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96 SWAMPSCOTT RD - BUILDING INSPECTION (19) No. -06 �. _.____.__ M P"WIV Low"tib P Wall Low"In ConNw 1 Awd Yq.No ENILDrIM PtId W APPLICATION POIN Permit Im ConsoW Dooir, &ode Pool. (C.If01e MAIidNllar apply) UFl- col �SWW�'���r- Ili 64DR G. iFV � MMAU PILL OW LEOIELY a COYPL MY TO AMOID DELAYS N PFA=M Ki TO THE MPECTM OF BUMNOG: The w ds s*W hi eby vWW for a permit to build a000 ft 10 Ow bllowinp OwWsNw % t/d��TT VaPcP, Ll-C- �S6'r �o ptl I 'f srr $ P s Gc t Fol*�T E22 (781 1 5o �c I wv oL q-►� Ndhlsars Nama WILL-iafagn � Address• Phona MA- C j 5 f 7b I 1 6a I - -Jn= Madroics Name g W �14� Address t Phone t ,;,�� E-rr�*I i �. o l�1-E:D_ j� WA anapotionitWMW -r. F: Mpe- Ft-TPC)F6T MONO a T�l �L�Cc c t� r a WmWS ar now MW WEN?- — M kd"GOMM 0 kW n o 11� arI of Yom= UA = PENALTY OP PE &RW DESCRIPTION OF VXM TO U DONE GTI`FE �6MC'sl.lZID1`l ( WUSG , f�Ef�T� TD f' I�US USA NON- 14Cl fAFT' i a-t5- td`6F U- !�-Ote Wq2C, lb 4 iTie� T,�-flues cF�Tt�uc,T �( wSU r* c MNL FPO ERMWM fQez�� APPLICATION FOR ^ Pomw TD PC9on01.f'on LOCATION PERMIT GRANTED C IN�6i OF OULLDO 02/09/2006 18:07 7816310916 PMT DEVELOPMENT INC /PAGE 02 Ile Commonwealth of Massachusetts � y� '�� Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 wnmttnassgou/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electritciaus/plumbers AlRyficaut Infohnatian Please Print Legibiv Name (RuMMMSMization/ladividoal): cat C,0 ��5�!v( �1 u n G (L f✓2/1 In(, Address,.- City/State/Zip: c n VV /A C)U: phone#: (j Are you an employer?Cheek the appropriate bole' Type Of Project(regnired): 1.( I am a employer with 2 5 4. ❑'I am a general contractor and I aMloyeea(fun and/or part-time).+ have hkcd aie sqb=cvatracmrs 6. []New rAtittlrtlt flOn 2.❑ 1 am a sole proprietor or pamper- listed on the attached sheet r 7. IM Remodeling SW and have no employees These sub contractors have s- ❑ Demolition working for the in any capacitor. workers' comp.insurance [No workers'comp_ntsttracce 5. ❑ We arc a corporation acid its' . 9' ❑ 13ur7dmg addition required.]: oflliom have C=ciscd their 10.0 F-Imttical t'epairs or additions 3.❑ I am a homeowner.doing all work right of exeruptim per MOL 11.0 Phlmbitlg repairs or additions myself.[No workeW,.com : c. 152,§101 nd w havn inswancequired]t x 12. Roof rpairs cmpioyoes. [Nwkers' comp,insurance required.] 13 ❑ Other Any opplio-t tine eh.cU boa M1 uww.utm fin out the section below sbowing theit.cw!9rua'contpenaation Policy iagommlion: t Hanteowncrs wlp sulstnR this at6dava irlditxting they ate doing all wok and than hiie on"tnvtnec. nhw submit a new affidavit indicating gueb. tContad=that checkflis bojMuAt$aacltod ee eddiCion'a$heat showing the Amon bfthe subcoutinixos and Aeit workers'oonm.policy ifflb nri. I ma an`employer that Is providing warkers'compensaiten bauranceror lnyeiiployeea. Below h s el thepolliq and ja>!i its informatim Insurance Company Name: 'A�Lov\kIL Policy#or Self ins. Lie.# W C 1 `3yc,cz,-1 `( � (o • Expiation Date: Job Site Add,,.: _ 9(o 1jw o MS wt-k 12 L Lr —Ci1y/Statr/'7.' :— C, kAM VOA Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiraaon date). Fail=to secure cDvcmg,a as t'equired under Section 25A of MOL c. 152 can lead to the imposition ofcriminel penalties of a tmc up to 51,500.00 and/or one-year irrtptisovment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup to$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Offs a of Investigations of the DL4 for fl awmce coverage veriGuadom I do hereby cent&a the and n ofDerjury that the Information provided above is tree and mrrcei i atlue: D (o Phone..: OaleAd use only. Do not write In this area,to be completed by chy of fawn o,QYclaL City or Town:_„ permWLicease# Issuing Authority(circle one): 1.B02r4 of health 2.Building Department 3.Cky/Town Clerk 4.Klectricai Tnapector 5_plumbing Inspector 6. Other Contact Person.- Phone# 02/09/2006 18: 07 7816310916 PMT DEVELOPMENT INC PAGE 03 Information and. instructions Massachusens General Laws chapter 152 requites all employers to provide workers' compensatim for their eroployee3. r,Dauant as rids statute, an envAg a is defined as"...every person m the stavice of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association,corporation dr other legal Maly,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 indwrdaal,partnership,association or other legal entity,employing employees. However the owner of a dwelling bonne baying 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 ucensing 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 appi;cant who has not prndnced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neitbcr the com monweahh 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." Applieants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contract r(s)aame(s),add'Hgs(es)and phone number(s)along with their certifieAte(s)Of insurance Limited Liability Companies(LLC)or Limited Liability partnerships(LL.P)with no employees other than the numbers or partners,am not required In carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required Be advised that ibis affidavit maybe submitted to the Department of industrial Accidents for con fyrmation of insurance coverage. Also be sure to sign and date the affidavIL The atTiidavit should be returned to the city or town that the application for the permit or license it being requested,ant the Department of Industrial Accidents. Should you have any questions regarding the law or if you are requited tb obtain a workers' rut Venation policy,please call the DepmU=t at the member fisted below. Self-insured companies should enter their self-insurance license number on the appropriate line. C Hy 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 perrnrtlhecwc 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 m (c-ity or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the appUcaut as proof that a valid affidavit is on file fat friare permits or lireases. A new affidavit mustbe filled out each year'.where a home owner or citizm is obtaining a license or permit not related to any butsiness or=ummial vcotuarc (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 can. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial.Accidents of a of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia N'CCO63D CAFCO-1 06 29 05 CERTIFICATE ®F LIABILITY INSURANCE OF ID DATE(MM/ODIYYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Thomas Gregory Associates Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 601 Edgewater Drive S235 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wakefield MA 01880 Phone: 781-914-1000 Fax:781-246-2601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Acadia Insurance CAFCO INSURERB: Atlantic Charter Insurance Grp Cafco Construction Mgmt. , Inc. INSURERc: Joe Burkett 77 Charles Street South INSURER Boston MA 02116 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 OATEYMMIODIVY E PDATE MMIODn ON LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPA0054159 06/30/05 06/30/06 PREMISES(Eaoccurence) $ 300,000 CLAIMS MADE M OCCUR MED EXP(Any one person) $ 5,000 PERSONALS ADV INJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO LOC ECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT X ANY AUTO MAA 13000621 06/30/05 06/30/06 (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ Physical Damage COMPREHENSIVE S PROPERTY DAMAGE $500 COLLISION (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ 1 AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 5,000,000 A X OCCUR F7CLAIMSMADE CUA 0054158 06/30/05 06/30/06 AGGREGATE $ 5,000,000 s DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND X TORYLIMITS ER B EMPLOYERS'LIABILITY WC180007986 07/01/05 07/01/06 E.L.EACH ACCIDENT $500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER A Property CPA0054159 06/30/05 06/30/06 BPP $30,000 EDP $75,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate holder is named as additional insured for ongoing operations of the named insured CERTIFICATE HOLDER CANCELLATION JOHNPHI 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 LEFT,BUT FAILURE TO DO SO SHALL J P A 1 Management Co. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 200 Stuart Street Boston MA 02116 REPRESENTATIVES. AUTHORIZED RESENTAT ACORD 25(2001/08) ©ACORD CORPORATION 1988 02/09/2006 18:07 7816310916 PMT DEVELOPMENT INC PAGE 04 CITY OF .SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 4D 120 WASHINGTON STRFET, 3RO FLOOR OR MASSACHUSETTS 01970 STANLEY J. USOVIcY, JR. TELEPHONE; 978-743-9995 EXT. 390 M 1YOR FAX: 97e-740-9846 Salem ft1dinQ Deparpnent Debris Dl�� In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed Of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. The debris will be disposed of in: Z-e� A w c �.(Location of Facility) f3 o S-0v1 Signature of Apphican~t Z - Date I