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284 Washington Street B-671-05 284 Washington Street Remodel Commercial Unit No��\ -o� . •. APPLICATION FOR PERMIT TO LOCATION PE MIT GRANTED 2.0 APP OVFD INSPECT OF BUILDINGS t I ' ` The Commonwealth of Massachusetts Department of Industrial Accidents _ W offlceoflnlVosdgatlons 600 Washington Street, h 7` Floor Boston,Mass. 02111 1 _ Workers' Com ensation Insurance Affidavit: Buildin Plumbin Electrical Contractors A 1[cant form ion:•° . : ; address: % f�i cit mob. ' state: zip•Q # � work site location full address ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel ❑ ! am a sole ro rietor and have no one workin in an ca acit . ❑Buildin Addition IN, Ion I am an employer providing workers'compensation for my employees working on this job name.- company �. Address: s0 .City: z rb. insurance co, polic # I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company, name:�Lrci7) ./a4�=! address l ( 11c t r _ cityLL hone#: insurance co. : w company name: ;4 ... address: V c cit - "` hone#: .! a ' insurance ca. •_ -ohc ll•_ Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a(ice up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature rr�. Date Z-+3"y Print name A Phone# —6S(.1 D official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑check if immediate response is required []Licensing Board ❑Selectmen's Office contact erson: ❑Health Department Co sea t P Fuo3� phone#: ❑Other l I Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 twobr more of the.foregoing engaged in,ajoint 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.r However the owner of a dwelling house having not more than three.,apaents and who resides therein, or'the occupant of the dwelling house o rtm f 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 152 section 25 also states that every state or local licensing agency shall'withhold the issuance or renewal of Nieense,or permit to`operate a business or to construct buildings in the cominonw,ealth for`any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,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 in the workers' compensation affidavit completely,by checking the box that applies to,your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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 or license is being requested,not the Department of 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. 'ROW:; City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 Mice of Imlesdganons 600 Washington Street,7'h Floor Boston,Ma. 02111 fax#:(617) 727-7749 phone#: (617)727-4900 ext.406 Cam' CERTIFICATE OF LIABILITYT INSURANCE 1 7A-E.�,Mi D11NYlY1 Iogcnl'C6a(6li?�.25-555�- 17j3237U ��T S+�ERTIFICAT6 f$I6$VEb Ali A MATTER 0�INFORMATION Ss 1tlane.w 1 nSt�r�n:a AC,E I;:y ONLY':AND CfkMPER8 NO MIGHT$UPON TN!?CORTItxiCArl! 2154 WaSh'. atcJ m Street � w�O�L 911L HIS CER71FICATE,DOLO$NOT A' O,EKT fJ OR J vVeat Roxtury. 11 A 02132 �-�-��`�� Ar^F Y TH LICIR$MILOW. L _ INSUREAS ArFORrANO JOVER 13E {IN80RED rlann _...._..-� —�.. _�. ,. tllraK _OrIB Artq $On3 (�`GflSt,rUCtiJlil ,.-�N.-1Rta.h: ^ .._ •- •• .._�.,� Michael Na,,:ic-r.e iyrce Insurance Cam n; I CI&uitBKB' '�-}------- 30 Edward Ave 1 IH8uR9.F C. f Lynn f i+r i tl. "J1A 41 Sad+ .�. . _.�..�.�«__.......`.�--..... ......,,.._ I t t.JSURE•�.p THE POLIC19 W 4461,'I'ANCE WSTFD Bk ",Y a,f,\E Vto JS•3\•ED Tri TtIF„kVu,.ipeO 1jAtdEU AP.Q'iL+�CrW T is yOLll.`Y Oh"riiPJC+IIiL+'IG�1TEp y'T1f� LJ4Y R-CU:RFkIEN7,TF;zr,A?P.^ NTiph^F's.rJY w+;:r� d7.r`(yp:;THER v4Cv14EMT 41!'N F.ESF KC:1 TQ Wf•{"i{1F}i$t'EuTIFI Tr..61A1 SF I3� Ar.171. rl•+Y PERTZII*TWZ NZ -ANCE AFFORDS Clf THE FvL':l=S DESC,Rf = �-: IN °UFO GR 8 GI REI 9tlbli rT ,?,:L R?�',; I OLI r ES.aGd3R'G�,TE �wir"5$HI)WN MAY�v,'yE Bu'.JZEGJ� 91'PAIC'4LA111+8,� i; Tr:r c 11� C; �J" OM€71�CI�G or,N9uAiNCi ' FrLI^`i/UtY6ER Pr� Q,Y'i ''F•80T;V �OL�:Y E%i{W1T1CN--- ...•.- -_. i � ,• Offn£RALGiARIUT! - I ••-••' ,, ,�` `' ,er•��' 1 _- LIMIT$- - �` 1 1 \ 4' i -!.k.C/a.?F:�f,*�d ' i12/2' !'s.�G -i erl�•:r�;r+AE'•ra :s �-�., r, i .7;OMA76i': 1,!..CBNi NA;'40T1' - + ~"aiAA3a 10 1Rs c r vU•,J4� ur,:Luck ^YJ occt.R� � i i��'�xa�ru�-1.� i J,ocol � A f.. .,..� j I MS�I:xP ia�y�ri6 KiA:pd'i -!b; '.. -i I !aERi+?1JAL d A>1 a�JLr:' S (v ow V �._.. ,,._.,_�.._- 1 ! 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BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 079149 i Birthdate: 04/14/1961 Expires:04/14/2005 Tr. no: 79149 Restricted To: 00 MICHAEL A NARDONE 30 EDWARD AVE C.'�•'" �/ LYNNFIELD, MA 01940 Administrator _.� ��6-�/YiI'GYIC11-IY.C!{P,d�lil, a��(IIJJIlI,'III�G�J =A Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to. ' Board of Building Regulations and Standards Registration:S 131108 One Ashburton Place Rm 1301 Expiration: 6/2/2006 Boston,M a.02108 Type: Private Corporation NARDONE CONSTRUCTION&CONTRACTING INC. MICHAEL NARDONE 30 EDWARD AVENUE, LYNNFIELD,MA 01940 Administrator Not valid without signature CITY OF SALEM9, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT fl B 120 WASH INGTON STREET, 3RD FLOOR SALEM, MA O 1970 TEL. (978)745-9595 EXT. 380 FAX (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition of Building Permit# ,all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III,S 150A. The debris will be disposed of at:T ©c) I iCa�_(-)ne5 _,In+,e Location of Facility n-_3�os Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Nan:jQu _ naLiruc+'10 Name of Permit Applicant 1 Ibc�n - Wootp— Firm Name, if any Address,City& State The above statute requires that debris from the demolition, renovation,rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. NOTICE IZ4W NOTICE TO a TO EMPLOYEES EMPLOYEES �r T he Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727--4900 •— http://,tFww-.mass.gov/dia As re uired by Massachusetts General Law, Chapter 152, Sections 21, 22&30, this will give you notice that I�we) have provided far payment'to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY ONE TOWER SQUARE HARTFORD, CT 061.33 ADDRESS OF INSURANCE COMPANY (6KUB-90SX138-3-04) 07-18-04 TO 07-1 B-05 POLICY NUMBER EFFECTIVE DATES SALHANEY INS AGCY 5264 WASHINGTON ST n� e WEST ROXBURY MA 02132 NAME OF INSURANCE AGENT ADDRESS � PHONE# n� o NARDONE , MICHAEL A OSA 30 EDWARD AVE NARDONE & SONS CONSTRUCTION M L.YNNFI ELD ° NIA 01940 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of ° employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably •® connected to the work related injury. In cases requiring hospital auention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 000546 W20FIG02 LNSTALLNEALOOHWIN ❑ IN EXISTING OPENING l OFFICE EXISTING WINDOWS TO REMAIN KITCHEN FI I ❑ o O II ■ II II II II u CONFERENCE OFFICE � PROFE5510NAL BUILDING 3' I II II II OFF I GE I i I s INSTALL rmN wlNDows 48" N EXISTING OPENINGS 3'-10" EXISTINC DOOR TO 4 UB T STAIR HANDIOAPPED ��%j SINK � t� ❑ PLAY e'/ee ��„EL rl,"A`��Ca4�l,ar THERAPY TYPIG L HANDICAPPED IFXS„ WPEN�N06 ALL LAYOUT I/2"=1'-O GRAB BARS SHALL BE NOTE, 1-1/2'OD,1-I/2" V '}• / OFFICE ALL PARTITIONS IN LOWER ARE FROM WALL 2'9' 1, SHALL BE NEW. ABP/E FIN.FLOOR ALL DOORS IN LOWER AREA SHALL BE Sb"WIDE. �•r ®,�.'. +:i,"I�. .