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10 WOODSIDE ST - BUILDING INSPECTION (2) �UI 0 fL�11S1AdSiT�E{FWD ApPROV60 8Y T44E ASPACSOB PWIgR TDA PAWF AWO cWRANT W CITY OF_SALEM Ih�FYMoib lonatim OMdcl9� Yam_No Is AWN19 Loaffiftd In • common mn? Yq_No X Bully Iw MAW APPLICATION POR: Parma to: (Ckde whidewr apply) Root, Install 6MM9. Corona DscK, &ed, Pool. other: PLEASE RLL OUT LEGIBLY a COMPLETELY TO AVOID DELAYS W PROCEBBMI(i TO THE INSPECTOR OF BWLD W&- The ur>du& ad hereby applies for a permit to build a000Wq to the foWWV Owrwrr'� iM Ike �- �+Z�s Address& Phone 'DO,� jq'7 K) 45-- D-&71 Ardrited's Name Address & Phone Medenics Name k-� Address & Phorw war k n.wPo•a w ourdrgr RQ S, .�Q--.��-I msti a ouiarpy \,)g 1 k Dw.,rvx N a*me&*,for how a y won? WE ariarw=Iwm to we Mbnws7 EVWAW ood lIL4 0 0 cvv ug I NIA am Lkwm• C�3 � X �. Sots"of APW41nt SJQWD UNDER THE PENALTY OR POWARY DESCRIPnoN OF wows T/ � O/ BE DOME MAIL PERMIT TO:L . CIA IA T_ t No. d APPLICATION FOR PER l TO " LOCATION / U•. - a r /OlO 26 7) � d RESPECIM OF S ALOOM The Cornntoitwealth of Massachusetts I Department of Industrial Accidents Office of Investigations 600 Washington Street ` Boston, MA 02111 wwtv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lellibly N21lle (Business/Oreanizntion/Individual): Address: 2J a City:/State/Zip: Phone #: (�-7 k - PCs (o Are you an employer'? Check the appropriate box: Type of project(required): .® I am a employer with �� 4. ❑ 1 am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet : 7. LZ Remodeling _.❑ I am a sole proprietor or partner- _ 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 of additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] employees. [No workers' comp. insurance required.] 3.❑ Other *Anc applicant that checks box"I must also fill out the section below showi:c,their workers'compensation policy information. ' -lomeosvners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers camp.policy information. I ton an employer that is providing workers'compensation insurance for nlp employees. Below is the policy anal job site information. Insurance Company Name: Policy {, or Self-ills. Lic. # CtCt 5- Expiration Date: I 'G� 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 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 S250.00 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 herebP certify under it 3 this at penalties of perjury than the information provided above is true and correct. + - 9 -� L Signature: � � Date: "� Phone Official use onit% Do not write in this urea, to be completed hi city or town official. City or Town: Permit/License# Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk d. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an ernplQree 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 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 individual, partnership, association or other legal entity,employing employees. However the 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 deemed to be an employer." MGL chapter 151.§25C(Q.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 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." 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 LLC or LLP 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 cityor town that the application for the permit or license is being requested, not the Department of pp P � 9 P Industrial Accidents. 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 number on the appropriate line. City or Town Officials s Please be,sure that the affidavit is complete and printed legibly. The VDepartment 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 permit/license applications in airy 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 file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn 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 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. it 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT Is 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVIC2, JR. TELEPHONE: 978-745-9595 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) Signature of Applicant b Date MARSH s Y CERTIFICATE�OF INSURANCE j CERTIFICATE NUMBER =. .. ..Y_ .. . s .- _ - _ - AIL-000915907-11 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS MARSH USA.INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE ATTN:BRENDA BOOKER (404)995-2594 POLICY.THIS CERTIFICATE DOES NOT AMEN%EXTEND OR ALTER THE COVERAGE MAYA MCCLURE(404)995-3206 OR AFFORDED BY THE POLICIES DESCRIBED HEREIN. TAMI ROUSE(404)995-3430 FAX(404)760-5663 COMPANIES AFFORDING COVERAGE 3475 PIEDMONT ROAD,SUITE 1200 ATLANTA,GA 30305 COMPANY 00492-IPUSAGWA-03I04 A STEADFAST INSURANCE COMPANY INSURED COMPANY THD AT-HOME SERVICES INC. B ZURICH AMERICAN INSURANCE COMPANY DBA THE HOME DEPOTAT-HOME SERVICES,INC. HOME DEPOT USA,INC. COMPANY 2455 PACES FERRY ROAD NW C NEW HAMPSHIRE INS COMPANY BUILDING C-8 ATLANTA,GA 30339 caMPANr D AMERICAN HOME ASSURANCE COMPANY F r— C.OVERAOES::= -.... : Tlifa=celtlticele Supersedes end�repleFaB eny�av[Dusl)t f�gsi�tf:ae166cete ta�:ihe Roie�P�ioa oole�j.pe -: �=-a-� ..-,� THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDMON OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT 10 ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICES AGGREGATE UNITS SHONN MAY HAVE BEEN REDUCED BY PAD CLAIMS CO TYPEOFINSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION UNITS LTR DATE(MMIDO(YIT NITEIMWDNYY) A GENERAL LIABILITY IPR 3757608-01 030106 0=1107 GAL AGGREGATE S 4.000,000 X COMMECIALGENERAL LY191UTV 'LIARS OF POLICY ARE EXCESS' PRODUCTS_CCMPA AM $ 4,000,000 CLIMB MADE X❑OCCUR 'OF SIR:$1,000,000 PER OCC' PERSONAL AM INJURY $ 4,000,000 -" ONNER'SSCONTRACIOR'SPROT EACH OCCURRENCE $ 4,0D0,000 FREDAMAGE O Tim s 1,000,ODO MED EXP ere s EXCLUDED B AUIONOWLELULBTUTY BAP 2938863-03 ADS 0310106 03MI107 CCMBINED SINGLE LIMB S 1,000,000 Ix ANYAUTO ALLOWNEDAUIOS BODILY INJURY $ (Per Person) SCHEDULEDAUTO6 HIRED AUTOS BODILY INJURY $ (Per acedo-0 NONQNNEDAUTCG ELF-INSURED AUTO PROPERTY DAMAGE Z HYSICAL DAMAGE GARAGE LIABILITY ANDONLY-EAACGDENT $ ANYAUTO ' OTHER ITIAN AUTO ONLY ��.� _ EACH ACCIDENT ,$ AGGREfATE Z EXCESSUABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ G WO KERBODEMNSARDMANo 6610998(AZ,ID,MD,VA) 03/0106 030107 X I ER : >• '^ PLOYERSI LIAMUTY C 9 6610995(ADS) 030106 030107 EL EACH ACCIDENT $ 1 000 000 G THE PROPRIETOR/ X INCL 6611326(OR) 03101106 03MI107 EL DISEASE-Pwcr LIMIT $ 1,000,000 E �slocECAPTrvE Xu 6610999(NY,W4 0310106 03101/07 EL DISEASEEEACH EMPLOYEE $ 1,000,000 WORKERS E COMPENSATION CONTINUED 6610997(FL) 0310106 03101107 p 16610996(CA) 103101,06 0301107 DESCRIPTION OF OPERATION&LOCATIOKWVEWCLESISPECUL ITEMS ' 'CERTIflCATE HOLDER' "'�..."' '- "�'. "' -- CANCELLATION ' - - - 91011tD AN'F OF TIE FQLNA DESCRNEO HEREIN (rs CANCELLED M:FORE THE EXPtlUTdI DALE NEAEOF. THE NAURER AFF="CDJERAOE WLL FNDER"TO MAl 20 DAYS WRRiBI WK TO THE FOR INSURANCE PURPOSES ONLY cBnsrwTE NOLDEA IIIMFD HE W Mlr FAIURE TD ILAL sml NOTICE e L rvosE No MKIATON OR IWBLRTOFAMY RMDUPoN NE WSURER ANDRDHOTA/ERADE IBABBITX M AEPRFSBITATNFB,OR THE RSUEROFMrCDORLATE NAR 8H USA INC, ,,Y'. - Y: Weller Gilstrep 'vott - MMi(3102) " ;- VALID AS OF:.02I27 >, 06 LM