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12 1-2 WILLIAMS ST - BUILDING INSPECTION N Provnh Loomd in Ioaatiw, oc a.NWAO OrrIMaN Yes..No. a�i7/ly, S ft COFOWWaOR Ana? YML_No_ S�� BU LOM PERMIT APPLICATION FOR: Pam1t Im (Gr01a aAliotNlYar apply) IkOOf, R .IIItlaYIQ, COfINfIK Da01i. SIMd, PO4 FM�N�d�t�pl��OIlIK;1• J r i S PLEASE RLL OUT LEOt V&COMPLEiEL� Y TO AVOID OELAYA IN PROCEAiYiG TO THE DOPEiCTOR OF StN' NO& The anderalpred hereby applaa for a Wmk to bUM fMordN to ttre f IWA*rp qmoftaw&. Ow wa Nome Ad*M A Phoroe �a�z �.✓,r//ray„s S� _ � 1 7�fS-5/ 4S' Mhkod'a Name ✓��� Address a Phone Mgft6 a NON Addreaa A Pnaro j wrw a rr prpm ar ourdr~ kaft"a a~ r a dwMrq,for now wAny ?,r_ VM&Aft001r011ab*A ? Earwwud ooM /OD_ 0_ph uo«r r NIA. ale. • y r1SVdlftWofA~ SOM UNDNI THE PENALTY OP PERJURY OESCRWFION OF woo TO w DONE MAIL.PERMIT To: APPLICATION FOR PE l TO 3 LOCATION PERMIT GRANTED MWEGlM OF BUK MOS Deparrnaeoir ojlndus&W Acetdenrs Office of loswalgadont ._-- -- -- 6o0 Wishtinsroos Sled Bosro4 MA 02111 wwwaeosssewas Worken'Compensadon Insurance Affidavit: BuHden/Coutncton/Elecdicians/Plomben AppikaldInformed / Pie Print Leaibllt Name ...4 /'11C)//Ji`. %r lyr� /IU I2Pl9Dina Aftew:�� City/StsteJti� U. aiw.ola Phmt 9,;76' Are you an employe'?Checkti rappropride bon TM ctpro]ect(regdre M: 1.0 1 son a employer with/>!<iYn�f'9 /v" c4. ❑ I am a;meral cowww ad I 6 ❑New coutracdon bovemployees(a1B and/or pelt.time O goo heed the tachdffia�ad shoes, 7 e 2.0 I am a ack proprietor or Parma good a the attached sheet= ship and have no anployw Tate��"'0 8• ❑ Denolititm working for me in VI capackY• workw new•inner 9. 0 addition. S. Mo .COUP i ❑ We area corporation and its10.0 dition Electrical repair or ad ofHew have awdsed their ofezmlptionper MGL or additions 3.0 I a�homeowne+doing all work l l.p P)timbiai repair a rognumy� [Noi6tin' romp a 152, m of �1(4�and 12.p Rorepain iasoraned.]t CMPloYC• ( comp.boa-no required.]. 'AoYDPP»t oc6xbboxa1a"�Lo6aattdM?�odasb&w&ffi a ftk%"bts•aompm"MFomkY tflmneowsaiwtto�itaB imCMftftYadoieaonWO&edSMW"0CM&aooEne"trotoftI t&rowaff&"omcdina?melt. JCantnAOA�t,ebeek box rout thcbad m ttdd Hood ghwt ftwiq the mm of the wbconvacom and dick Wooten'CM*Poft bromoHoa• J ow an ewpraya rAer b provldlrra workora'cowpsnaodon kura%erja sty empbYees. 3dow 6 At pol"an/job Son pajarwarrwa hrseaance Coaapatry Name 17 i A ._t n S L)eekvic e Co . policy tt of SeK-in Lu t{ /J /Z1) d Expiration Data / S O Job Site Addreaa Y`��� W q�5 S L*/SWWZip: 5W 1-7 Attack a Copy of the wadwe_compasasfoo poky dedardloa page(tdmftg the PoNC9 somber and eaptration date). pyre to aeeore coverage as required under Section 25A of MGL c. 152 can lead to the imposition of Criminal penalties of a fee up to$1,S00.00 and/or one year io risoamept'as wcg as civl pmaltim in the form of a STOP WORK ORDER and a fine of up to$250.W a day against the violdw. Be advised that a copy of this statement may be forwarded lo me Office of Liveadpdm of dw MA far insurance wvaso va>9atim• I do bmay it atrhas olpalnl Am&W Wwwerloxpor"J As aw and cornet %Z /yo �7f3 66�/ 3 3/y • cell 9?e 360 a9 f T. r;IBo'wgd mwn opferalns PermbWeene 0 kority(drek one): Heakk 2.BuMal Depart at 3.Cityrrow■Clerk d.Electrical Inspector S.Plumbing Inspector (~Otker Coded Persoas Phone N• Massachusetts General Laws chapter 152 requires an employers m provide workers' oasflpensation for their empkoyees. Pursuant to this statute, an emV yw is defined as"...every person in the service of another under any contract ofhh% express or implied,oral or written" An enpfi w it defined as"as indivldnd,painerd*astociatioa,corperatica a other legal raft or any two or rnnse of the foregoing engaged in a joist eat rpriK and mchdiog ft legal representatives of a deceased employa,or tits receiva or.tntatea of at.indiyidtul,pataad*amdatioe or other iM d entity.aWbybt a*byeeL However tie owner of a dwelling house having not more than three aparooeatt and who resides thaei4 or the occupet of the dwelliog boose of awtber who argkys pasoas to do mamtessamA construction or repo wort on sock dwelling Lowe or on the gmnnds or building appsrtensat thaeb shah we because of such amployment be deemed to be an employer." MGL cbapoa i52,j2SC(6)abo antes that"every Mite or local lieesdq agog Stan withhold the iwanee or rawwal of s neaue or pamlt to operate a business or to eoaatrod bu0dbp In the eommooweakk for stay aE appoes who has sot p ame produced eptelde evkkee a of compliance tuft the buuram eaversge required." Additionally,MGL d wrtm 154125M stales"Nadw Ste commo swaldt mr any of its politicalsobdivisiom shall enter into my contract lbr the pakumma ofpublic wik marl acceptable evidence of ooraplimce with the insurance rognirentwo of this chapter bave been presented to the conuseft aathsmily" AppAmb Please till out the wotters'compmeation affidavit completely,by cbectieg the boxes that apply to yorQ situation and,if accessary,supply m0- G)nanu(sl address(es)and phone n nker(s)along with their catit3goe(s)of inn¢aoce. Limited Liability CmWaides(LI.C)or Limited Liability Partnerships(I.LP)with no employees"othea than the members or psrmen,are not required to easy women' compeossdan ins u=clL If m LLC of LIP does have employees,a policy is required: Be advised that this affidavit may be submitted to the Department of Indaaald Accidents for confirmation of insurance coverage. Abe be sure to dip and date the&MdavlL The affidavit ahoald be returned to the city cc lown that the application far the permit or license it being requested,ant the Department of bulustrial Accidews.. Should You have my quettlons regarding the law or if you are required to obtain a workers' compentadoa policy,pleato can the Depatrnrat at the mmba listed below. Self-inorced oompmics should enter their self msuraw h-censetnmba on t>ieappropriate Has. cuy or Town Ofndali 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 care to 0 in the pamiNleeme I which will be used a a rehreace number. in addition,au appHcaot that meat submit multiple pamioticense applications many given year need only submit one affidavit indicating caurpit- policy information(ifnecaeaY)and under"Job Site Address"the applicant should write"an locations in (city or town}"A copy oftbe a9ldsvu tip has been otHcidly stamped or.pusW by the,city or town any be provided to the applicant as proof that a vapid affidavit it on Me for thtore permioe or ticemes. new affidavit must be tined out Back year.Wham a home awns or citisee is obtaift s license or permit not related to my busiaas or commercial venture (ic.a dog license or peimit b brain leaves etc.)said pawn is NOT required to complete this affidavit The t>Bx of Investigations would like b thank you in advance for your cooperation ad should you have any gnadops,; pleade do not Ii. W Five w a CWL The Depatmexes addrea,telephone and fa rumba The Cotnmonweallh of Massachusetts Departuted of Industrial Accidents Office of Investigations 600 Washington Strid Boston.MA 02111 TeL # 617-7274900 ext 406 or 1-977-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mm.gov/dia CORD CERTIFICATE OF LIABILITY INSURANCE GAYEVµ Dnn"I PRooucER 01/OS/2004 (508)651-7700 FAX THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Lumber Insurance Management Services ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE an Eastern Insurance Group co. 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 0 INSURED Em3ay ea ty Trust Etal WSURERA: Acadia Insurance Company 164 Chestnut Street INSURER B: North Reading, MA 01864 INSURERC: —" INSURER D: WSUREA E', QOVERAGFS 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 OD'rA SURANCE POLILh'NUMBER POLICY EFFECTIVE POLICY EZPIRATION DATE(MMtQQnlfI DATE MMDrfYI OMITS Y CPA008 111211 10/15/2003 10/1S/2004 EACHOCCUPAENOE s 1,000.001 GENERAL LIABILITY _ lef-A E 2 S 0,OO 1ADE.�OCCUR - - - ,On) S S,001A AM Rr E 1 000,OOLE S 2,000,00( LMIR APPLIES PETL RODUCTS-LOMPIOP AGG S 2,000 OOC !EC LOC AUTOMOBILE UASIU Y 5A007281611 12/01/2003 12/01/2004 COMBINED SINGLE LIMIT X ANYAUTO (Ea xxk) S 1,000,OOl ALL DINNED AUTOS SCHEDJLm AUTOS BOvDILV INJURY S A [P Pm-opn) HIRED AUTOS BODILY INJURY S NON.OVVNEO AUTOS tPer ACO.�fl�fJ PROPERTY DAMAGE S (Pe-sccitlenq ', GARAGE LIABILITY ALTO ONLY-EA ACGOENT S ANY AUTO OTHERTHAN EA ACC E AUTO ONLY; AGG E EXCESSNMBRELLA DABIUTY CUAO08413011 10/15/2003 10/1S/2004 EACH OCCURRENCE S 1Q,000 QQQ X OCCUR ❑CLAIMS MADE AGGREGATE 5 lO,OOD,000j A s DEDUCTIBLE $ RETENTION E E WOR)(ERS COMPENSATION AND WCA007303811 01/01/2004 01/01/2005 We sTATU- OTH- EMPLOYERS'UABTL" A ANY PROPRIETORIPARTNEPJEXPOLMVE E.L.EACH ACCIDENT E 1OQ,OQQ OFFICER/MFMBER EXCLUDED' II 6,'QOeu 6d ' El.OLGEASE EAEMPLOYE E 100,000 SPECIAL PROVISIONS 0t4Pw OTHER EL Di•POLICY LIMIT I S SQO,QQQ DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS T FI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFDRE THE EXPIRAnON DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3D DAYS WRITTEN NOTICETO THE CERTIRCATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABWTY OF ANY NIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) FAX: (97S)664-9078 ©ACORD CORPORATION 1988 CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR I* SALEM, MASSACHUSETTS 01970 STANLEY J. LISOVICZ, JR. TELEPHONE: 978-748-9595 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: (Location of Facility) v a,n gnature of Applicant )"; S� Date