2B STILLWELL DR - BUILDING INSPECTION (3) qo/-off
CONTRACTOR INFORMATION
Name
Address 2 -0 a
Telephone 97,E 3/
Construction Supervisor's Lic #
Home Improvement Contractor#, -
%RCIIITEUVENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $7/$1,000 + $5.00=
COMMENTS ,
The undersigned does hereby attest that all information stated above is trite to the best
of my, knowledge under the penalties of perjury
Signed
Date
1
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1 .9-8-15-')."6 I.0:''1—N
APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS
IMPORTANT: Applicants must cony lete:dl items on this page
SITE INFORMATION
Location Name Building
Property Address
Map#
Located in: Conservation Area Y/N Historic district Y/N
Use Groups
- (check one)
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel RI
(check one) Assembly (churches) At—
New Building_ Assembly (nightclubs etc) A2_
Addition Assembly (restaurants, recreation) A3_
Alteration Business B
Repair/Replacement _ Educational E
Demolition_ Factory (moderate hazard) Fl _
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard 11
Accessory Building Institutional (residential cure) 11
Other(describe) Institutional (incapacitated) 12
Institutional (restrained) 13
Mercantile M
Storage(moderate hazard) S1 _
Storage(low hazard) S2
OWNERSHIP INFORMA"r1ON(Please type
or Print Clearly)
OWNER Name i 4u14 /--,`/a'r)
Address of J3 44,`11 LAG
Telephone 97S _ S-q
DESCRIPTION OF WORK TO BE PERFORMED
94P A6 6zrL en � Gy�`n�Ni�uis
ESTIMATED CONSTRUCTION COST
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,INHI UE`t DRIS0 I[.
10.-vTVR 120 W.A_i I HN(;10N S I R ITA 0 SAL FS1, AIXS5AIlit-SGl 1i01970
Tel.: 978-745-9595 • FAX: 978-74G9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
%pplicant Information Please Print Legibly
Name (Busi Less Organ iza tioni ln ea v idual): 1 Y ` U� fJ �J�C� a 0 Ini C j-z]!;2
u
Andress:
City/State/Zip: SIG ��r✓t �/ /�C7 7� Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with Q _ 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).` have hired the sub-contractors ❑ Remodeling
2.❑ 1 ❑m a sole proprietor or partner- listed on the attached sheet.
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' coin insurance 5. ❑ We are a corporation and its
( p' 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work g exemption
right of per MGL I LD Plumbing repairs or additions
Pon
myself. [No workers' comp. 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 applicant that checks box III must also till out the section below showing their workers'compensation policy information.
i I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l 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 Selt=ins. Lic. #: Ll/C /' Expiration Date: 7 ^A
Job Site Address: rJ S' ll1�P City/State/Zip: �el"7 zyA. 0_&70
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
tine 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 S250.00 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.
l do herehy terrify un er the poins and penZte ofp 7ury that the information provided above is true and correct
Si n our 6{z�J1 Date' .� ^ 2,)—''d�
phone 4
O/ficiul use only. Do not write in this area, to be completed by city or town official.
Citv or 'fow.n: 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 and Instructions
q ,
%LIS53chUSCUS General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
1'ursu:mt w this statute, an emplgree is defined as "...every person in the scn ice of another under any contract of hire,
express or implied, oral or written."
An eiuploper 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."
\IGL 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, NIGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the perforniance of public work until acceptable evidence of connpliance'with the insurance
requirements of this chapter have been presented to the contracting authority." - -
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) 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
(own)." 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 burn 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 its a call.
The Department's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or I-877-MASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
r
Liberty Mutual Group
Liberty P.O.Box 9090
Mutuailll® Dover,N11-03821-9090
Telephone (800)653-7893
Fax (603)-245-5330
February 20,2008
CITY OF LYNN
ATTN: INSPECTION SVCS
3 CITY HALL SQUARE RM 401
LYNN, MA 01901-
RE: Certificate of Workers Compensation Insurance
Insured: STEVE HADLEY
DBA STEVE HADLEY CONTRACTING
239 JEFFERSON AVENUE
SALEM, MA 01970
Policy Number: WC2-31S-329064-017 Effective: 7 /10/2007 Expiration: 7 /10/2008
Coverage afforded under Workers Compensation Law of the following state(s): MA
Employers Liability(Limitsl. Sole Proprietor/Partner Coverage Election:
Bodily Injury By Accident: $ 100,000 Each Accident The workers'compensation
policy does not provide
Bodily Injury by Disease: $ 100,000 Each Person coverage for:
Bodily Injury by Disease: $ 500,000 Policy Limits STEVE HADLEY
As of this date,the above-referenced policyholder is insured by Liberty Mutual Fire Insurance Co under the policy
listed above.
The insurance afforded by the listed policy is subject to all the terms, exclusions and conditions, and is not
altered by any requirement, term or condition of any or other documents with respect to which this
certificate may be issued.
This certificate is issued as a matter of information only and confers no right upon you, the certificate
holder. This certificate is not an insurance policy and does not amend,extend, or alter the coverage
afforded by the policy listed above.
If this policy is cancelled before the stated expiration date,Liberty Mutual will endeavor to notify you of
such cancellation. � I
AUTHORIZED REPRESENTATIVE
LIBERTY MUTUAL INSURANCE GROUP
This Certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those companies.
cc: Insured: Producer of Record:
STEVE HADLEY M P ROBERTS INS AGENCY INC
DBA STEVE HADLEY CONTRACTING 1060 OSGOOD STREET
239 JEFFERSON AVENUE
SALEM, MA 01970 NORTH ANDOVER, MA 01845
2/20/2008
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
N L'C WAS)RXi;:JN 5:3 EET )t, \fASiAC:n 14.C.i::')':
978J4C-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Ch1R section 111.5
Debris, and the provisions of)1GL c 40, S 54;
Building Permit # _ _ is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by v1GL c
111. 5 150A.
The debris will be transported by:
!name of hauler)
fhe debris will be disposed of in
i � sIV
rn�
(nume tit lacr,ty)
qD/-ate
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