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0003 CRESSEY AVENUE - BUILDING JACKET
CK --057 • )S , o,-to-aao6 ave SalCmis PIONIV Low"In LYs!►� � No N Aft vMt«.� ,..� �M�w Ioornd a No Y BULONQ poW APP . T"Mft D" &I" Pool. TO TW IIrBP&w=OF 61 UNGa Thy wwwoo" haft app" for a PW" w buYd a000ldYp to tlla IoMowirlp G�� i i � � vstrtiln OmoWs Now � a Pilwo So hie l Q�8 /1rd�ct'a Ntma #Awm a Phm» . WdWMa NIM �erclih 60 Addlws� Phony Soeh,'( a te ,a9c7. 1MIrt U�prior d OiMdY�l /1 �a m` � 7� NO�S Iwwl a arwno► WOCA IIa1M*MforOW WAIN bl"9 IQ's r6 iowtwd 30'�._gi rvlonMo• N A &AN UMM• y �wr!c 6s of I1ppIi0rlt iffal m f"m 11f�pillALTY OF PliiflW DEIiCRIP nam OF WORK T tU DONE rn Sr<<n1, `l' 7at e�- Q-vx `F(oo�?— o �� S�G�� ell Net✓ Luc✓ F 12eQ aee YYteY4s W t uJ efkti u �e F vO rn l ?oi-� �nsd� Scl- 1( �Qvv sub Flc6� k+ ,V(!" t oa FtoofL aX8'- I�' Re late � geglas�c,` R vum zhsds II Ham w� A-e Sv�al� 6o hW IAWPEIOMT ro4, o1Y60 CTeaalpl w CTSAle to -7 Say hl`e. Rol Peal�.Q� I , 1I NO. Pffmwlro w1o� — /el LiOCATXW = PEWT ORAMM i OF The Commonwealth ofMassaehusetts Department oflndustrial Accidents Office oflnvestigadons 600 Washington Street Boston,MA 02111 www massgov/dla Workers'Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers Applicant Inf rmation Please Print Le ibl Name Musmessro�pmZationft&vidual): gellmCt e >1 60 Address SO h e _�Q3 City/State/zip: 4a�,WX m , 0/&,/7 Phone#: 31$K An you an employer?Check thr aporoprlateox b Type of project(required): 'lama i.❑ I am a employer4 with ❑ general contractor and I 6 ❑New construction employees(fell and/or part-time).* have hired the sub-eontractora 2..3 1 am a sole proprietor or partner- listed on the attached sheet = 7. ;,Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working,for me in any capacity, workers comp•-�'an� 9. [� Building addition [No workers'comp,insurance . 5. El We are a corpora"a>;a i�' required.] officers have execised their 10.0 Electrical repairs or additions 3.El am a homeowner doing all work right of exemption per MGL* I.Q Plumbing repairs or additions myself [No workeW,comp c. 152,§1(4 ;and we have no 12,❑ Roofrepars insurance regnirod;]t. empkryeea (No amkers' , comp.inatrrance r `ed ME] Other Any epplicmt diet clechta box#1 nuat also fill out{he section below showing tbec,wotkea'000>peneeEoa policy mfimnetion.^ t Homeowner who submit tiro''affidavh indicating they ere doing all work and then hive ootmde con6aetors mint submit a new affdevit indicating such tContracdon diet chock this boiTnust attached an additional sheet sbowina the nets:of the sub:coettec on;ad v ek worker'cmgx policy mfonnstion. I ant ag'employerthat/s providing workers'compensaAm buumnee for my employees: Below is thepolk7 and fob site Information. ,� Insurance Company Name: / /n t�' a'yl*t , 1 U S -TnSo y an e O, Policy#or Self-ins.Lia #: /r `17 a 57 Expiration Date: S—Du—0 6 Job Site Address: CRsSey QVQ - City/StaWZip: S41eyn ynR , 01970 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 hereby ce r the and pe of Information provided above h bae and correct S� x �' Date: Phone C/(79-52S— O leld use only+. Do not write In thir area,to be compiled by city orMm osee dleiaL City or Town: PermMcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.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 employee is defined as"...every.person in the service gf 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 at enterprise,and including the legal representatives of a deceased employer,or the of the foregoing engaged m a Jo lo 'm bees. However the receiver or trustee of an individual,partnership,association or other legal entity,emp Yg y ant of the owner of a dwelling house having not more than throe apnts and who resides therein,or the occupant do maintenance, construction or repair work on such dwelling house dwelling house of another who employs persons to or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employe." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or perate a business or to construct buildings in the commonwealth for any renewal of a license or permit to o applicant who has not produced acceptable evidence of compliance with the insurance coverap required. shall Additionally,MGL chapter 152;§25C()states"Neither the com>mmonwealih not any of its political subdivisions enter into any contract for the performance of public work until acceptable evidence of contplimmce with the insurance requirements of this chapter have been presented to the contracting authomity." Applicant by checking the boxes that apply to your situation and,if Please fib, out the workers compensation affidavit completely, _ necessary,supply sub-c°ntracto>(s)narne(s),address(es)and Phone numbers)along wit no employees other than the insurance; Limited Liability Companies{1.LC)or Limited Liabm7ny Partnerships(LI P) members or partners,are not required to carry workers' compensation insurance: If an LLC or LLP does have employees,a policy is requved. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be;,sure to sip and date the affdavit. The affidavit should be returned to the city or town that the application for the permit law or ifbeing��to obtain not the �r��t of Industrial Accidents, Should you have any questions regarding compensation policy;Please can the Department at the number,Usted below. Self-insured'companies should enter their self-insurance license>romb�on the to 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 f to app applicant Please be sure it fill in the permiUlicense number year,need only submit oneffidavit indicating current that must submit multiple permit/license applications in any given y policy information(if necessary)and,under"Job Site Address"the applicant sboukl 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 orcs. A new to any business must b nercial venture 61W Out each year.Where a home owner or citim is obtaining a license or permit not tel (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 bike 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,telepbone and fax numbr The Commonwealth of Massachusetts Department of lnduslrW 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 wwwxaass.gov/dia CITY OF SALEMO MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 Mwroq 9TANL[r USOVICZ, Jq. TELEPHONE: 978-745-9595 EXT. 380 FAX: 978-740-9848 Salem Building Denarhnen 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: m-85.3-6 yo �o �atf L � a1,L"e, y� (Location of Facility) kvc� DuhQSdb,ti co, Signature of Applicant Date r ��ea �mxoea�uaea-ll�i n�,.i�Laatac�anally p _ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 121110 Expiration: 4l8/2007 Type: -DBA ALL CITY REMODELING GERALD CASALETTO 3 SOPHIE RD PEABODY, MA 01960 Administrator BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 066091 Birthdate: 10/09/1963 Expires: 10/09/2007 Tr.no: 4562.0 Restricted: 00- GERALD W CASALETTO 3 SOPHIE RD PEABODY, MA 01960 Commissioner 3 ��2rs sty /aN� i rsupocr-roob, SOX UWW'db" /// 9 M EACF NEEPING YOU ORMNIZED No. 10301 Certificate No: 659-06 Building Permit No.: 659-06 Commonwealth of Massachusetts City of Salem Building Electrical Mechanical Permits This is to Certify that the RESIDENCE located at Dwelling Type 0003 CRESSEY AVENUE in the CITY OF SALEM ----------------------------------------- ------ -- - Address TownrCitY Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires __-- unless sooner suspended or revoked. Expiration Date , -----------_-_- Issued On:Thu Mar 30,2006 ---------------------- - ---- - --------------------- GeoTMS®2006 Des Lauriers Municipal Solutions,Inc. ------------- ----------------------------------------------- 1 { r s ss I • i *CIV � 0003 C-_RESSEY AVENUE 659-06 —=- GIs# 297s__ COMMONWEALTH OF MASSACHUSETTS 1Map: -- 17 Block: i -- — CITY OF SALEM Lot_ — —:0269 Category: REPAIR/REPLACE!, P rmit# ,659-06 -_ PUILDING PERMIT Project# .JS-2006-1334 Est Cost: 1$30,000.00 Fee Charged: 1$185.00 j '!Balance 'i$.00 _ �! PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: fuse Group: I -- JI ALL CITY REMODELING CONSTRUCTIO SUPERVISOR-066091 T ,Lot Size(sq_ft.): X5795 — --'Owner: CASALETTO,GERLAD. Zontn — g ---R2 - --- 'dn,1i amt•_ v z:n. �_ �I. ;Cn_ItsCieiitc_ti: . , j' C �,LLs.�.IT::R--�CnF_T.L ('. Units Lost: 1,AT: 0003 CRESSEY AVENUE Dig Sate# — ISSUED ON: 13-Feb-2006 AMENDED ON: EXPIRES ON: 13-Aug-2006 TO PERFORM THE.FOLLOWING WORK: 659-06 REPAIR FIRE DAMAGE/WINDOWS/KITCHEN/BATH TJS POST THI'S CARD SO-IT-IS-YISIBLE FROM THE STREET- Electric Gas Plumbing Building Underground: Underground. Underground: Excavation: Service: Meter. Footings: Rough - Rough: SF's tt,l, E04Foundation: , Final S� Final j:. - _ Fm31 r Ruugh Frame: �7 Fireplace/Chimney: D.P.W. Fire Health Insulation: A Iq / Meter: Oil: - - Final- House House# Smoke: �� O Tre ry: Water: Alarm: Sewer: Sprinklers: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON LATION OF ANY OF JTS, RULES AND REGULATIONS. / Signature: Fee'rype: - Receipt No: -Hate Paid: Check No: Amount: .;; BUILDING 1, ,a:;l . RP_G2006-061924 13,Fe6062957 $185.00 � t GeoTMS©2006 Des Lauriers Municipal Solutions,Inc.