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No. �
APPLICATION FOR
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PERMIT GRANTED
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APPROVED
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CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
40 SALEM, MASSACHUSETTS 01970
STANLEV J. USOVICZ, 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: G
(Location of Facility)
na f A licant
Date
Depardnent ojindastrid Accidents
O,Q7cs of l avesdsadons
6" Washington Shot
` Boston,MA 02111
wwwMaess,89WAN
Workers'CompensatJoll Insurance AfMavit: NWIdemContradorsM dans"embers
Please Lellfth
AVDW8I Is rite
Name (S�( tl C—
Address' ��
�'u ��z,�
CjtyiStawz;a -
Are you to employes?CM&for 4 Pe of p"JM(regdreM:
1. I am a env"with 4. I am a general oo raaor and I 6. ❑New oo
employees(m2 sawar pars-UM4 bout hfred 16e wb aoa>ta a 7 ❑ Remodeling
2 ❑ I am a soh proprietor of pf mor fisted on the adached dw t
These sob-convaclota Mro 8. ❑ Demolition
ship sad have no UVIWees worketa'coaq %xim ion. 9.jErBwVbg addition
worlong for me in S. 0 we weers have orsd isaadd is their 10. Electrical mpdm
�requWJ Cor additions
right of exemption per MGL 11.[]Plumbing marts or additions
3.❑ I am a homwwna doing all work
a 1s2,41(4h and we have no 12.p Roof repags
ref (No wattage• cow
iasataoce regniied]t �i required.] 13.0 Oth
'terWPtiWthedwksboxe1tensdwMaA�rxefo.bdowdies*M*wanw Pftm&=dm
a on wk adtbm bin cub*wausco.=0 abma,p raw ova bacat na X"
abU*Mbd8dwifadk.tlnsm•ty des
tHomaowom�vcb tdMMafarabaoeuadmaddrbWO& aaatP P f iatom+.tiae
o addtdaaal tend iowtq
tCm>Adonma(cbeetlhnboxmut.Arbed ..
a laserrurre� or ltelow is thepvft xxdj rB slat
I eau ew ctsPleyer tAue hid wrrken eew/eeseuie I wY�'ees.
IttstuancecbmpatyName: ( LG �Z-!Nl S �
Policy q or Self-ins.Lie,# Expiration Date 9
eT L C L Cttylstawg* � (—�n"1 L,��- O/ / �O
Job Site Address: 2 2 r=oa�date}
Attach A copy of the worksW.eompeafrtlor polky declaralles pap(slog the ply number and erplratl
panore te secure coverage 0 required under Section 25A of MGL C. 152 can lead tD the unpontiion of criminal penalties of a
fine rap to$1,500.00 and/or onayesr impri9oome0.�as well as evil penaldw in the thins,of a STOP WORK ORDER and a floe
of rap m S250.00 a day against the violator. 4e advised that a copy of tbis statement may be forwmded to die Office of
Znvestigstims of the Dll►fir insurance
verb
I is hereby eon*UnderA# penabo 000fi"dear At wwweda' b and cone
r
s ar(P Do xM wrdar/n tkk ene,is Air ewnplad bl go orwn PermWiueenses
athor[ty(drde one):
f ffeakh L Building Department 3.Ckylrowa Clerk 4.Electrical Iuspeetor S.Plumbing Inspect
6.Other
Contact Person Phone M:
Massachusetts General Laws chapter 152 requires all empkrym to provide vodkas' oon>penmhon for ftk employees
Pursuant to this statute, an sawpleyeur is defined aa-...evay person is the service of another onda any connad of bye, "
express or implied,oral or wrbm"
An ermp&j s►a defined as"an individual,psrmas*associati4 corporation or other legal entity,or any two or more
of the foregomt aped m s joint awpis%and iacb ft the ko waves of a deceased employer,or the
receiver Of.tfmfte of tta.iad vidttaL ptrtuaft association or other legal entity.employmt employees. However the
owner of a dwelling house having not mace than three aparsmenta and who resides theri m,or the ooarpant of the
dwelling house of another who employs 104210121110 do m1hAm81Moe,construction or repair wort on inch dwelling house
of on the gtarmda or bm7dint appmtemnt thaem shall rot because of such employment be deemed to be m employer'
MGL chapter 15%125C(6)oho states that"eva'Y estate at local keadnt agency shar withhold the ka usaee or
renewal of a license or permit an opaata a business or to construct batNsp In the eammoow mM for my
spponaf who hsa ad produced acceptable evldem of eompBaoa with the Inrrasa cowman required--
Additionally.M%upow 152.125CM stains"Neither the commonwealth nor terry of its political subdbadmss shall
ems ins/any cons uses fbs the perfoammce ofpnblk wart on&accmptable evidence of cmWH m with the issuraoos
requirements of&Jfcbmpter have been presented to the caatkactind awhafhy."
Appknb
Please fill out the works compensation affidavit completely,by cLectiet the boxes that apply m yaw situation s4 if
necegmy,supply n b-oonvmm*)name(sl address(es)and phone number(s)abut with their cati&ate(s)of
imunaoca Limbed Liaba'hty Ccmpania ty(IM or Limited 1JdM Partnerships(LLP)with to empl yea other dm this
mcmb.ca or pa mcM 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 rosy be submitted to the DepwWmW of Industrinl'
Accidents for confirmation of fi aaanoe coverap. Also be sure to dp sad date the affldavft. The affidavit sbooM
be wturned to the city or town that the application for the permit or license is being requested,act the Department of
Industrial Accidents. Sboold you have any questions regardingthe law or ifyou are repaired to obtain a workea'
compensation policy,please call the kpermuent at the saber listed below. SehT*sensed comps nies should eahter their
wlf insurance&CUse mm6a on the appropriate lmiL
aty or Tows OffidaM
Please be sm`e that the affidavit is cmmpkte and printed k&ly. The Department has.provided a spat:at the bottom
of the affidavit f x yore to 0 out in the event the Office of Investigations has to concoct you regarding the aWHc:M
please be sole to till in the pamtttlicia a realer which will be used as a reference number. In addition,an applicant
that most subunit multiple Pamit%="applications many given year,need only submit one affidavit indicating cttr.
policy kbimation(if necessary)and m da"Job sift Address"do applicant should wri%te"all locations its (sty or
town}"A copy oftbe affidavit that has bees ofilcially stamped or,maskedby due city or town may,be provided to the
applicant at proofdbat a valid affidxvk is on fik for Amm permits or Sca= A new affidavit moat be filled out each
year.Where a borne owner or citizen is obW t a license or permit not related to any business or co>m emial venue
(ia a dog Nee=or permit to born leaves etc)said person is NOT required to mMkw this affidavit
The Office of Investigations would bike to thank you in advance for your cooperation and should you have any questiom.
please do unt besito b`gtve ut s cWL
The Depa mmrs addmu telephone and 6a comber:
Ile Commonwealth of Massachnse to
DepartmM of Industrial Accidmb
OtIIbe of Invtmadont
600 Washington street
Boskmp MA 02111
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26.05 www.mm.gov/dia
01/04/2006 09:22 7815937260 DLIFFY INSLIRANCE AGCV PAGE 01
CERTIFICATE OF LIABILITY INSURANCE DATE(IrMVDD/YTYY1
PRDDuceR (781)593-1200 FA% (781)593-7260 01/04/2006
Duffy n5uranCe Agency, I nC. Ti'IIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
g y• ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
31 7 Brpgdwey HOLDI•R.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Wyoma Square ALTER THE COVERAGE AFFORDED 8Y THE POLICIES BELOW.
Lynn, MA 01904-2602 INSURERS AFFORDING COVERAGE INSURED Rektech I nC NAIC#
NSURER A:
196 Haynes Road Sutlhury. MA 01776 INSURERS: Pilgrim Insurance Compan 0045
INSURERD:
Travelers Insurance Cam an 0056
NSURER D:
INSURER E'
G V RA $
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ASOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDinON OF ANY CONTRACT OR OTHER DOCUMENT WITH RFSPECTTO WHICH THIS CERTIFICATE My SE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE PCUCIES UCSCRIBED HEREIN IS$VBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IV R D TYPE OF INSURANCE
POLICY NUMBER PC CY EFFE P UCY PIN,NFNPRAL LIARIMTY TF IN YMRE
COMMERCIAL GENERAL UABUT- EACH OCCURRENCE g
CLAI IAS MADE OCCUR DAMAG._SEMISEESrPoEmM.,ED S —
MEOC.P(An Ap�
Y�^o Po•e I S
PERSONAL$ADV INJURY 8
GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5
.
POLICY ECT L� PRODUCTS-COM06P AGG 5
AUTOMOBRELIARILJTY PMC7194539 01/27/2005 01/27/2006
ANY AUTO rnMe NEO SINCLE LIMITALLOMEDAUfCS IEB aERIJgDI) T
8 X SCHEDJLEDAUTO$ BODILY INJURY
X MIKGUA TOS Nwpereap 2501 DU
X NON-QI41NEDAUTOB BODILYINJURY
(Puzewom g 500,00
PROPERTY DAMAGE
GARAGE UABNm (Per WJOW) $ 250,00
AW AUTO AUTO ONLY•EA ACCIDENT 5
OTHER TY'AN EA AQC S
E%CE53IUMRpEL1A LIABILITY AU70ONLY. AGG 8
]OCQIR El CLAIMS MADE EArHOCCURRENCC y
AGGREGATE $
CEDUCTIELE 5
RETENTION S $
EMPLOY RS' IAENSATIDWAND 6KUB7402A34-3-05 04/08/2005 04/08/2006 X $
WORKG ERS'LIA ENITY V\C STATµ OTH.
AIJ1 PNIIVRIETOR/PARTNEFNEXECUTIVE TORY.LII
C DFFICERIMEMBER EXCLUDEq E.L.EACH ACCIDENT 5 100.000
fas,`c'o Bunt al.DISEASE-EA EMPLOYE S SPECIAL PROVISIONE Cahn 1�,�O
OTHER FI IN.SEASE POLICY LIMIT i 500,DD
0ESCRIP71CN OF OPERATIONS 1 LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED RY ENOORSEMEMT I SPECIAL PROVISIONS Dntractor
CERTI ICATE OLD
E CANOE I ATI
SHOULD ANY Or TIIE ABOVE 0MCRIBED PDUOES BE CANCELLED BEFORE THE
DUNRATION DATE THEREOF,THE ISSUNO INSURER WELL ENDEAVOR TO MAIL
City of Salem 10 DAYS WRITTEN NOTICE TO THE (CATE HOLDER NAMED TO THE LEFT
.Arrn Flr-'r , -'J—p 8
L I ty Hall ep 'FEmgdlr. AIL E TO MAIL$UCH N E S LL I SE NO 09UCATION OR UABILITY
EANyq pUPON THE INS ITS DE $DflR R NTATIVE$.
Salem, MA 01970 E N
ACORD25pool/Dal FAX: (978)745-3018
0 PORATION 19aB