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44 BROAD STREET - BUILDING JACKET { 44 Broad Street � //n//ielllG® UPC 10332 Nom HASTINGS, UN 4 3 CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH,RS,CHO NINE NORTH STREET HEALTH AGENT June 27, 1997 Tel:(508)741-1800 Fax:(508)740-9705 JDS Really Trust John Spinale, Tr. 71 Columbus Avenue Salem, MA. 01970 Dear Mr. Spinale : In accordance with Chapter III, Sections 127A and 127B of the Massachusetts General Laws, 105 CMR 400.00; State Sanitary Code, Chapter 1: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter Il: Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property located at 44 Broad Street occupied by Sue Dalton conducted by Jeffrey Vaughan, Sanitarian on Thursday, June 26,1997 at 1:00 P.M.. Notice: If this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to ensure that this unit complies fully with 105 CMR 460.000: Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the Salem Health Department at 741-1800. You are hereby ORDERED to make a good-faith effort to correct the violations listed on the enclosed inspection report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins with receipt of this Order. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A raquest for said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of Ns Order. At said hearing, you will be given an opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Please be advised that the conditions noted may enable the occupant(s)to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. Ja the Board of Heatth: Reply to: nne Scott Jeffrey Vaughan -lealth Agent Sanitarian c: Tenant, Building Inspector Certified Mail # P 153 314 467 JS/Sjk -wn ae 4/ 6 Page t of 1 SALEM HEALTH DEPARTMENT 9 North Street Salem,MA 01970 - State Sanitary Code, Chapter fl: 105 CMR 410.000 Minimum Standards of FRness for Hurnzcn Habitation Occupant: Sue Dalton Phone: 458-0857 beeper Address: 44 Broad Street Apt. 1 Floor 1 Owner. JDS Realty Trust, John Sp.inale Tr. Address: 71 Columbus Avenue Salem, Me. 01970 Inspection Dale: June 26, 1997 Time 1:00 P.M. Conducted By: Jeffrey W. Vaughan Accompanied By. tenant Anticipated Reinspection Date: G ec£S Fxo Com, �i/� i eco fr Specified Reg # Violation -rime 410. . . . Due to a tenant complaint about no screens an inspection was conducte in accordance with Article II, State Sanitary Code, 105 CMR 410. Upon inspection the following were noted: lee S V - ,✓eN CG. w✓0lG ,CJ G- ✓itJsPEcTo � One or more of the above violations may endanger or malenally impair the health, safety and wellbeing or the occupants(s) C�L- 110 -^ -/ , Sanitarian_____ /� gz'Code Enforcement Inspector Este es un documento legal imporiante. Puede que afecle sus derechos. Puede adquinruna traduccion de esta forma APPENDIX IY(14) Legal Remedies for.Tenants of Residential Housing The following Is a brief summary of some of the legal remedies tenants may use In order to get housing code violations corrected: 1. Rent Wiihholdine(Massachusetts General laws,Chapter 239,section 8A): If Code Violations Are Not Being Corrected you may be entitled to hold back your rent payments.You can do this without being evicted if. A_ You can prove that your dwelling unit or common areas contain code violations which are serious enough to endanger or materially impair your health or safety and that your landlord knew about the violations before you were behind in- your rent B. You did not cause the violations and they can be repaired while you continue to live in the building. C. You are prepared to pay any portion of the rent into court if a judge orders you-to pay it.(For this, it is best to put the rent money aside in a safe place.) 2. Ren it and D A t r(Massachusetts General Laws,Chapter 111,section 127L):The law sometimes allows you to use your rent money to make the repairs yourself.If your local code enforcement agency certifies that there are code violations which endanger or materially impair your halth,safety,or welt-being,and your landlord has received written notice of the violations; you may be able to use this remedy.If the owner fails to begin necessary repairs(or to enter into a written contract to have tbedt- made)within five days after notice or to complete repairs within 14 days after notice, you can use up to four months'rent in,any; year to make the repairs. 3. R .talia ory Rent Increases or Evictions proyibitod(Massachusetts General Laws,Chapter 186,section 18,and Chapter 239 section 2A):The owner may not increase your react orevict you in retaliation for making a complaint to your local code enforcement agency about code violations.If the owner raises your rent to tries to evict within six months after you have made the complaint,he or she wilthave to show a good reason for the increase or eviction which is unrelated to your complaint. You may be able to sue the landlord for damages of he or she tries this. 4. Rent RrQ6y shin(Massachusetts General Laws,Chapter'II,section 127 C-H):The occupants and/or the Board of Health may petition the District or Superior Court to allow refit to bepaid into court rather than to the owner.The court may then appoint a "receiver" who may spend as much of the rent money as is needed to correct the violation. The receiver is not subject to a spending limitation of four months'rent. 5. Breach of Warr?nty of Habitability: You may be entitled to sue..your landlord to have all or some of your rent returned if your. dwelling unit does not meet minimum standards of habitability. _ 6. Unfair and Decen ive Pm 1f rc(Massachusetts General Laws,Chapter 93A): Renting an apartment with code violations is a violation of the consumer protection act and regulations, for which you may sue an owner. The information presented above is only a-summary of the law.Before you decide to withhold your rent or take any other legal action,it is advisable that you consult an attorney. If you cannot afford to consult an attorney, you should contact the nearest legal services office, which is: Neighborhood Legal Services 37 Friend SL Lynn, MA 01902 (617) 599-7730 raiem Historical Commission CITY HALL. SALEM. MASS. 01970 r ��OINM6 fP� CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed construction [ ] ; reconstruction [ ]; demolition [ ] ; moving [ ]; alteration [x] ; painting [x] ; sign or other appurtenant fixture [ ] work as described below in the . . . McIntire Historic District. (NAME OF HISTORIC DISTRICT) Address of Property: 44 Broad St. Name of Record Owner: JDS Realty Trust DESCRIPTION OF WORK PROPOSED: Replacement of siding, alterationof windows and replacement of overhang roof as per drawings submitted. Windows to be wood, 6 over 6 with intregal muntins and mullions. Install shutters - wood, hung so as to be workable or appear workable, so when shut would shed water and would fill window. Paint colors to be Old-Salem Grey body with cream trim. Commission Helen Sides has beendelegated to review details of shutters and windows. will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act (Mass. General Law Ch. 40C) and the Salem Historical Commission. Please be sure to obtain the appropriate permits from the Inspector of Buildings prior to commencinv work. Dated: August 4, 1994 SALEM HISTORICAL COMMISSION BYC��f '/ ' Chairman }+ o rn .� N � M LN L U `a as co ca M_ x 1 l D! 3 CL CD °' aC xi, T;rlN V � � cm i N aC Z r 9A1R- '.��� -4 REVISIONS: b t ��• 'F— i ° DATE. I'� A �)2� ��04 re 7 r G\S�ERED AR0,i 4111, >. OFF D'wg' No. A -i PHOTa- EXIS71Ny CuN�;7�o,y �ZoM �ko11Q 5T b, Plans must be filed and approved by the Insp�;Abtir�" prior to a permit being gran e&t &P. ICY— L� CITY OF SALEM P4Ahu ARQF'Y FCnI 7 - '',i L`- ,(+ NO. / ' I /�S� AND LOC !�r�r I°E FU7 1, ALL H ALL SEP� LS QCTiU ! D!:rEGi HISTORIC DISTRICT? N a Date` /z ` ;iz i IF FOR SIDING, HAS ELECTRIC • wr Home Phone 7YJ=/biz PERMIT BEEN OBTAINED? Y N ? Bus. Phone 75rr/6a� rPa✓gsJ APPLICATION FOR PERMIT TO RCrPL//GCr f/D/.✓F r wr,J n a w s �'c 'Lr rc �)/ PCr/C�✓ Crltl 1( TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the.,--.- following he.,_:following specifications: Owner's name and address JaN� S'PiwAGc 7i CoCvr•+d�� g� .rAcC'r Architect's name N�A Builder's name Location of building, No. 4 What is the purpose of building? :A-' If dwelling, # of units? Material of bldng? ; Will building conform to law? a—x Asbestos? Estimated cost2J�d0 City Li^c.11 X028 State L/circ.#©370S'0 Signature of Applicant TIED UNDER THE PENALTY OF PELMRY " DESCRIPTION OF WORE TO BE DONE /e'6;lav6- OLD s4.'97L-- -r1Dire . Ren4cc- w,TN PC,4D Mail Permit to: 0)4 sPi✓r14C- 4,rAcr.,r nn -T 0)4 � �o � A �.-.ems., e; s A� {;,}i RS` IF��(�!1`�µi'�rK� 'e 1Q" ?��'!�.( .. Y• SIy•�r �li� �2k'.V { t.l � 1. a. ' r r No. Ward APPLICATION FOR PERMITTO ROOF •I, S.( 1 - 1 gri t Y.' k �tS�'[' t i: . I. ' REROOF OR INSTAL 81DNG Location PERMIT GRANTED 19 As�mvei� I Bulldiny Inspector i 10200 The Commonwealth of Massachusetts RECEIVED Board of Building Regulations and Standards INSPECTION V Massachusetts State Building Code,780 CMR - USE QBuildingPermit Application To Constru Re Renovate Or PP One-or Two-Family atr Dwelling , This Section For Official Use Only, " ', •r*., hr'. BuildingPemtitNumber: Date .pplied• I .3 /5 Building Official(Print Name) - Signahne Date SECTION 1:SITE INFORMATION 1.1 Property Address: L 1.2 Assessors Map&Parcel Numbers — —r—�epted T i.la Is this an accepted street?yes no Map Number Parcel Number 13 ZoningInformation: 1 a V' " Jti*•r ' .%tYiti;l3"� 1.4 Propert�Il�menslons: d11F'ittl mwn^ fy)t 31 I� ZoniagDistrict Proposed Use LotAtea(sgrtt),n / f fit•,iet�Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M G.L o 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: — Outside Flood Zone? Check ifyes❑ Municipal❑ On site disposal system [3 SECTION 2: PROPERTY OWNERSHIP' 2.1 Clyne rt of Record- et]] Ci t^an.-i4aro Sc �ewt /Kl a/570 Name(Print - City,State,ZIP Li &Pad {• q?s-76y-a91-/7 No.and Street ' - Telephone - Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building❑ Owner-mupied ❑ RepaW(s) ❑ eiation(s) ❑ Addition ❑ Demolition ; ❑ Accessory Bldg.❑ NumberofUnits_ Other Specify: SI✓s 't— Brief Description of Propgsed WorO. a r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials Official Use Only 1.Building $ 3(��S_ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/1'own Application Fee El Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ ' 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Su ression $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6,Tota1 Project Cost $ ?j 7�• ❑Paid in Full ❑Outstanding Balance Due. tmtatt_L---)D SECTION 5: CONSTRUCTION SERVICES 5.1 Constriiction'Sugervisor License(CSL) g 79 /7-� � 23 ? ''. `• 1il License Number Expiration Date Name ofCSLHolder Eric W.Palm Lin ).a f Type(see below rta •It... No.and Street �"`�'rgtB®( Type :- Description , Salem MA 01970 u um estrietea main to 3s000 na s R Restrictedl&2Famil Dweilin City/rown,State,ZIP M Masonry RC goofing Covering WS Window and Siding SF Solid Fuel Bmamg Appliances q7�• 71-fY- p ty lq 3 I Insulation Telephone Email address D I Demolition G 5.2 Registered Home Improvement Contractor(MC) HICRe&hadoaNumber Expiration Date HIC-Company Name or r1Z75011, 61 itMe bn AVOW No.and Street Email address - Salem MA 0197Q Cityfrown,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.r-152.§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance a building permit. Signed Affidavit Attached? Yes.......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner ofthe subject property,hereby authorize �✓�Z. PCG YH to act on my beba%in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) _ _ Date - SECTION 7b:OWNERr OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information containedpplicati on is e�rnd accurate to the best of my knowledge and understanding. zlzy � � Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES- 1. An Owner who oblidw a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fiend under M G.L.c.142A.Other important information on the HIC Program can be found at www.mass.goy/oca Information on the Constmcfon Supervisor License can be found at www.mass. ov�/di)s 2. When substantial work is planned,provide the information below: Total floor area(sq.R) (including garage,flaished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms -Number-of bathrooms Number-ofhalf/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost". ill , Hassachusetts]RO le limn a oveme I �a This torm m le contract sapmIcal baac requirem®uafThestates Home&IIa allasroasproCtetthaQdd rs.Seek legal advlceffae6CCCI An�Caooatdorlan•(MCL chWter 14?A)•butdoes not lnNodesmadard Olfimorco nerA is,, to Aoma lmPrasaaed"beforea Any pla®n8 hameimprm CcUshouldfost obtainaw asrtmaA$'aito and ausinesgRemtlation's Crttnttm ng tommy worts nnyomreidence-Yen PYaF"A IdomeaWner IIII'ormatl0n ivfd°1°tlO°Hotliev at6l'!_p]3-gja]ar l.ag¢+obtain efreccopybYambIgtha -83-1]5]°ran ourrrebsitc Nnoe - Contractor lnfartnation Lei ---Addres(do nanseaPm-t OlEaaosatldress) - � CanoattodSalesp Cinlroun Sete ��• 69 R Te Sall" LPCed !,, y 9°sinesAddtessmua)ml IAVeRue Dartme(Phpm 9 70 -17d �� , Eating/P'a-7 / ` T Sue :TheContmao Addles Ili dnfetmt Fttm Lp Cade "I BmmesPbme pedemt�Pt°-+erID art$,Number �mwea�m�m�e �t�ox em-at�e..t+��/760 �o 4grees to do the fuliowrogwor4 far thenetvcawnere tDesedbe in tlerail the m*taeumpb,4 VOdty ng Nen CAv.f <?�= 9edeof mars d mbeu eq aeadtl" ) RequiredP A/J dand �O�ecuredb"e Uoa'inorastiegpermitsarerzgwny Prnposcl Smrtand CompleSon Srhedn(e- (O n rs Wfi secured mIre their Own eperomeonaefs (Ownerstvhosecuretheirotrup a_aent headheredromlessrircmnyencesbes 13efolloniogscaedumaill esciuded from erprovW116e :ond Weronoamats a000l arise• the �. MGL chapter 142A.) Ptnetstons of > Da a wfim co UMMAn7l begin ma atted na k 31.E Daze when<aauamed ssork at71 Told Cocteau Primand Payouts,Schedule be �nti�Y completed The Comemoragrnm to ped'mm The nods.fumislt he material I d lahor specified above farthe roml sum og Payments wtll6emadeaccordinero the fopmvingschodulc � --P1 S Won signing camatt(not met( ceM lB afdie total conaatt Price or the Canofspecial order items,n'hicho v isgaater). S t by / n completion of ( "���—. or upon cmmpletim of 1 �Won aompletim ofthecootm¢(lavfadridsd nto fall t The follmingamerkm g Y°'e�t uonl contract iscm m both Parry's satisfaction) or-acdbefotethe Warymemmua 8espaie 5 to Paid/yr/ ronsm the unl°mon s�dl�(..)msed in aim g hW m NOTES.,(•)no'exxxgalle -harges(")latcre h,dres am-den twdmw-paamon reapdted yv themmrzerm bemrewakbym me nhith« rhegatQaf(a1oncyhbd ofaamtalemnaa also 6espedal ordered in adsavammaTthemmPle®sehedPT l ulee���rafam•sp¢ial equipmemmemammede Y tnnerid Rss lS'arM N-1 ei rq n Submntmacus- ry she ors or° ❑Nn Qq v he. 7keconaampragreesrobesoldr °ar rrav •m 6 Panydsubconauctorua7izedbvdse canoattOr. The n�bleforcpmple'imoFtbesvorkdcsmibeds t the mn ateri is h r his amaattorfia tua_mees lobesotcl °�dlas ofthe acdanscfany third CanhactAtto rooce- Yresponnble fora'IP*menutoaasuba000acros Far contras shaE oot' Uponsilminq this document becomesahind"mg aoatrammderlase unless otbe auefitny beforesimtina ibis con oroNersettuiry mte2s has been placed an The �nol�nirroathisdacument,the axt residence.Review mefollotsing cautions and notices •° Don't be ptesstaed into signing the comma,Take time to tend I(uIl understand Make srne the aacm has vd'd Hom 1 Yit Ask questions ifmmethin subcomoattors to be — . the Di n a o The lav g is unclear. rato the the Di 1mProssmeol Caame w _ te@strahon M•ntitiog to The teaorofAome requires moabomeimpmvemeat contrattors and ° Does the contmclorhaee rnauaPce?rAsk0�Piam,Room al7Q Bagan,MA 0211 oa Ig61on�7ymqute about 8&aactor see a copy ofa'proofofinsutaaa"douunent aactorforhis-ustuance cbmPattviofammtim so that ou coo nfi 83-37Sr. ° Knowyaurriehu and ) co rm cavemge,or ask to Guide to tha me bn�onmbdities.head thelmportmain i ion mthe resetuside ofthis Proremant CantractorLaw, farm and get a copy ofthe Consumer You may cancel this agreement ifit bar been signed m a play otherthan the mnaattofs natnml cold inci in nritingathine the on cembranchoftimbyordiamymaiipoAed,bytdenarn of third business day foilonin¢the si placeScalortyclelivet prodded you notifi•the erring oFthis agreement See tde atie�cbcu aotia ofmcdladm ffo�m torso vim'•not latertbm midoight of the DO NOT SIGN THIS CONTIZAC I emlaaation ofthis right roafaepyae�erateomett assspe CpWs� �Tu,TBEIcaddzu E;�gE Anr1,BLANK SPACESIr�em!'smvldsamaede>:yava;]7r-ewcsp�'sbaild he Oq lsptbr V_smssac !�r Homemsaers Sgaam, r f rCOnaaatar9 g-wa aI3I �� D z13l& Contractor Arbitration ' The Home Improvement Cant-actor Law provides homeowners with the tight to initiate an arbitration action(as an alternative to court anion)if they have a dispute with a contractor. The same right is,urn automatically afforded to a contractor,however. The contractorwould have to resolve any dispute hefshe has with a homeowner in court unless both parties aree to the optional clause provided below.'Ibis clause would give the coutractorthe same right to arbitration as is afforded to the homeowner by the Home improvement Contractor Lae. - I The contractor and the homemmerhereby mutually agree in advance that in the event the contractor has a disp b conceminethis contract,the contractor pray submit the dispute to a private arbitration firm which has been approvedy the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration asprovi a—uh.vtassachusettsGeneralLmvs,c i terla2A. LQX i nS" Homeowner's Signatu re Cohtactor's Signatureomeow to alternative ' to - t of the awes ducats \07ICE:The simatures of the parties above apply only to the agreeman p resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed bythepatties. I Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(IAGL chapter 142A)and other consumer protection laws(i.e.MOL chapter93A)may not be waived in any way,eian by agreement However,homeowners may be excluded from certain rights if the contractor they choose is not pioperlyregistered as prescribed by law. Homeowners who secure their own building permits are automatically e�duded from all Guaranty Fund provisions of the Home Improvement Contractor Lac. The contractor is responsible for completing the work as described.in a timely and worimtanhlre manner. Homeowners may be eadded to other specific legal rights if the contractor guarantees or provides an express warranty for worlmianship or materials. In addition to guarantees or warranties provided by the contractor.all goods sold in Massachusetts carry an impliedwamairty of merchantability and fitness for a particular purpose. An enumeration of other matters on jvhich the hoin6vner and contactor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. Ifyou have questions about your constimedhomeotmer rights.contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duolicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised notto sign the document until all blanksections have been filled in ormarked as void,deleted or not applicable. One original signed copy ofthe contractw•ith attachments is to be given to the owner and the other kept by the contractor.;Any modification to the original contract must be in writing and agreedlo by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract and the three day rescission period has expired Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him(herself to be financially insecure. However.in instances where a contractor deems himlherself to be financially insecure the eontractormay require that the balance of fonds notyet due be placed in a joint escrow account as a prerequisite to continuing the contracted work Withdrawal of funds from said ac otmtw•ouldrequire the sienanrres of both parties. I I Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer riebts.or if you wish to obtain a free copy of"A Iwtassachuseps Consumer Guide to Home Improvement contact Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Pizza,Room 3170,Boston.MA 02116 617-973-8787.888-283-3757 or visit the OCABR welim;te at ifyou want to verify the registration of a contractor or ifyou have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor In,,contact Director of Rome Improvement COUM ctorRegistration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room5170.Boston MA 02116 617-973-8797,888-283-3757 or visit the HIC website Go online to vietv the status of a Home Improvement Contractor's Registration: :r' ��rnrstr4iumzim�mee-erViFxasr�fist:asp For assistance with informal mediation ofi isputes or to register formal complaints against a business,call: consumer Complaint Section Officiofthe Attorney General 617=g27-8400 j A 'MIOR Better Business Bureau 508-652.4800.508 755-2548 or 413-734-3114 Fmio"7r-i 1nr010 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street -- Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Analicant Information ��p�tt� pg(�t�(i T i Please Print Le¢ibly Name(Business(Organintion/individual): A-""'-"W-----r " -�'LLC VCIIIIC Address: Wem MA 01M City/State/Zip: Phone#: Are you employer?Check the appropriate box: Type of project(required): 1.aam a employer with . 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-tune)." have hired the sub-contractors 2.❑.I am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling 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.] off cars have exercised they 10.❑Electrical repairs or additions 3.❑ i am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or additions myself.(No workers'comp. c.152,§1(4),and we have no 12.❑R repairs insurance required.]t employees.[No workers' 13. Other comp.insurance required.] ���G 'tl?-.� *Any applicant that checks box#1 most also fill out the section below showing their workers compensation policy information. t Homeowners who submit this affidavit indicating they moo doing all work and then hire outside wmne[ors must submit new affidavit indicating such.. !Contractors that check this box must attached an additional shell showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance CompanyNamer Zu r Policy#or Self-ins.Lic.#: ✓� 6 970I Z 1 Expiration Date+J / Job Site Address: t4"L`, [t�t'T!aA ✓� City/State/Zip: >Oe%C fyt 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 aSTOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under theparigsand 's ajperjury dim the information provided above' true 1/ad come As A Signature: . Date: Phone M 7Mf- 3 2 Ad 2 Official use only. Do not write in this area,to be completed by city or town orkial City or Town: Permit/License# Issuing Authority(circle am): 1..Board of Health 2..Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: THIS CERIII CATE 15 ISSUED Or Lfl ��� �9 p A 1 HOLOER. THIS C AS A MAi:ER OF 1NFORleATfOn! 1 ��� _ """�E DA;e i AFFORDED BY I-HE POLICIE 00ES MOT ONLY AND CONFERS Q3 72�074 I THEfSSUINGtMSURER a1FFlRFHARVELY OR NO RI i BELOVl. THIS C NEGATIVE " GHTS UPON THE CERTIFICATE) (5),AUTHORIZED REPF. ERIFICAie OF INSURANCE DOES S NOT GOMSIIDTUTE ESENTATIUE OR PRODUCER OR ALTER THE COVERAGE, nIMP a 'a th tFthe ccrttricale hDlder s A AND THE CERIIII E 11 HOLDER.�RACT B Djcof }haFsmsandcondry,onsDfthepODROVEENi net corderridhls' ,NSURED thspOGcy(zs)mustbeead0;sed, file cErcatE holder inpfDlicy,cEr Ein PaLsFes 1av a IF SUSRO 1»pwe a [DFsuch endorsemarr(s).quire analorsement A StatenEnt OQ 5 oN t5lflsdVED IEASTERN IN "rhfica7E d038 33 4rcS7 S GROUP LLC ccr,Aa NAI^. 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TrIE POLICIES OF INSU ER�p a W HAV CERTIFICATE ANDING ANY P,EOUIREME�CE LIST- EXCLUSIONSAND BE ISSUED OR MAl•pERTAIIV NT,TERIM OR SS CONDITI E BEEN CONTRA TO THE ENSURED SION NUMBER ILTS�gI CONDITIONS OF SUCHP TFIE INSUPANCE Y ON OF '�E PO C ESCW NAME ABOVE ESP rYPE OFtNSURANCE DLICtES.LINII t�S, St{OyyA, AF $ 8Y OTHER DOCUM yy(� RESPECT RTME POUCYp OD GCE AO I EEN REDUCED EREIN t5 O 4AiIC PERIOD RALUABIUyY R BY PAID DESCRIBED ECTT t H 1 IS POucYNU CLAIMS_ SUBJECT TO p I COLINg1Olty GEN- L�eR I APThOVO°O vVY '�, c ExP U-THE TERMS, I �UABILITt ( OCCUR I EACH OCCURitEA,CE[500042826 O"8• R S 1,000,000 3/20/2024 /20/2015 PREIA- !E HEED es.P °fie, I5 50,000 ''-nGGREGi_UC9T• lNnr ene r�'xcn) S „PPOES PER I P-RSOVNL3 AOVIN,IURY 5,000 POLICY i J_ IS l AUbgi061LEUABIJ •r CCC GENERALAGGREC.tr- ,000,ODo Un' PRODUCTS S 2,0001000$ d!lAUTO -COaPfOPNGG I S FUi SALL t�Jm SCHEDULEDI S 2,000.000 I" NIP,EDA n N� . 02002 I -'. /EOtSaelt�SwOIE UNR DOE a' AUTOS I- 5871 + BDDILY INJURY(Pp, IS t f 0120/202A /20/2015 Ps'scn} IS - 000.0On n UL;BRELLA UAa I eODILYINJURY(ppraal�l S +a I OCC PP.OPrryO.V.UiG� L I EY.CESS LIAB UR - Para , 1, S I OED I CLAVASdJAOE PIRBasy� S I���V10RIt6Rg IONS 600058fi5a ENCH OCCURREPIOE $ 000 AND m"III- LOVERS• TtON I 1 S t 'ram C nORj�I�GR, ,'�'/20/2024 �/20/2015AGGRr:@AeIs ,000,000 nHHUN�D� �VE I S 2,000,000 Il;a�axsn3e } N/AI .CRL�TI �n=� I nCSTq�J- OLl O�OPERAIONS pO1c,r I °OFJ+IT"_'LOA? yy38IL.�g,Y, I� EL SCNAC(jDE.yr S I I 'AE__gi E1.IPL0YE,�S �L200376602 EL OISENSE-F 0/1/203a �LO/1/2014 OUCYUI•:r( 5 :PJPTION OFOPERA7IONS/ f - C ER.ALAGGREGATE LaCpT 0 1 .Y5lVE}UOLS(Atkep}1CORD70f, I 51,000,000 Ei�U-ImO,V CONOmON Autlltl°Hal RaAartaaS t St erledule RmaresPaa ls'regwraE} -,000,000 IFICA T HOLDER CANCELLATION L'ITY OF S y SHOULDANYOFI HE c3Sfi�rG•0 S aCCDRD IP ITION DA E HEREOF,ABOVE DESCRIBED pOUGES BE CANCELLEDB a._!;,Iy, r�_y 1sT ACCORDANCE Y,7Tt(THE NOTICE WILL EFORE 0197D POLICY PROVISIONS. BE DELIVERED IN AInNORMED RSPRSE,,,A r S 26(2010/08) >n:nnnn, _ Ronald Cleaves/MM T"°r-nl?n Haan end 1„nn avn ®7888 2010 AC ✓� � � M n fnrc,t T PL,,of JirryR ORD CORPORATION. All rin ghLs reserved. 9M Massachusetts -Department=af Public Safety �f Board of Building Regulations and Standards Construction Supervhor � � License: CS-087977 EBIC W PALM 3 HILTON ST Salem MA 01970-, r Expiration Commissioner 04/2312016 �e Uorirrrmnrrrerrl�/ a:tnr�ruelG Office of Consumer Affairs&Bostness Regulation MEIMPROVEMENTCONTRACTOR F; - gfstratfon: t42089 TYPE: ' pica ion: �;3l1212076 Ltd Liability Corpora ATLANTIC WEATHERI7ATION LL.C. ERIC PALM - - 61RJEFFERSONAVE - _ SALEM,MA 01970- Undersecretary