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14 SUTTON AVE - BUILDING INSPECTION Ew 1 ACORD CERTIFICATE OF LIABILITY INSURANCFY OPID B DATE(MM/DD/YY) DYMIl 01/08/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE M.R. •Shaw ,,insurance Agency Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 4428 /c0/0 (tea ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Salem MA 01970 Phone: 978-744-4540 Fax: 978-745-8584 INSURERS AFFORDING COVERAGE INSURED INSURERA: Patrons Mutual Insurance Co. INSURER B: One Beacon Insurance Company Michael Pydynkowski INSURERC: Mass. Workers' Comp. Assigned 9 Brooks Street INSURER D: NSURER E: Salem MA 01970 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. IN SR P LEFFECTIV TYPE OF INSURANCE POLICY NUMBERICY EFFE I LIMITS LSR DATE MY DATE MM/DDNY GENERAL LIABILITY EACH OCCURRENCE $ 300000 A X COMMERCIAL GENERAL LIABILITY APPLICATION 12/27/06 12/27/07 FIRE DAMAGE(Anyone fire) $ 300000 CLAIMS MADE [X] OCCUR MED EXP(Any one person) $ 5000 PERSONAL B ADV INJURY $ 300000 GENERAL AGGREGATE $ 600000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 600000 POLICY PRO LOC ECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ B ANY AUTO FB1E53848 06/16/06 06/16/07 (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ 50000 HIRED AUTOS BODILY accident) $ 100000 NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ 100000 (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR 71 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORV LIMITS I ER C EMPLOYERS-LIABILITY APPLICATION 01/09/07 01/09/08 E.L.EACH ACCIDENT s500000 E.L.DISEASE-EA EMPLOYEE $ 500 000 E.L.DISEASE-POLICY LIMIT s500000 OTHER A Commercial Applica APPLICATION 12/27/06 12/27/07 A Property Section APPLICATION 12/27/06 12/27/07 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER N ADDITIONAL INSURED;INSURER LETTER:_ CANCELLATION 1111111 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _DAYS WRITTEN NOTICEfAIR(;E WD1I D A 1 Et4oU )6[LL rO SO SHALL IMPOSE NO OBLIGATION OR BILI F Y HE INSURER,ITS AGENTS OR REPRE T TIVE AUTHO ,�6RE — - M.R.!jiShaw Insurance Agency ACORD 25-S(7197) ©ACORD CORPORATION 1988 1 t IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S(7/97) CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT .%Wka nie 7..A vw.ONs a•lu:�ltavgtyu Tat:v7►7af91s6�F.�'17W�C9eM Construction Debris Disposst Affidsvit (reyuiral for all deewlidon and mwvadon work) in accordance with the sixth edition of dw State fluildity Cods.7SO CT` R section It 1.S Debris,aM dw provisions of vtGL c 40.S S . Btdidins Permit 0 _ _ is isated with the condition dust the dduis rmddns fiom this watt shall be disposed of in a properly licensed waste disposal tbeility as defined by%(GL c I l 1.S 150A. The debris will be transported by: �Ili10e,u'tlaul+d fhe debris will be disposed of in : illy�t nxl:lty) 10101102 _ ..Aga Information and Instructions %lassachusetts General Laws chapter 152 sequins all employers to provide workers' compensation for theiretnploytss Pursuant to this statute.an employee is defined as"...every person to the service of another under any contract of hire. eapress or implied.oral or written." employ is deBsod as"an individuslo partnership,anocu cos.corporation at other legal entiry,or any two or chore of the foregoing engaged in a joint enterprim and including tie legal representatives of a deceased employer,or the association or other legal entity,employing employees. However the receiver or trttstes of as iudividual.Pt mom h e erAma and who rcsidas therein or the occupant of the owner of a dwelling house laving not more.that throe maiapantenance. dwelling house of another who employs persocls m do maintenance.construction or repair work os such dwelling house a th=0 shall ttet betatoe arse!employntmr be deemed to be an employer.' or on the grounds or building PPS AtGL chapter 152.;25C(6)also stave that"every stab or local Ueesslng agency shag withhold the huuues or renewal of a Itcew or permit to operate a haslssss or to eosseruet buildings lo the commoawcalth fer coy appoesat wbe has not produced acceptable evidawA of compWnee with the Insurance coverage requirmV Additionally.MGL chapter 152, s)25C(7)state"Neither the commonwealth not 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 atahority.' AppUeasts Please fill out the workers'compensation affidavit completely.by checking the boxes that apply to your situation and.if necessary.supply subeone aetods)name(s),addree(as)and phone numbeds)along with dtcir certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employe"other than the members or partners,ace not required to carry workers'compensation insurance. If an LLC or LLP does have omployees,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. 'nte 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 Aceidecu. 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 lined below. Self-insured companies should enter their ,elf.haturanoe license number on the appropriate line. City or Town OAkish please be sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom. of the affidavit for you to fill out in the event tie office of investigations has to contact you regarding the applicant. I'Icaso be sure to till in the permit/license number which will be used as a refbrence number. In addition,an applicant that must submit multiple permit"icense 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 towel."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to du applicant as proof that a valid affidavit is on file for future permits or licenses. A now affidavit must be filled out earl 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. ['he Otiix of lavcstiyatiuns would Cue to thank you in advance fur 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 OMW of lovesdpdoN 600 Washington Street Boston, MA 02111 Tel. N 617-7274900 ext 406 of 1-977-MASSAFE Fax 0 617-727-7749 2cvised 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT wNth:'RIF.Y UaL4ta1LL M.�v<In 12C�A5W.�t."rO13 S�1tpgT a SAtLM.W.aB.t<la.:ft7 iN01973 ThL 97111•745.959S o F.ax:97i740.9846 Workers' Compensation Insurance Affidavit: Builder/Contractors/Electridens/PMmbers Applicant Information Please Print Leeibiv Name IBuvncsfloraani:uioNtmLvuluoq:y/��•/DGr.//76Cc�1�✓.S'/L! Cf.Jl�l � �C�e>l�J Addre", city/sl�tmz�P:s�1� �-r 0/9 7� rune a: Are you player?Cbeck the appropriate box 'rype of project(required): 1. am a employer with- -Z 4. ❑ 1 am a gimeral contractor and 1 6. ❑New construction *mploycm(full srullor part-time).• have hired the sub-coruractom 2.❑ 1 am a sole proprietor or pariner. listed on the attached sheet : 7. ❑Remodeling ship and have no employees 'These cob-contractors have N. ❑Demolition working for me in any capacity. workea'comp.insurance. 9. a Building ion (no worker'carp. insurance S. We are a have axcrcix and its 10.❑Electrical repairs or additions requirl;d.j otTleers how exdreistxl their 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself.(No workers'comp. c. 152,¢1(4).and we have no 12.0 Roof repairs insurance required.) t employees (No workers' comp. imunmcc require!.] •Ally appAwn the chccka ban al meat also a1r art the maim laiow+howio8 their woraaa'esmpantstuum pulley in ins. '1lwwumwa who submit ma atlldavir inditarina*my am doiryl tll wart treed than him manse eammamm minis audnit a saw amldava ia.11adina cock. -fumrxvn than that this ban mutt artadmd m additional chat%haw6y Ike name orthe subcanuacion,and their,warkem'tamp.policy manneauoa /um un employer that It providing workers'compensation Laurance for my employees Below is the pulfay and job site iujurmial" n Inurance Company Name: Qhf- 3CaGOY)., Policy As or Self-its. Lie.N: _ .. _ .._. Expiration it; /A9 O Job SiteAddress:2y TGe17/Zdtt �� CityiStateiZip:�ez`Pf`7 stsQ • O�g7C� Artach a copy of the workers' compensation policy declaration page(showing the policy number and cspiratiun date). Failure to secure coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties ors ri nc up trt S 1,500.00 andlor one-year itnprisonincnt,.ns well as civil penalties in the form of a STOP WORK ORDER and a leas of up CO S250.00 a day against die violator. lie advised that a copy of this slatcmcnt may be forwarded to the Office of lq%'CPIigpumts ofthc DIA for wiurance covRaft:%criftearon. /do hereby cen' ruder the peens ut ptnu/ r uj /ury hat the injermutlon provided above/:erne and correct PhiIlia t)pkid use an/ no cot wr•/to/n th/r area,to bi rumple ted by dry or Iowa oJJlejai Cityorfawn: PermittLieenseN___ Issuing Authorily (circle ohs): 1. Board of Health Z. Building Department 3. Civrown Clerk 4.Electrical Inspector 5. Plumbing lospccior 6. Other Coulact Person: Phone N: EITY`®F M PUBLIC PROPERTY DEPARTMENT A\� wwa 130�esnttwTnw sntssr•seu�wneow:.,,:01970 ' =-M745 4M•Fete M74&9eN wrpt�iCATIO 4 FOR THZ REPAIR. RZNOYAnoN_ 0NrrtRU( rrn y DE,rIOLPTIO .OR CHANGE OF USE OR OCCUPwIvtr_v_ Fog ANY EXISTING S'TRU TURZ OR B13LE NG 1.0 wM INFORMATION LocatIon Narne: Qd;; Property Property to located in a;Conservation Ate@ YIN_ HhMflo DI &kj YM 2.0 OWNERSHIP INFORMATION 7.1 Owner of Land . Name: Address Telephone: 97f- - c.,/ 3.0 COMPLETE THIS SECTION FOR WORK IN E MNO BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use NOW Demolition Existing Approximate year of Area Per floor(sfl Renovated construction-or renovation of existing building New d Descrip tion ption of Proposed Work: �e.�-ia Z� Cs��� ���c� L✓��-ems'-��✓' --- -- ---Mail Permit to; ggI46: Zl v ✓ What is the cuunrrt use of the Building? /its Material of Bull w A-le- / If how many units? - Wir U»BuOdinp Conforrn to Laws Asbestos? tiM Architects Name Address and Phony Medwo s Name Address and Phon 9 Sf So�/e c yam- c�f97c� Constn+cdior+ Superv'ears License 0 HIC Regatrstfon 0 EstYnated Cost of Project Per"Fes Calm tlon Permit Fee i 2'' Eallmated Cost X$7/51000 Residential EstYrwtedCOdX$4i/$1oOGCMWrMdd ---- - . . M AdditJonM MW Is added as an AdminWtWve chwga Make sun that ati fields are properly and ably written to avoid delays in processing. The undendgned does hereby apply for a Building Permit to build to the above stated spodkaftw. Signed under permAY of perjury Da vl N � a A . � 4 a Ci � - 4 --