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APPLICATION FOR
PER W TO
LOCATION
PEf�NT GRANTED
to
INSP OF BURMO os
All drawers and doom get pull handle
Knobs will be applied to cabinet above
the microwave and above the relrig.
Farmer's sink.Final dimension will need to be
determined and cut onsite by installer. Trash bin and DW can be switched
Mullion Doors on Comer cabinet Sink will need to be supported from bottom Final say by customer
Glass supplied by customer by installer.
Max cutout dimensions-9 1/4"H x 28"W
Trash bin
r
w0 wasao/
0
eas DFea]0 26.DI9HW RCp1B
= Rs f224
9 \..........._..._._....----.---------_ ,,
Spica Pullout .x'
4 drawer base with bread drawer - ti
Shegmounled lazy suean
Tray base-12"
Oj
B12
O � C fyj Finished side and t�k
@Y' m
O m'
Customer would like plugs in
LS island to be concealed as best as possible
Paneled side on base cabinet v Pullouts �NI_wi llllll�y�y�y
Reduced depth to 18"
/r
/ 11 Pullout trays
Finl�ide antl bac
3 Drawer base........27."-wide- ,,,_ @@@ There will beat"space above refrigerator.
Door to be moved by contractor Valance filler can be added if desired.
Mullion Doom above fridge.
Glass to be supplied by customer
-------------
Existing pantry to be removed
Opening to be expanded.
All dimensions size designations given are n/1")1"1y This is an original design and must not be Designed: 10/20/2005
subject to verification onjob site and nrnnumaiu released or copied unless applicable fee has Printed: 10/ 5/2005
adjustment to fit job conditions. been paid orjob order placed.
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEV J. USOVICZ, in. TELEPHONE: 978-745-9593 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
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:
I17E//a's y�g , c> eR 2R7roj(Location ofFacility) &Pa26e-1ocW MA
Sig tune of cant
1 s �!
Date
Client#:54974
AEORDn. CERTIFICATE OF LIABILITY INSURANCE 0DATE
7/25/5D
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
USI Ins.Services of MA,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
12 Gill Street,Suite 5500 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 4043
Woburn,MA 01888.4043 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: The Travelers Indemnity Company 25658
LEMAY CONSTRUCTION CO.,INC. INSURERB: Charter Oak Fire Insurance Company 25615
9 CURTIS AVENUE INSURERc: American Home Assurance Company 19380
MIDDLETON,MA 01949
INSURER D:
NSURERE:
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.
POLICY EFFECTIVE POLICY EXPIRATION
LTR NSRE TYPE OF INSURANCE POLICY NUMBER D D DATE D LIMITS
A GENERALUABILITY 68025ON994A 06/27105 06/27/06 EACH OCCURRENCE $1000000
DAMAGE TO RENT D
X COMMERCAL GENERAL LABILITY $300000
CLAIMS MADE Q OCCUR MED EXP(Any one person) $5 000
PERSONAL i ADV INJURY $1000000
GENERAL AGGREGATE $2 000 000
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2000000
17 POLICY PRO- LOC
B AUTOMOBILE LABILITY BA-672K4434-05-SEL 06/27/05 06/27/06
COMBINED SINGLE LIMIT $1,000,000
ANY AUTO (Ee eooldent)
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person) $
X HIRED AUTOS BODILY INJURY
X NON-OWNEDAUTOS (Per accident) $
PROPERTY DAMAGE $
(Per ecddent)
GARAGE UASIUTY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGO $
EXCESSIUMBRELLA LABILITY - EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
E
DEDUCTIBLE $
RETENTION $ $
C WORKERS COMPENSATION AND WC6709708 07/14/05 07114/06 WCSTATU- OTH
EMPLOYERS'LABILITY I TORY LIMIT ER
E.L.EACH ACCIDENT E100 000
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100000
If yes,denwibe under
SPECIAL ROVI$IONSbeIow E.L.DISEASE-POLICY LIMIT 1$500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Evidence of insurance:
Scope of Insured's operations: General Contractor-Commercial/Residental Remodeling
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1n DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
.
AOORD 25(2001108)1 of 2 #S116856/M116855 LCNCD B ACORD CORPORATION 1988
The Commonwealth of Massachusetts
Department of Industrial Accidents
OKIce oflnvestigations
600 Washington Street
Boston,MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Businessiorpnizationnndividual). X/ (' j0,VS1FuC7Tor) C061RH�1 `S J NC
Address: 7--Q w L--
City/State/Zip:/YI.TI /?Ze7-aA 17M, 01999 Phone#:
Are you an employer?Check the'appropriate box:' Type of project(required):
I.®I am a employs with " 4. ❑ I am a general contractor and I 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 i 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 an a corporation add its' 10.❑ Electrical repass or additions
required) + officers have exercised their
3.❑ I am a horneowner: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 repays
insurance required:.]t, employees [No workers' 13.❑ Other
comp. insurance requred] '
•Any applicant that checks box#1 titre[also fill out the section below showing their,wmtM'compensationm policy infomtion.'
t Homeowners who mlinut this affidavit indicating they are doing all work and then h$e outside coobgotors trust submit a new affidavit indicating such
tContractom that check this buxmust attwhed an additional sleet showing the name ofthe mb-conVectors and they workats'.comp:policy inforrrmhott
I am air,employer that Is providing workers'compensadan insurance for myeirrployeea. Below is the polky and Job site
information.
Insurance Company Name: USE 7A)S SFRUree3 19M4-ZT-e4d l c)mt- ASSURg.nrec Co
Policy#or Self-ins.Lic. #: td,e 4 90 9 7 a i- Expiration Date: 71�1d-1
Job Site Address: 6u q 2Kc N. 7 City/StACIZip: S19IP111 /Y/R 01 R,26
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
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 here r the and penahks ofper/ury that the information provided above Is true and correct
Si tore: Date: J U
Phone#:
Official use only. Do not write in thin area,to be completed ly city of town offlelai
City or Town: Permlt/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CltyiTown Clerk 4.Electrical Inspector 3.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employer .to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as ,an individual,partnership, association,corporation or other legal entity,or any two
re
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employ or the.
Parmership,association or other legal entity,employing employees. However the
receiver or trustee of an individual
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 doe mod to be an employer."
MGL 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,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any Of'is 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."
Applicants
Please fill 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 I LC or LL P 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 of license is being requested,not the Departument of
IndusuW'Accidem. 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 1mmmber 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 permidlicense 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
town)."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 fide for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner of citizen is obtaining a license or permit not related.to any business or commercial venture
(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 Ile to thank you in advance for 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
Office 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