Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
131 BRIDGE ST - BUILDING INSPECTION
IahOPWAI Los"b W3MM �--- w odoo OYI, N �„ M011MMr1rIw�* No'�' MONO pWM APPLICA M Folk PM M 10: DIOk. 904 POO' PLEA MLOUT UMLY a ppYlLai OTO tvao WLAVO IN PROG" o TO THE INBP6 =OF W LMM TiMwdwgoW hm* 006 fora penrA b ba0d SOOCOp to to 1oYo ft �- I1dd1Ns PhOnal`37A 7yJ AIOIIroOYi HWM Adorn a Phony . machwift Now MUM& PhWw Z 3u SA+ q�e•-3�0�� wu�b rr proor a eulmlo� wUw a brr�t �ldoD ��011o�b<howlobNMb�9 sN� w�l�a000�o.dwn t �s fr.Mo.� Na ._— 1 ��n� N A one41 • C 07 277 of V� PIMLn oascr&vnomOFWDrX7OKDM Z Sr Do u 136Luw n. pl✓k-�.wrw9� to MALPwo Tur,� Z3o ��lo s1Y✓' u�C S� CW#VA /oq vJilUNvL) Co, 23 o A-r,LAIC6v4-ram Wi LM)AIG rOA// A4 D/887 lib. J"Q APPLICATM �J /�TO FOR LOCATOW 131 9/ci ac c s7 PEFPST GRANTED;=OF - ,7 CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR 4D SALEM, MASSACHUSETTS 01970 STANLEY 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 I1I, S 150 A. The debris will be disposed of in: Z3o (Location of Facility) --1 Signature of "pplicant 1131 Date BOARD OF BUILDING REGULATIONS .Icense: CONSTRUCTION SUPERVISOR Number: CS 072772 1,%oe,1 3lrthdate: 0 4/0711 9 6 2 —_ Expires: 04/07/2006 Tr.no: 24177 Restricted: 00 JEFF STEELE 24SHiiRWOODAVE DANVI:RS, MA 01923 commissioner 1" J/ ^ ��C -C90!li2[dlLlllCR.l��" OlLv.//'GIfJJ¢f,�G4/:C�M1 Board or Building Regulalions and Slandurds l HOME IMPROVEMENT CONTRACTOR •,3* Registration: 127172 Expiration: 9l15I2006 Type: Supplement Card CHA4IPION WINDOW&PATIO RO 24 S��1-E . 230 E ALLARDVALE ST WILNiNGTON,MA01887 Administrator arurlosrrator C`-A'MPION 'NINDOW MFG. PICTZ)fee 31GO SeilES PAT10 DOOR "---1, ") L NFRC '.a CHAMPION WIND; CPD#E A C01 MFAC 7"SERIES PICTURE YANDOW RIGID VINYL FR,tA{E/q CP-43-%s,-004 Ai ,Vrjjjj I OOUBLE:GLAZc ARGON fILL10W F f, a i I'- COmjj w,. " 9,ht -qs+t`. a t ftIGiD!I NYL 60A7rf ENFNNCED FRAME ' IBMVLE G .V2GONjFlUyfOW E tI IYq- I I'�f 1 'ce t1 >1s'i.+askW tVr�Y ' 1a14 nYc#vsu umj�-LI II .y• id577at n,R `�` '' '�e ..- MFgC'rt neb eRe>K ......_.....3b `�.^�.. I 2 w� • .52 �„Q .E. .:� _',• r.52 SLIDES I�SIN r7UW gIlln O1 CHAMPION WINDOW MFG. 300 SERIES SL'C£R a CHAMPIOPI '111NJOW ac�ea, oo< 3C0 SERIES COUEI._ HUNG ?�GIO NN'/L FOAM EDINANCE`•N O F ll.x CCL'eLE GUIE->R(sc a}AIE Refnr,Ccvtl " =:LL�LCIN E—� p-ah1 EdIFIAi ICEC?=a;�'c �i s -nee�dm cL L=_Gu«>;-.GCN F;Ly.cW .i • �,.n;y,,,,, . e P Fv n„a„Morvely 69.rtd 7aur cpecilo Clm+d,roue I'd llf" . *rr,,llR. q M1vil fdty-d;yZ l3a Hait NFRCa' �'1eTJ+av' a ~- ' web ilb cl j ^A MilleFery+svour I II ror non vll -h'ti".r•5.,y� 34 own m n 3m3 -•---.....:1 5 ., Or d I ....... .�............5.. 5 2w 54 aoC .33l.. .50 awe"y one"ma aMar'�xs..e zati -�' Y'Ccx-Ica'.,=afdrrr;-..+'> �I1�a CHAMPION WINDOW MFG. 1 • 700 SERIE3 CA3E',4FNT Y/1. 1 PIIC CPClg56,A-00: VCCY/ RIGIO VIM.FCAU ENHANCED FRAM coUeLE CI}— F . Mtrq L.a+d �.ARGCN 1�1 • Evr7„v� ' Frn,ve!,•, +•l�Petb furePec111e`yvy houve and Ilf-Y. '`*,cnl �'�tHpy Tyc3i3a Hvl H F2Ce'wd syx 2 I!I � 32� .46 ' ��^� ....... .. 32 .47 .55 may:>�y��n'�''m,trm a ecotcw�FF.0 r'aaa.m M aem^T9 q ,Y�M��f awe��•�,,,'m,:ne t>,.�k d,l„ro,l,,,w �� !'(� �(c) The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 606 Washington Street Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricianst.Plumbers Applicant Information Please Print Leeibly Name (Businessforganization/Individual): �` } ( 'p� �� (J ; dos- ..J Address: 2-`3,o 13 A-i y+r (✓4?-Uz S City/State/Zip: i l n. - µ^'/► Phone M rF7 7- Are you an employer?Check the apgiroprtate Pe of project(required): I.❑ I am a employer with " 4. 0 I am a general contractor and 1 6. []New construction employees(full and/or part-time).* have hired the suli-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ?• 0<eemodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working;for me in any,capacity. workers' comp. insurance. 9. [1 Building addition [No worker:' comp,insurance 5, ❑ We are a corporatign and its, required.],i iL officers have exercised their io.❑ Electrical repairs or additions x, 3.❑ I am a homeowner doing all:work right of exemption'per MGL' 11.0'Plumbing repairs or additions myself. [No workess'.comp., c. 152,§1(41,and we have'no 12.Cl Roofrepairs insurance required:]t_ employees. [No workers' 13.❑ Other comp.insurance requir J_ 'Any apph mt that cbcb box#i must also fill out section below showing thev.worketa'cmMeasstmon polity,infomtation: t Homeowners who submit thisaffidavit indicating they are doing all work and then him outside coutt'actors must subrnit a new affidavit indicating suck tCmtractors that check this box'raust attached an additional sheet showing the nine of the sob-contractors and their workers'camp:policy information. I am an employer that Is providing workers I compensation Insurance for my employees.Below Is the polity and,job site information. Insurance Company Name: 2'n S'(�,(a.C-,r t4 e e Policy#or Self-ins.Lic.#: TR 'Sk C —2?I O'er Expiration Date: tz o/ c, Job Site Address: 1-3( 4;:e-- City/State/Zip:- 5r�6¢in VV 0- al 5 Zv 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 insuraa¢e-ibverag-e erification. - /-. I do hereby ce i the and penalties of perjury that the Information provided above is true and correct Si lure: Date: j Zr Phone#: 77. Y'-f Co— 3 f- i Official use only. Do not write in this area,to be completed by eily or town offlcial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all enployers:to provide workers' compensation for their employees. Pursuant to this statute, 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 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''' use dwelling house of another who employs persons to do appurtenant thereto shall not becaus of such employment be deemed to be an emploenance,construction or repair work on such dwelling yer." or on the grounds or building MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall commonwealthwithholdtheis uance r any r renewal of a license or permit to operate a business or to construct buildings _ 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 ceaificate(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 city or town that the application for the permit or license is being requested,not the Department of Industrial'Acciden%. 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 eater their self-insurance license nuiuberon the appropriate lino 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 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 permiNlicense applications in any 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 rrntst be filled out each year.Where a home owner or citizeais obtaining a license or permit not related;to any business or oommercial venture (i.e. a dog license or permit to bum 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. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 wwwr,mws.gov/dia S 4 ACORDM CERTIFICATE OF LIABILITY INSURANCE Dizioi/z 05 PRODUCER (513)221-1140 FAX (513)872-7519 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMAT ION C A I Insurance Agency, Inc. OI JLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3481 Central Parkway, Ste. 300 HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Cincinnati, OH 45223-3397 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Kevin Schlotman INSURERS AFFORDING COVERAGE NAIC# INSURED Champion Window Co. of Boston North, LLC INSUPERA: Firemans Fund Insurance Compan 18,i3 230 Ballardvale Dr INSUIIERS: St Paul Fire & Marine Ins. Co 47C7 Ste B INSUI IER C: Wilmington, AJA 01887 INSURER O: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATEII NOTWITH ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CIJNDITIONS POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS& OD' TYPE OF INSURANCE POLICY NU MBER POLICYEFFECTIVE POLICYEXPIRATION LIMITS GENERAL LIABILITY IGENE�L URRENCE S COMMERCIAL GENERAL LIABILITY RENTED S CLAIMS MADE OOCCUR ny one person) S B AD INJURY S GGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: -COMPIOP AGG S 17 POLICY JE`CT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO _ (Ea acaGenl) S ALLOWNEDAUTOS BODILY INJURY 5 SCHEDULED AUTOS - (Per person) HIREDAUTOS BODILY INJURY 5 NON-0WNEDAUTOS (Peracooenl) PROPERTY DAMAGE S (Perawdenl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANV AUTO OTHER THAN EAACC S AUTO ONLY: AGO S EXCESSIUMBRELLALIABILITY XAU877390704 12/01,720 5 —12/01/2006 EACH OCCURRENCE § Li DDD 00 X OCCUR CLAIMS MADE AGGREGATE S 15 ODO DD A s DEDUCTIBLE ' S RETENTION $ ' 5 WORKERS TRJUB-281K593-1-05 12/01iZ005 12/O1/2006 X wcSTATu- oTH- EMPLOYERS'LIADILITY B ANY PROPRIETOPoPARTNERIEXECUTIVE E.L.EACH ACCIDENT S .I OOO 0O OFFICER/MEMBER EXCLUDED? 1(yes.tleunbe muter E.L DISEASE-EA EMPLOYEE S it 000 00 SPECIAL PROVISIONS W. - E.L.DISEASE-POLICY LIMIT S JI, 000 00 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECU,L PROVISIONS ELLATION SHC ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXP,RATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVORTOMAI. 3('* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Client Copy BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Sample OF;NY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Wilmington, M1IA 0I$87 AUTHOPD:ED REPRESENTATIVE Kevin Schlotman/SCHLKE ACORD 25(2001108) ©ACORD CORPORATION 1988 A OW. CERTIFICATE OF LIABILITY INSURANCE Die":11/zoos' PRODUCER (513)421-6515 FAX (513)421-0130 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Walter P. Dol l e Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 201 E. Fifth Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 1000 Cincinnati, OH 45202 INSURERS AFFORDING COVERAGE NAIIC# INSURED Champion Window Co. of Boston North, LLC NSW ERA: Liberty Mutual Ins Company 230 Ballardvale St. INSUFER B: Wilmington, MA 01887 INSUFER C: INSUFER D: NSUF ER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.II"I HSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD' TYPE OFINSURAHCE POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION LIMITS LTA INRRGENERAL LIABILITY YY7-541-434193-014 12/01/2005 12/01/2006 EACHOCCUR13ENCE $ 1,000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,DDD CLAIMS MADE O OCCUR MED EXP(Any one person) $ 10,ODD A PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000.000 POLICY PRO LOG ECT AUTOMOBILE LIABILITY AS1-541-434162-014 12/01/2005 12/01/2006 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident $ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ A SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ ' NON-OWNED AUTOS (Par accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR ❑CLAIMS MADE AGGREGATE $ 3 DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND WC STATU OTH EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERrMEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ANI'ELLATION SH)ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED SEFOR E THE EX 1IRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MI IL _0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMEDTOTHE LEFT, Bur FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LO BILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. TO WHOM IT MAY CONCERN AUTHC RRED REPRESENTATIVE Paul Young ACORD 25(2001/08) ©ACORO CORPORATION 1988