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26 WINTER ST - BUILDING INSPECTION (2) CITY OF SALEM Z/ " PUBLIC PROPRERTY DEPARTMENT KLNBERLEY DRISCOLL MAYOR 120 WASHtNGTON STREET 4 SALEM,MASSACHUSETTS 01970 TEL. 979-745-9595 *FAx:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): DeIulis Brothers Construction Co. , Inc. Address: 31 Collins Street Terrace City/State/Zip: Lynn, liA 01902 Phone #: 781-595-8677 Are you an employer?Check the appropriate boa: p 17ype of project(required): 1.❑% I am a employer with 25 4. ❑ I am a general contractor and I employees(full and/or part-time).' have hired the subcontractors 6. ❑New construction 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.® Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.© Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4), and we have no 12.[2 Roof repairs insurance required] t employees. [No workers' 13,❑ Other comp. insurance required.] Any applicant that checks box#1 must also fill out the section below showing their worker,'compensation policy inforaation, t Homeowners who submit this affidavit indicating they are doing aU work and then hive outside contractors must submit s taw affidavit indicating such. :Contractom that check this box most attached an additional sheet showing the name of the sub-contractors and their worker'comp.policy infomnstion. I am an employer that Is providing workers'compensadon insurance for my employees. Below is the policy and fob site information. Insurance Company Name: American Home Assurance Co (see attached) Policy#or Self-ins. Lic. #- CPA130127616 1/1/07 Expiration Date: Job Site Address: 26 Winter Street Salem, MA 01970 - City/State/Zip: Attach a copy of the workers,comlTensatitill policy declaration page(showing the poilcy 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 S 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 under the pains and penalties of perjury that the information provided above is true and correct Signarure: —��,?SJ+Z Date: 11/13/06 Phone#: 781-595-8677 [6. y7cial use only. Do not write in this area, to be completed by city or town officiai ty or Town: Permit/License# uing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other C'nntarr Pare-„• CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) TM 07/05/2006 PRODUCELR (97n887_4900 FAX (978)887_2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 16 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 457 Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC # INsuRED DeIulis Brothers Construction Co. , Inc. INSURERA: Acadia Insurance 31325 31 Collins St Terrace INSURERB: American Home Assurance Co Lynn, MA 01902-2205 INSURER C: - INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDINI ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR TEN ,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH GREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE MMIDOIYY DATE MMIDDM RAL LIABILITY CPA130127616 07/01/2006 07/01/2007 EACHOCCURRENCE $ 1,000,00( OMMERCIAL GENERAL LIABILITY DAMAGET PREMISES Ea occme0nce $ 250,00( CLAIMS MADE � OCCUR MED EXP(Any one person) $ 5,00( PERSONAL 8 ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,004 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMMOP AGG $ 2,000,001 OLICY PRO LOC JECT MOBILE LIABILITY MAA130127715 07/01/2006 07/01/2007 COMBINED SINGLE LIMIT $ NY AUTO (Ea accident) 1,000,00( ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person)HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ .(Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: G $ EXCESSIUMBRELLA LIABILITY CUA130127815 07/01/2006 07/01/2007 EACH OCCURRENCE $ 10 QQQ 00( OCCUR ❑ CLAIMS MADE AGGREGATE $ 10,000,00( A $ DEDUCTIBLE IS RETENTION $ $ WORKERS COMPENSATION AND WC893-39-72 01/01/2006 01/01/2007 ORV LMITS ER EMPLOYERS'LIABILITY B ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,00( OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1,000,00( If yes tlescribe unb er SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ 11000,00( OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL City of Salem 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Building Dept BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 120 Washington St OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Salem, MA 01970 AUTHORIZED REPRESENTATIVE / /f Robert Sennott/LA %�"�`��✓-GJ� ACORD 25(2001/08) ©ACORD CORPORATION 198E I CITY OF SALFE,, ' n PUBLIC PROPERTY DEPARTMENT Kj> MAVW DMC= SWIM IMWAs70K.ZL7MMW•S EKMAMAa*;MWM019ta Tm M744S"*FA=V&746-M4 Construction Debris DispWal Affidavit (requued foe all demob&= and rewvstiast wash) la xmdanae with the sixth edidou of the State Building Code,M CMX secdoa 111.3 Debris,and the pmviaions of MGL a A 9 A Buildhls Permit to is issued wilt the condition the the debris reud&S ftas this wont shag be disposed of is s properly licensed wtute disposal &ci ty as d48aed by MGL a The debris will be transported by: ,Northside Carting _ (A&=o[bsular) Ths debris will be disposed of in : 12 Swampscott Road (natal o(haity) Salem, MA 01970 (addrt"or heility) sisaawa o(pt�applicant 11/13/06 duo :ctriw7.J..r �I e Y. CITY OF SALEM PUBLIC PROPERTY I � DEPARTMENT KIMBFR1.EY DRISC011: MAYOR. 120 WASHINGTON STRFEr♦SALEM,HA.SSAcHLSEIIS 01970 TEL,978-745-9595 ♦ FAX:978-740-9846 APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION, DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING y STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: A/ ,tg p� Building: SUSepu Property`Address: Property isiiocated in a; Conservation Area Y/N -,61-- Historic District Y/N 2.0 OWNERSHIP,INFORMATION 2.1 Owner of Land Name: t lVe14 -4- M� . Address: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY `Additi or!, 3 r Existing Renovation y Number of Stories Renovated -3 Change in Use , lb New / Demolition Existing Z�� 14 vG ; zq Approximate year of Area per floor (so Renovated 3 �r2 _ 4 7,) construction or renovation New of existing building Brief Description of Proposed Work: 2 c-An 4 nY-A-�c /W U/TL w I�r R// �o ftv9/7t.3o W1 Mail Permit to: / r What is the current use of the Building? �Z�/D&u--e Material of Building? If dwelling, how many units? -7 Will the Building Conform to Law? , � Asbestos? �r Architect's Name 2«% _2e- La Address and Phone /J�4 r 2 ( ) Mechanic's Name ` C0 T.4,k 64-0S C—s✓s — ✓� . Address and Phone i/ CIJ1,4 i bT TL-vc y 7.JJ hll 0/ 5 u z Construction Supervisors License# 0 3 9s8 HIC Registration# I0 5 7e y Estimated Cost of Project$ U 23 OvO Permit Fee Calculation Permit Fee $ Estimated Cost X$7/$1000 Residential Estimated Cost X $11/$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury Date o y H � H a � L a ro � o o � at °o V F a G > 1