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96 SWAMPSCOTT RD - BUILDING INSPECTION (2) fL�NS1Atl6ir�EfN�Ei�MID AP~VEO BY T4IE NSPIS 9 POOR TDA.PEROT BEING GRANTED CITY OF SALEM Is plowly womad b Looattm of "HWMM orlaa9 ea,TRo r t�oprq tooatid b :� by 1"o�aoa Awa9 Y«No� BWLDING PERMIT APPLICATION FOR: Pam►R UK (Girds whidm w apply) Roof. Rwocf, IMM SWWO Conatnx:t Dock, Shed. Pool, Rapawpaphm. Ottlw: 1�e offLctCarrluL, 0.1 PLEASE RLL Olfii LEMLY i COMPIMELY TO AVOID DELAYS W PROCESSM TO THE INSPECTOR OF BUILDINGS: The undom nod hweby appliaa for a pwmit to build aa:w&g to the foWwmg Owa a Name .1nc Address& Phone a4 E„Pr !��i�� I ��a 3135 5 v4A px�Yr t-1a a 101 Arcbibc s Name 1 `i� N �^ 4a F�� tl, Addnaa & Phorw j9-A l -14r, 822, Mochw= Nan Addroaa 6 Phono j 1 w w Is"pupou d ewwrpy ta�l■w a ourar�5T ��,. ,. Ifs„ 1 (=�r r a dwwrq.wr tow array lamlwa4 vm t A&Q aodmm a wo Aab y No tyWMMd ao�t` (54 oc b aw Uorw r N A slab • t.�. 0 of AppiWt SHINED UNDER THE PENALTY OR PERJURY DEWJWn WN OF WORK TO BE DONE MAIL PERMIT �;A S No 67 APPLICATION FOR PEFWr TOl LOCATION PERM T GRANTED 7 L Z F° - INSPECTo F BUILDINGS 9 The Commonwealth of Massachusetts Departineirl of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 WW m/nass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Groom Construction Co. , Inc. Address: 324 Essex Street City/State/Zip: Swampscott, MA 01 907 Phone #: 781 —592-31 35 Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling 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' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: American Interna i of na 1 Group Policy #orSelf-ins. Lie. #:_ WrgFRR7SR ' Expiration Date: 03-10-07 Job Site Address: City/State/Zip: 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 a 152 can lead to the imposition of criminal penalties of a fine up to $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 $250.00 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. I do hereby certify nder(�the paias and penalties ofperjury that the information provided above is true and correct. Signature: — Date —I •113-" Phone Pt: "Iis t .riq� CIS Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority le one): 1. Board of Health'/Z. ljuilding Department 3. City/Town Clerk 4. Electrical Inspector EPlumbingctor 6. Other Contact Person: Phone #: 03/14/2006 09:15 FAX 508 655 8853 EASTERN INSURANCE NAP CL Q 001 DATE(MWDDIYYYY) ACORD,N CERTIFICATE OF LIABILITY INSURANCE 03/10/2006 PRODUCER (800)333-7234 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION EASTERN INSURANCE GROUP LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 233 WEST CENTRAL STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, NATICK, MA 01760 INSURERS AFFORDING COVERAGE NAIC# INSURED room Construction Co. , Inc. INSURERA: St. Paul Travelers 39357 324 Essex Street INsuRERB: American International Group Swampscott, MA 01907 INSURERC: INSURER O: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN 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 d TYPE OFINSURANCE PDDCY NVMBER PODGY EFFECTIVE PoLICYEXJ.M um DATE IMIWCOfYYI PIRATION LIMITS GENERAL LIABILITY C0463D947A 03/10/2006 03/10/2007 EAcHOCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TORENTEO f 300.00 -EREU[SE&EEaDcmmncaJ- 7 CLAIMS MADE I-XI OCCUR MED EXP(Any one person) f 5,000 A PERSONAL SADVINJURY 5 1,000 OQ GENERALAGGREGATE f 2,000 00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,00 POLICY X jEC LOC AUTOMOBILE LIABILITY 81 3D9481 Q3/1Q/2006 03/10/2007 COMBINED SINGLE LIMIT $ X ANY AUTO (Ea aoddent) 1,000,000 ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) A X HIRED AUTOS BODILY INJURY (Par o=ident) It X NOWOW'NED AUTOS PROPERTY(DAMAGE $ acdclen GARAGE LIABILITY AUTO ONLY-EA ACCIDENT f ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S FXCESSIUMBRELLALIABILITY BE4953127 03/10/7006 03/10/2007 EACH OCCURRENCE S 10 000,000 X OCCUR a CLAIMS MADE AGGREGATE S SO,OOO,Q B S X1DEDUCTIBLE 0 S RETENTION f 10,00 f WORKERS COMPENSAPON AND WC9688758 03/10/2006 03 WC /2007 X STATU- O.- EMPLOYERS'UAWLnY E.L.EACH ACCIDENT S 1,000,00( B OFFICEER MEMBERR EXCLUDED?ECUTIVE E.L UISEASE-EA EMPLO 5 1,000,00 If Yee,desaihe under EL.DISEASE POLICY LIMIT 5 1,QDD QQQ SPECIAL PROVISIONS below OTHER CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT, UUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY I(IND UPON THE INSURER,ITS AGENTS OR REPRESENTATNES. AUTHORIZED REPRESENTATIVE Rosemary Fulham PMA ACORD 26(2001/08) ©ACORD CORPORATION 1988 p.p . ass gddy jo sa8}9 -177 ODPOW lI;o pmodsW o4 WAIL WgVP OU ,IDIKAqpmMnAMM 'Vogl SOw XWWD pmodW s4 UM 40b � _ wm 4ndoid s al jo anal;jo oop fg s " S 069 �� aOd 19MA pgos pnow sE�d gonna swRPlb owspiwm sl hsso►cyu olvr Os[ IASM ppifL.SLs %p""dV"WL OLSto ttatasrnt>vww Ms"s No" for 'walue Imm"Ism is Ot t ANDFUNrtN0 ALUNdowd onerw suasn"*vssvw sKsosys ao uID