proprietor or partner. listed on the attached sheet t 7. 0 Rerradoling
ship and have no emplayuat These mac- ttraotor have a. 0 Demolition
working for me in any capacity. worker' comµ insurance
f No worker'carp. insurance 3. 0 We are a corporation and its 9' ❑ Building aaWitim
11
required] officers have exercised their 10.0 Electrical repair or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(no worker'comp. c. 152.044).and we have no 12.0 Roof repair
insurance required.) r employees.ENo workers' I3.❑Other
comp, insurance required.)
•Wiry yplicml the chocks boa sl moo aiao nh w Ihs wum lalow amwiaa ibair wrkam'aaapYWiun pulivy iature u&Wft
' I I,wnwnwnws who submi the Glad wii iadirmi ns May,tea&%"au wWt and Mm War oawfes eamn miss a m a.ubmit a now anUbvi lndtadina a c
:Caturaam%this rhsk this box mute aladre m addiimrl Am.hawing as"am of ate we Ihelr wurkera'asap.policy intbrmmita
law ten employer that 8 providing workOrs'comptntadon latarance for my emptoydex Below Is the pulfry and fob aim
Irmurancc Company Name:
Policy a or Sclr-its. Lic. 0: _ .. _ Expiration Date:
Job Site Address: Ci(yrSlatuZlp:
Attack a copy of the worker'compensation ptdlcy declaration page(showing the policy number and nupiratium date).
Failure tv wcwv coverage as required under Section 25A of.1GL c. 152 can lead to the imposition of criminal penalties ors,
fine up to SI.500.00 and/or one-year impriminrncnt, ss well as civil penaltics in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day,against the violator. Ik advised that a copy,urthis slatcawnt may be forwarded io the Office of
lu\.angmn as vl*the DIA °or insurance covcraye Yeri Fe JflUn.
I do hereby terrify antler the pains and penaltes a/perjury that the inJorwat/on provided above is true and correct
0111rial use an/yt DO Not write Is this area.to be rompleyd by dry or town o/Jleful
City or Town: _ Permidl.leense a
Issuing Aaihurily (circle one): — —
1. Ruard of lioulth 2. Building Department J. City/fovea Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Qntiael Person: _. _ Phone 9:
Information and Instructions
Massachusetts General Laws chapter 152 requites all employersthe service of another�unation for their C131010yem
fer any connect
hire,
pursuant to this atasme,an eas/bree is defuted as-...every person
to eapress or implied.Ural or writted"
aesedetioa.oosporatioa a odter legal entity,or'any two a more
Vt errpfeyer is defiled• u �' representatives of a deceased employer.or the
Of the foregoing enppd in a joint daterpsea,and ioehstfittg the legal repro However the
uweiuion or tuber lode)entity.employing e�Y
receiver or uuams of an individual.ei musb'P. and who resides therein or the oocupam of the
ownet of a dwelling house bovtag net more then th fa apertrneols
dwelling house of another who employs persons to do maintenance.cunboucdon or repair work on such dwelling house
or on the grounds a building appttttenarn
thteeto shall not because at such essployroset be tenoned to be an employer."
.%tGL chapter 152.42SQ6)also states that"every state or toed Ikeasb►a apusY shag wkhloM the Issaaaes er
a operate a business or to coeutruet buildlap In the commonwealth for any
renew d of•Ileenao or per�� eptabis evidence of coespBues will the insurance coverage required."
appticant who bee act prod Of ttteel subdivisions shall
Additionally.MGL chapter 132,42 (7� "Noidter the coouttottwealth nor any pot
ewer into any contract for the 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 waken' compensation affidavit completely.by checking the boxes that apply to your situation and,if
necessary.supply sub.cateracauf nattte(s),addteas(es)and phone number(s)along with their certifka�s)a than the
Companies L a Limited Liability Part rshlps(LLP)with no emPIOY
insurance. Limitedacu Liability required
carry compensation insurance. If an LLC a LLP does have
members or policy
i are sir required v carry of IndufQial
employees.a policy is required. Be advised that this affidavit may be submitted to the Department
Accidents for confirmation of insurance coverage- Also be sun to sign and date the affldavk. The atTdavit should
be returned to the city or sown that the application for the permit or license is being requested, not the Ibparanent of
lajusmial Accidents. Should you have any questwas 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 line-
City or Town ORkiak
Please be are that the affidavit is complete and printed legibly. The Department has provided a speed at blue bottom.
of the affidavit sure
et for you ra fill out in the event the Office of Investigations has to contact you regarding the applicant.
t'Icuse be sure to till in the permitllicense number which well be used an a reference number. In addition,an applicant
that must subunit multiple permivlicentse applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Addreu"the applicam 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 licensee. A now affidavit must be filled out each
year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
r i.e. a dug license Or permit to burn leaves etc.)said person is YOT required to complete this affidavit-
I'hc d)ilicc of Investigations would like to thank you in advance for your cooperation and should you have any questions,
p:caze do not hesitate to give us •a call.
The Department's address.telephone and fu number.
The Commonwealth of Massachusetts
DepaMent of Industrial Accidents
Ofsu of favadsadeft
600 waadin6tan Shaer
Bo om% MA 02111
Tel. p 617-72749M ext 406 of 1-977-MASSAFE
Fax 0 617-727-7749
nevi>cd 1-26-05 www.mm.gov/dia
ACQRD CERTIFICATE OF LIABILITY INSURANCE DATE("..%OD""ff)
r" 04/02/2007
PRODUCER (781)447-5531 FAX (781)447-7230 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
..McSon & Mason Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
458 South Ave. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Whitman, MA 02382 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Meaghan Walker INSURERS AFFORDING COVERAGE NAIC#
INSURED AlUma l t, InC. INSURER Western World 000071
50:Getchell Way wsURERB: The Travelers Indemnity Company 25658
Canton, MA 02021 INSURER C: Penn America
INSURERD: Savers Property & Casualty Ins. 000203
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.
INSR WITI. TYPE OF INSURANCE PENCE
EFFECTIVE PODGY EXPIRATION PODGY NUMBER DATE WMADD� LIMITS
GENERAL LIABILITY REN OF NPPI011831 04/01/2007 04/01/2008 EACH OCCURRENCE IS 1,000,00
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ SO,OO
CLAIMS MADE �OCCUR
MED EXP(Any are Parson) $ 1,000
A PERSONAL BADVINJURY S 1,000,00
- -- GENERAL AGGREGATE S 2,000,00'
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000
X POLICY JECOT LOC
AUTOMOBILE UA51UW BA424D7018075E L 04/01/2007 04/01/200$
COMBINED SINGLE LIMB
ANY AUTO (Ea arrldeM). S 1,000,0O
ALL ONMED AUTOS
X SCHEDULED AUTOS BODILY INJURY $
B
X HIRED AUTOS
X NON-OMED AUTOS BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
(Pe,ecn M)
GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $ -
AUTO ONLY: AGG S
E%CESSNMBRELLq LU\BBJTY REN OF SUB101 0078 04/01/2007 04/01/2008 EACH OCCURRENCE $ l,OOp 00
OCCUR �(:1AIISMADE AGGREGATE $ 1,000,00
C
$
DEDUCTIBLE
$
X RETENTION $ l0,00
EMPLOYSCOMPENSATIONAND REN OF WC0002363 04/01/2007 04/01/2008 We sTATu- X oTH-
EMPLOYERS'LUIBILIIY
D ANY PROPRIETOR/PARTNER/EXECUTNE E.L.FACH ACCIDENT SEE
OFFICERIMEMBER EXCLUDED? OFFICER(S) INCLUDED
I(yes,desvibe ender EL DISEASE-EA EMPLO $
SPECIAL PROVISIONS below
OTHER E.L.DISEASE-
POLICY LIMIT $ 500,00
Aerations: HomeNImprovement,C Installation OfYWindows,Tdoors,Pvinyl$siding, roofing
CE TI ICA E HOL DER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFF,
Hartwell Exteriers BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
50 Getchel l Way OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES.
Canton, MA 02021 AUTHORIZED REPRESENTATIVE
ACORD 25(2001/08) ®ACORD CORPORATION 1988
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a� PUBLIC PROPERTY
DEPARTMENT
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NAVOR 130 WASMNGMW bME T
��XnstAa/t:sh-1is 01970
7TL 975-74i95"• FAIL 979.74O.9W
APPLICATION FOR THE REPAIR RENOVATION, CONSTRUCTION,
DEMOLITION OR CHA,'NGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Nams: /`/ -9411/ her 21-. Building:
Property Addrear.
Property is located in a; Conservation Area Y/N N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address: y She//as6cH Ste,
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXIST1NCi BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building I New
&ief Description of Proposed Work:
Mail Permit to:
What is the current use of the Building?
Material of Building? �i9/v� ��i^^ If dwelling. how many units?
Will the Building Conform to Law? ; Asbestos?
Architect's Name
Address and Phone
Mechanic's Name �lUhi •/f1y� 17�� 2 S
Address and Phone O
Construction Supervisors License 0 3S/2G HIC Registration 0 6 6
Estimated Cost of/Project S OVO Permit Fee Calculation
Permit Fee $ Estimated Cost X$7/$1000 Residential
Estimated Cost X 511/31000 Commercial
An Additional $5.00 is added as an
Administrable charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date ZL� j=
1 � N
O�
t\ r 0
cam. •j � O O
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