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6 STATION RD - BUILDING INSPECTION (2) I as The Commonwealth of Massachusetts OF Board of Building Regulations and Standards SALECITY M VA Massachusetts State Building Code, 780 CMR eelMar� ReviseJ,Llnr 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: DqWApoli ' Budding Off w Print Name). . '' Si - ,Date - SECTION I':SITE INFORMATIOM LI Property-AdVs� b( r /j L2 Assessors iVlap 3c Parcel Numbers I.I Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 "Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq tt) Frontage(R) 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'? Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP` 2.1 Owner of Record: p rn QOCJ u�L 41�2 Mme(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': S Y\ 1 p --i N �1^ SECTION 4: ESTIN[ATED CONSTRUCTION COSTS Item Estimated Costs: O Official Use Only Labor and Materials 0 I. Building $ 1. Building Permit Fee:S- Indicate how fee is determined: ❑Standard City/Town Application Fee. - 2. Electrical S ❑Total Project Costs(Item 6)x multiplier _ x 3. Plumbing S 2. Other Fees: S 4. Mechanical (FIVAC) S List: . 5. iNdechanical (Fire S Suppression) Total All Fees:S Check No._Check Amount: Cash Amount: 6. Total Project Cost: S O 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL holder List CSL Type(see below) No. and Street Type Description. U Unrestricted (Buildings LIP to 35,000 cu. It.) R Restricted 1&2 Family Dwelling City/Gown,State,ZIP M Nlasonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date FIIC Company Name or HIC Registrant Name No.and Street Email address Ci /Town,State,ZIP TOO hone 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 I affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR'APPLIES FOR BUILDING PERMIT' I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION- By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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 N.G.L.c. I42A.Other important information on the HIC Program can be found at www.mass.gov%'oca Information on the Construction Supervisor License can be found at www.ntass.goV./des 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage, finished basementlattics,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" CITY OF S.U-&Nc PUBLIC PROPERTY DEPAM ENT wvae t�e vr�a.w,�cn,lrssaf�txsy.Vow s�rt7 as Y'0 ro.9's1715.9714 •t+.%& gwlo7ay HOMEOWNER LICLNSL EXE.MnJ04-4 Piew Mat Date Job l.acad" to 4�n �0& Home Owner Addreae (o ,� b IfomeOwner?elepbone l Present Mailing Address o "Cc I bI The current asempdoo of"Homeowners"was extended to include owner-occupied dwellings of fto Unite or teary and to allow such homeowners to engage an individual for hire wbo done not Poston a Uans%provided that the owner acts as superviaer. DEFINMON OF HOMEOWNER Person(s) *be owns a parcel of land on which bloke reaidae or intards to residei, on which than it~ or is intended to ben a one or two Qtmily dwelling, attached or detached structures aecesaory to such use and/or tsam strucftwe& A panne who constructs more than One home in a two year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building 0Qlci4 on a forn acceptable to the Building OtTlcia4 that helshe be responsible for all such wart performed under the Building Permit. The undersigned "homeowner'assumes responsibility for compliance with the State Building Coda and other applicable bylaws and regulations The undersigned "homeowner'cent Iles that helshe understands the City of Salem aWlding Department minimum inspection procedures and requirements and that helshe .viIf comply with said procedures and requirements HOMEOWNERS SJGNA TL'RE 2-1 no kPPROVAL OF 9UILDING LYSPECTOR See Other side far stare code .K t CITY OF S,�LEM, T%L-1SSACHUSETTS BumDNG DEPARTNIEZNT • 120 WASHNGTON STREET, 3"°FLOOR TEL 978 745-9595 F.qx(978) 740-9846 KINtBERT F.Y DRISCOLL MAYOR THOMAs ST.PtERRs DIRECTOR OF PUBLIC PROPERTY/BUILDNG CON IISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris wilt be transported by: y _ C0- VV\ (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signature of permit applicant �1L date en�;�rea,x o0, The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR SALEM Revised ibfnr 20/1 Building Permit Application To Construct,Repair, Renovate Or Demolish a One- of Two-Tnmil)�Dwelling This Section For Official Use Only P3ijildiiig Permit Number ateApplied: Building Official Print Name) Signature Date SECTION L SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Nunbers 6 Station Road, Salem, MA 01907 L la Is this an accepted street? yes Y no Map Number Parcel Number 1.3-Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sit 11) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Pror ded Required Provided equired Provided 1.6 Water Supply: (M.G.L c 40,§54) L7 Flood Zone Information: 1.8 Sewage Disposal System: Y' Zone: _ Outside Flood Zone? Municipal On site disposal system Public Private Check if yes P P SECTION 2: PROPERTY OWNERSHIP 2.1 Owner 'of Record: Swampscott, MA 01907 Station Road LLC Name(Prue) City,State,ZIP 31 Longwood Drive 617-504-6235 snitkovmagmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK '(check all that a lv New Construction Existing Building weer-Occupied epairs(s) Alteration(s) ddition Demolition jAccessoyy Bldg. Nmnber of Units Other specify: Brief Description of Proposed Worlr: Controlled construction. Kitchen and bathroom remodeling. SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor.vtd Materials I.Building s 10,000 1. Building Perm Fee: $ Indicate how fee is determined: 2. Electrical $ 2,500 Standard City'Town Application Fee Total Project Cost(Item 6)x multiplier x 3. Plumbing $ 2,000 2. Other Fees: S 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost : $ 14,500 Paid in Full Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-084339 5/26/2014 Robert B. Tarquinio License Number Expiration Date Name of CSL Holder U P.O. Box 1080 Lis[CSL Type(see below) No.and Street T e Description Derry,NH 03038 U Unrestricted uildin s up to 35,000 cu.ft. R Restricted 1&.2 Family Dwelling City/town,State,ZIP M Must nry RC Roo mo Coverin WS Window and Sidin- 603-537-0300 Parkviewci@gmail.com SF Solid Fuel Bunting Appliances I Insul ion Tel hone Email address D Dem lition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Comp my Name or HIC Registrant Name No.and Street Email address Citv/Towat,Slate,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT .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 .......... No ..... ..... SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. b Print Owners or Authorized Agerrt's Name mtronic Signature) Date NOTES: 1. An Owner who obtains a building pennit 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 infonnatlon on the HIC Program can be found at www.ntass.eov/oca Information on the Construction Supervisor License can be found at wnlv.nnss.eov/dus 2. When substantial work is planned,provide the information below: Total Boor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable romn count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/batirs 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" Details Page 1 of 1 Tl,e Off bi vvebsite of the Ezecut^ve Office of Pubilr Safety and Secwity;EOPSS) ensee Details raphic info ull ame: r�MRYTAROUINIO ender: Owner Name: dress: ddress 2: City: Derry EState: NH pcode: 03038 o nt U 'ted tates License o: CS- 3 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 7/9/2012 Issue Date: Expiration Date: 5/26/2014 License Status: Active Today's Date: 9/13/2013 Secondary License: Doing Business As: atus Chan e: 18 o Prerequisite Information No Discipline Information ocumen um _ I Close window m 2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state,ma.us/Verification/Details.aspx?agency_id=1&license_id=273285& 9/13/2013 NOTEPAD. HOLDER CODE CITYSAL STATIA - PAGE INSUREDS NAME Station Road LLC OP ID: DH DATE 09118113 s required by Massachusetts Workers Compensation Rating and Inspection Bureau: All requests for (workers compensation) Certificates of Insurance must be submitted to the servicing carrier or voluntary direct assignment carrier. A request has been faxed to the Insurer named on page 1. g 0�34011R CITY OF Siu-&Nf, NL L-kSS.ICHUSETTS BUIMIING DEPAMLENT 120%V.ssHL�IGTON STREET, 3"'FLOOR TEL (978)745-9595 FCC(978)740-9846 Kl\[BERLSY DRISCOL-L THo,%usST.PTE.RR13 tiUYOR DIAECCOR OF PUBLIC PROPERTY/BI:II.DL�IG COMMISSIONER Workers' Cmnpensadon insurance Atiidavit: BuitderslContractors/Electric(ans/Plumbert 411111icant information Please Print LeQibiy- Vallee(0usinesyOrganiraliorvindividual): Address: City/StatclZip: Phone M: Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with 4. 0 I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-r:onttactors 2.0 lain a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub-contractors have S. []Demolition working.fur me in an capacity. workers'comp.Insurance. Y a ry• 9. ❑building addition (No workers'comp.insurance 5.'❑ We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workcra cutup. c. 152,)1(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' 13.0 Other comp:insurance required.) •Any appllcum that chicks box tl most also rill out the aeclieo below rhowing their wmkew'compenwion Polley intmmallm, 'I bveeowm"who submit this affidavit indicating ihey am doing all work and thca hire oubide conlmctan most submit a new amdavit tndiaing ruck !oinn:xton thal chcrk this bus moat anachud an addiliurud+hero ahuwing the numa otltlQ sutKronlnQorx and their worked sump policy iniomunon. l um an employer thatIs provldbig workers'compensation lasurance for my employee: Below Is the polliy and Job silt laforuradan. Insurance Company Name: Policy 4 or Sclf--ins.Lie. 0: Expiration Date: Job Site Address: City/State/Zip. Attacts a copy of the workers' compensation policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or arse-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line Of up to S250.00 a day against the violator. lie advised that a copy of thiss statement may be rurwarded to the Office of Investigations ufthe DiA fur insurance eovcraga verification. /do hdreby certify turddeerrheppahts and iteuuUler of per/ury drat the hifonnutlon provided above i.r true uud c•o rece. I S i fir �Y-� f�G� Dare: �' q/lZ//3 ennlurc: Phona;Y C (-7 .S 6 c 2`S S� . O/)iciul uae only. Du not wrilt art rldi area,to be completed by city or town n/JlrluL ' I City or rown: Per mit/f.Icell"0 ► Issuing Authority(circle one): L Ilourd of(Health 2. nuilding Mparhncut 3. Cityi ruwn Clerk 4. Electrical inspector 5. Plumbing Inspector i 6.0ther _- ----_.. Contact Pcreon: _...... --- .. Phone it: MASSACHUSETTS WORKERS' COMPENSATION ASSIGNED RISK POOL ONLINE APPLICATION FOR WORKERS' COMPENSATION INSURANCE Processed By: The Workers'Compensation Rating&Inspection Bureau of Massachusetts 101 Arch Street Boston,MA 02110 Requested Effective Date: 9/17/2013 617-439-9030 Employer Email Payment for the MA Workers' Compensation Assigned Risk Pool Online Application (OAR) must be made by electronic check. Coverage will not be provided if the correct payment or deposit premium is not received within two business days from receipt of the confirmation email sent once the application has been approved and assigned. Under no circumstance will coverage be assigned if: the declination requirements are not met;there is a record of coverage in force for the entity making application; the applicant is in default of premium for prior workers' compensation coverage; or, the applicant has an audit or inspection from a prior workers'compensation policy that remains incomplete due to the applicant's failure to cooperate with the prior insurer. The earliest possible date coverage ran be bound is at 12:01 a.m.the day after the application is submitted to OAR. The undersigned employer has failed to obtain workers'compensation and employers' liability insurance in the voluntary market and hereby applies for such insurance in the Massachusetts Workers'Compensation Assigned Risk Pool and expressly represents that such insurance is sought in good faith. 9. GENERAL INFORMATION Name of Employer(Name the sole proprietor,general partner(s)or the trustee(s)along with the trade name of the business.) Federal Employer Identification Number(FEIN) Total Number of MA Locations: CO MICHAEL SNITKOVSKY 31 I ONDWOOD DRIVE SWAMPSCOTT MA 01907 617-504-6235 Mailing Address City Slate Zip Phone 6 STATION ROAD SAI FM MA 01970 617-504-6235 Principal MA Location City State Zip Phone COMICHAEL SNITKOVSKY 91 I ONDWOOD DRIVE SWAMPSCOTT MA 01907 617-504-6235 Location of Records City State Zip Phone Other Massachusetts Location City State Zip Phone Legal Status: ❑Sole Proprietor ❑Partnership ❑Corporation ❑Trust [_]Limited Partnership ❑✓LLC ❑Municipality ❑LLP [-]Other(Explain), II. ELIGIBILITY REQUIREMENTS To be eligible to obtain assigned risk coverage: •The employer's application for voluntary Massachusetts workers'compensation coverage must have been rejected by two (2) carriers licensed to write workers compensation in Massachusetts; •The employer must not be in default of premium for Massachusetts workers'compensation insurance; .The employer must have complied with all laws,orders,miss and regulations in force and effect relating to the welfare, health and safety of employeeE and, .The employer must not have an audit or inspection on a prior workers' compensation policy that remains incomplete due to the employer's failure to cooperate with the insurer. 1. List the names, representatives,date(s) of discussion, and phone numbers of two insurance companies licensed to write workers'compensation in Massachusetts who have refused to write voluntary coverage for this risk in the past sixty days. Each representative named must be an employee who has authority to bind coverage for the insurance company. A failure to reach such a representative cannot be construed as a refusal to write coverage. Name of Insurance Company Full Name of Representative Declination Date Phone Employers Mutual Rose McCarthy 09/16/2013 401-244-1800 Arbella Protection Leah Eely 09/16/2013 800-972-5348 la.Has the employer's coverage,either voluntary or assigned risk,recently terminated or expired? ❑Yes ❑J No Note:If Yes,a copy of the cancellation or nonrenewal notice must be attached,and the reason for the cancellation or nonrenewal must be indicated on the notice. If the coverage was in the voluntary market within the past sixty days,the cancellation or nonrenewal will serve as one of the two required declinations. Generally, coverage must be replaced in the voluntary market if voluntary coverage was cancelled or nomenewed at the employer's request. 2. Have you received any offers of voluntary coverage? _ Dyes Q No , 2a. Does the offer of coverage include multi-line,deductible,or retrospective rating terns? Dyes ❑No 3. Is there any unpaid workers'compensation premium due from you or any other commonly owned enterprise? ❑Yes ❑✓ No ❑Unpaid Premium ❑Premium Dispute ❑Payment Plan (Select most appropriate) If Unpaid Premium selected,provide: Entity Name Balance Policy Number(s) If Premium Dispute selected,a copy of the letter sent by the employer to the carrier disputing the premium with full explanation must be attached to this application for Bureau consideration. If Payment Plan selected,a copy of the signed payment plan agreement between the employer and the carrier must be attached to this application. f4. Does the employer have any outstanding audits or inspections on a prior workers'compensation policy? Dyes J❑No If yes,provide the name of the insurance company and the policy number(s). Insurance Company Policy Number(s) 4a. Has an audit been scheduled? Dyes ❑No If yes,provide the insurance company contact name and phone number. Insurance Company Contact Name Contact Phone# - Ill. CORPORATE OFFICERS, SOLE PROPRIETORS, PARTNERS&MEMBERS For Sole Proprietors,Partners,LLC Members and LLP Partners: List the names,titles,ownership and duties of all proprietors,partners or members, and indicate whether each is electing coverage. Sole proprietors, partners and members are not covered unless they elect coverage.To elect coverage,a letter must be attached on Company letterhead in accordance with MA Regulation 452 CMR 8.07. Refer to the MA Workers' Compensation & Employers Liability Insurance Manual,to the Rates Page with Miscellaneous Values,for sole proprietors',partners'and members'basis of premium. In Section VI include the Basis of Premium for all sole proprietors,partners and members electing coverage. For Corporations: List the name, fitle, ownership, duties and actual salary of all officers listed in the Corporate Articles of Organization and indicate whether each has chosen to exempt himself from Coverage in accordance with NIA Regulation 452 CMR 8.06. Corporate officers will be included unless a Form 153 has been submitted to and approved by the MA Department of Industrial Accidents.A copy of the DIA stamped and approved Form 153 must be attached to this application. Corporate officer salaries may be subject to payroll limitations; refer to the MA Workers' Compensation & Employers Liability Insurance Manual,Part One—Rule IX.In Section VI include the salary,subject to minimums and maximums,of all nonexempt corporate officers. Name I Title %Ownership Elect l Exempt Duties Salary MICHAEL SNITKOVSKY I LLC MEMBER 100 EXEMPT GENERAL CONTRACTOR 10.400 IV. INSURANCE RECORD 1. Has the applicant previously had Massachusetts workers'compensation insurance from a licensed insurance company? Dyes ❑✓ No 2. If Yes,complete the followinq for the most recent three years: Insurance Company Policy Number From To Period premium 3. If No,complete: ❑✓ New Business ❑Uninsured ❑Self Insurance Group ❑Self-Insured ❑Other(Explain): 4. Was the applicant self-insured within the last twelve months or was the applicant's expiring policy subject to the Premium Dyes ❑✓ No Determination Endorsement—Former Self-Insurers 1? If Yes,former self insurers who are subject to Premium Determination Endorsement—Fortner Self-Insurers 1 cannot submit an online application through OAR.A paper application must be submitted. Refer to the Pool Procedures for New Applications for details. Former members of self insurance groups are not subject to this endorsement. 5. Is the employer in bankruptcy? Dyes ✓❑No 6. Does this entity or any other commonly owned entity have operations in states other than MA? ❑Yes ✓❑No 7. Has there been a name change within the last five years? Dyes ✓❑No 8. Has there been a merger or consolidation within the last five years? Dyes ✓❑No 9. Has there been a sale,transfer or Conveyance of ownership interest within the last five years? Dyes ❑J No 10.Did the applicant purchase or otherwise acquire the physical assets of another entity whose operations they took over within the last Dyes ❑✓ No five years? 11.Have the owners or officers ever had ownership interest in any other entity,either currently or previously existing? Dyes ❑✓ No 1 V. BUSINESS OF EMPLOYER 1. Completely describe all operations of the employer.If there are multiple locations,provide a description for each. Completely describe any changes that have taken place in the last three years that might affect the classification of the operation. 7777! idence.New kitchen and bath,etc 2. MA law provides that you,the employer,are liable for injury of employees of uninsured subcontractors.Premium will be charged in the absence of a certificate of insurance from subcontractors. Is it anticipated that subcontracted labor will be utilized during the policy term? ❑✓Yes ❑No 3. Do you use independent contractors? ❑✓ Yes ❑No If Yes,you must maintain documentation which supports that they are,in fact,independent contractors. If such documentation is not available, or if the designated carrier finds evidence of an employment relationship,then premium may be charged as if the individuals were employees. 4. Is the employer a temporary help agency? ❑Yes ✓❑No 5. Does the employer lease employees from another business? ❑Yes ❑✓ No 5a. Is this application for your own employees not subject to an employee leasing arrangement? ❑Yes ❑No 6. Does the employer lease employees to another business? ❑Yes ❑✓ No 6a. This application is for: ❑Your own employees not subject to an employee leasing arrangement. ❑Employees leased to a client company. Client Name Client FEIN Street City State Zip VI. MASSACHUSETTS CLASSIFICATIONS, ESTIMATED EXPOSURES,AND PREMIUM CALCULATIONS Shift Class s Number of Estimated Location # Code Classffication Phraseology L Employees Remuneration Rate Premium H Exposure 1 1 5645 CARPENTRY-DETACHED ONE OR TWO FAMILY 1 10,000 8.68 868 DWELLINGS 1 1 5190 ELECTRICAL WIRING-WITHIN BUILDINGS&DRIVERS 1 2,500 2.84 71 1 1 5183 PLUMBING NOC&DRIVERS 1 2,000 3.50 70 Are Admiralty or FELA higher limits of liability(25,000125,000) ❑Yes ❑No Factor being requested? Manual Premium 1,009 If coverage 11,voluntary compensation selection: ❑USL&H ❑Massachusetts Waiver of Our Rights-No Employers Liability 9845-Standard Limits Deductible- None Experience/Merit Rating - VII. DEPOSIT REQUIRED: MA Construction Credit- 0% 1.Installment Options Standard Premium 1,009 Total Estimated Installment Deposit Additional ARAP Premiui I Factor Payments QLMP% Under$5,000 Annually 100% None Balance To Admiralty/FELA Minimum Premium At Least$5,000 Semi-Annually 75% One Loss Constant At Least $10,000 Quarterly 50% Three Expense ConstantV.03 338 Terrorism Premium 4 At Least$25,000 Monthly 25% Nine Premium Subject to Total Policy Minimum Premium 1,351 2.Is premium being financed through a premium ❑Yes ✓❑No finance company? Total Policy Minimum Premium 500 3.Any binding of coverage is conditional until the electronic funds have Total Estimated Premium 1,351 Geared. If the electronic funds requested are denied,the employer will be DIA Assessment .034 34 given ten(10)days to provide the carder with a bank check or money order Total Estimated Premium Plus CIA Assessment 1,386 for the full amount of the required deposit. Only if sufficient funds are received by the carrier on a timely basis,will coverage be effective as of the Deposit Premium- Annual 100% 1,386 tentative binding dale on the Notice of Assignment issued by the Bureau. r VIII.APPLICANT'S AGREEMENT By signing this application,I certify that: (1) 1 am the employer or have been authorized by the employer to complete this application on its behalf; (11) 1 have read and understand the following statements to which I agree by signing this application;and (III)All information provided in this application and on its attachments is true. In consideration of the issuance of a Notice of Assignment and subsequent policy of insurance, I hereby certify,under the pains and penalties of perjury,that: 1. I made a good faith effort,but failed to obtain coverage through the voluntary MA workers'compensation insurance market; 2. lam not knowingly in default of premium on any MA workers'compensation insurance policy; 3_ 1 have complied and will continue to comply with all laws,orders,rules and regulations in force and effect relating to the welfare,health and safety of employees,including but not limited to: a. Allowing the carrier to make a careful inspection of my operation for the purpose of measuring the hazards, making recommendations for the health and safety of employees,and determining the rate or rates which are adequate and reasonable; b. Complying with the carriers'reasonable recommendations aimed at controlling or reducing the hazard(s)insured against; c. Keeping records of information needed to compute premium and providing the canner with copies of those records when asked for them;and d. Fully cooperating with the carriers'attempts to conduct premium audits or inspections of the premises for loss control purposes. I understand that the employer's compliance with each of these certifications is material to the issuance of assigned risk pool coverage. Station Road LLC Michael Snitkovsky Member 9/16/2013 Business Name of Applicant Signaa�ture //! Title Date of Application Original Signature For Printed Copy: r NOTICE: This insurance is being provided through the Massachusetts Workers' Compensation Assigned Risk Pool, and not through the voluntary market. The employer's non-compliance with certifications 1,2 and 3(a-d)may,to the extent allowed by Massachusetts law,cause the carrier to initiate a mid-term cancellation. FRAUD NOTICE: Massachusetts General Law,Chapter 152,Section 14(3)provides: "(A)ny person who knowingly makes any false or misleading statement,representation or submission or knowingly assists,abets,solicits or conspires in the making of any false or misleading statement, representation or submission,or knowingly conceals or fails to disclose knowledge of the occurrence of any event affecting the payment, coverage or other benefit for the purpose of obtaining or denying any payment,coverage or other benefit under this chapter; and any person or employer who knowingly misclassifies employees or engages in deceptive employee leasing practices for the purpose of avoiding full payment of insurance premiums...Shall be punished by imprisonment in the state prison for not more than five years or by imprisonment in jail for not less than six months nor more than two and one-half years or by a fine of not less than one thousand nor more than ten thousand dollars, or by both such fine and imprisonment." IX.AGENCY INFORMATION AND PRODUCER'S STATEMENT The producer hereby certifies,under the pains and penalties of perjury,that all information provided is true to the best of his/her knowledge and belief and that he/she made a good faith effort to place the coverage in the voluntary market as required by M.G.L.,C.152,Section 65A. DANIEL HURL FY INSI TRANCE AQENCY INC Name of Agency 042973558 1781425 FEIN Producer License# 7 FFDFRAI STREET Mailing Address of Agency DANVERS MA 01923 978-777-9394 City State Zip Phone DANIEL HURLEY Producer Name , DANIEL J HURI EY 09/16/2013 Signature of Producer Date Original Signature For Printed Copy: 0 By checking this box,I certify that I am the producer of record. ❑✓ By checking this box,I certify that I have reviewed Section VIII of the application with the applicant prior to his/her signing. O By checking this box, I hereby acknowledge the signatures to this application as original signatures. I request, on behalf of the applicant,the designation of an insurance company to provide insurance in accordance with the provisions of the Massachusetts Workers Compensation Assigned Risk Pool,and I certify that I have reviewed the applicant's responsibilities with the applicant and will retain a copy of the completed application with the applicant's and the producer's original signatures for a period of not less than five(5)years. 6 STATION ROAD 180-14 GIS#:� � , 4596 � 31 COMMONWEALTH OF MASSACHUSETTS Block: , - CITY OF SALEM Lot: 0060 ,. Category: _ 'REPAIR/REPLACE_ Pemnt# 180.14. TIZBUILDING PERMIT Project# JS-2014-000375 Est. Cost: $22,500.00 Fee Charged: ` $194.00 Balance Due: $.00 ' PERMISSIONIS HEREBY GRANTED TO: Const. Class: .p Contractor: License: Expires: Use Group:". - 'at ?.. ROBERT B.TARQUINIO Lot Size(sq. ft.): 14600.0052 jM Zonnig: RI ''• ,) 'ai Owner: STATION ROAD LLC i nits Gamed: r k� ' ; "' Applicant:"STATION ROAD LLC Units Lost:"` u AT: 6 STATION ROAD Dig Safe#:'_'� . 'ISSUED ON: 22-Aug-2013 AMENDED ON: 19-Sep-2013 EXPIRES ON: 22-Feb-2014 TO PERFORM THE FOLLOWING WORK: REPLACE WINDOWS, INTERIOR REPAIRS; Added KITCHEN&BATHROOM REMODELING 9/19/2013 EST. COST $14,500. CK$133. ADDED POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: Underground: Underground: Excavation: Service: Meter: Footings: Rough: Rough: Rough: Foundation: Final: Final: Final: Rough Frame: Fireplace/Chimney: D.P.W. Fire Health Insulation: Meter: Oil: Final: House# Smoke: Treasury: Water: Alarm: Assessor Sewer: Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: BUILDING REC-2014-000585 19-Sep-13 0 $133.00 BUILDING REC-2014-000407 22-Aug-13 134 $61.00 i' . !GeoTMS®2013 Des Lauriers Municipal Solutions,Inc.