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0003A CLEVELAND RD - BPA-14-320 DECK CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ::I�tflrRIF.V URI%t:ULL M.%Vrat M WAsru.NGra<STRUT• SALEM.MASACtn.rt:l-tyG197 T'eL:978.745.9595 •FAX:9M740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Leetbly Name tdusittcs/OrgmizatloNlndivtduup: F Address: Pt K City/Stare/Zip: LW tA�V IN1IA . 2 shone /l: (7_81) 91-T-6 9/1 Ara you an employer?Check the appropriate box: Type of project(required): I.D I am a •mpluycr with 4. ❑ I am a general contractor and 1 6. new construction pluyces(rull andlur part-time).• have hired the sub-contractors _ 1 am a sole proprietor or partner- listed on the attached sheet r �• ❑ Remodeling ship and have no employees These subcontractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required) officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LC] Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑ 11wof repairs nn insurance required.j a employees. [No workers' 13. Other ��d J !V comp. insurance rcquir d.] 'Any applicant Ilea chctka boa lit must also Fill out the section bcluw atowiag their wurkaas'eumpanud"I policy in6ntruttum ' It m uwnan who submil this affidavit indicating grey are doing all woek and then hire onside eontr=on most oubmtl a new arndava indicating roach. �Contractun that cbvck this box muri attached m additional short*hawing the name or"sub-coatrwloni and their women'comp.policy information. I ant on employer that&providing workers'roc»pensadon hnsurance for any employees. Below is the policy and fob site iafarrnatiom Insurance Company Name: Policy q or Self"ins. Lic�,./^1t1: _ .. Expiration Date: /1 Job Site Address: aY f I 1 [JC1!'i� !�! t City/StatU2ip: �Ct nlAA— + Altuch 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.\1GL c. 152 can lead to the imposition of criminal penalties of a ti nc up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of Im esngalioas al'Lhc DIA for insurance covcragc veriticalion. l do hereby rertijy a r the pains and )r tapirs afper ry at the information provided ab elf rue and correct Si,natiire- Uat Pha anc,' Oricial use only, no not write in this area,to be caraplefed by city or town oJJ'iciaL City or'rown: __ .._ Permit/License q___- _ Issuing Authority (circle one): 1" hoard of llealrh 2. Building Department 3.City/fown Clerk 4. Electrical Inspector 5. Plumbing laspector 6. Other Gnitucl Person: _- . _ Phone p: 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 of another under any contract of hire, express or implied,oral or written.- .An partnership,association,corporation or other legal entity,or any two or more s defined as"an I.paean tp Art employer t of a deceased employer,or the t enterprise,and including the le representatives Of the foregoing engaged in a joint tp lr !� receiver or uustce of an individual,parmership,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 dwelling house of 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. §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any 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-contractors)name(s),address(es)and phone number(s)along with their certificatc(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 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Official 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 till in the permitilicense number which will be used as a reference number. In addition, an applicant that must submit multiple pennit/license 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 must be tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. the Ot'ticc of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hcsicarc to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investiptions 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Rev iced 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT NIAWA I_'C W.t:9aur:0NS BEET •SAL`M.MAN&U::u eLCU::91'. TFf:971.745-95" •F-%X:9M740-9946 Construction Debris Disposal Affidavit (required ror all demolition and renovation work) in accordance with the sixth edition of the State Building Code, 7S0 CNIR section 111.5 Debris, and the provisions of MGL c 40,S 54; Building Permit N _ . _ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by VGL c l L L. S 1S0A. The debris will be transported by: (nama of hauler) fhe debris will be disposed of in I 11. s r ��'l�1 �T (mane of faulty)of / fSCt'C3�u��_,s�'ofl 1� Proposal Greenleaf Exteriors Mass lic#cs083846 (781)249-6747 Mass lic#cs092635 (781) 913-6411 Mass Hic lic# 143204 Fax(781) 581-2118 Fully Insured B.B.B member Date: 6124/07 p Customer: Murphy Home #: Street: 3a Cleveland rd. ext. Cell #: q q 9— g)&— (,o `.�Q 9 0 Ca) City/State/Zip: Salem mass Work #: Q 12 - 1 dip—'`5(0_s S Greenleaf Exteriors proposes to furnish all listed material and labor necessary for the completion of the following job specifications: Remove existing rear deck. Construct new two level deck with continuous stairs. Using pressure treated frame, composite decking, and "Azek" composite trim boards. (This is based on square foot quantities of design as discussed. Design is not final and may be change per owners request). Greenleaf Exteriors proposes hereby to furnish material and labor with above specifications` For the sum of: Twenty thousand four hundred dollars. ($20,400.00) Payment schedule as follows: $6,800.00@ start, $6800.00 @ 50% completion, $6,800 @100% completion and acceptance All material is guaranteed to be as specified and the work will be completed in a workmanlike manner in accordance to specifications. Any and all alterations or deviations from the stated specifications involving extra costs and materials will be executed only upon written orders. These changes turn into an extra charge, over and above the estimate. All agreements are contingent upon strikes, accidents or delays beyond contractor's control. Owner of property to carry fire, tomado, and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. If either party commences legal action to enforce its rights pursuant to this agreement, the prevailing party in said legal action shall be entitled to recover its reasonable attorney's fees and costs of litigation relating to said legal action, as determined by a court of competent jurisdiction. Submitted by: Donald Greenleaf This proposal may be withdrawn if no acce ted within 14 days. Acce tance of Proposal 0 As stated in the above specifications. The costs, materi , aN specifications pha satisfactory and are hereby accepted. I authorized the contractor to erlo the work as specified and payments will be made as summarize above. Customer Signature: UC" r Date: G B- &4q 1r y��1_ Board of Building Regulations and Standard` , g�s _. .tea�.. HOME IMp_ROVEMENT CONTRA&:OR Registration�143204 s , v + 3YpeA REe iL"EA jE v a '� E I, 74Oia ""uO +_ ,�' ZO6L0 VWlNN1.l+ : y 7' 0 HONK Ine ss N33110 S N3A31S g591Z :ou'J1 'g00'�7�'ZIlO ft6l.�bt3y ..� {1 9L8Ff5Z+r,YO grgEa0" 5'Ja, u1nN E",i asnenl� ,s g, "a0S1Aa3df1S NOIlOf1a15NOO 94 •.:mA?-^:"a*'s'x,v+^gnn•�.'.9. yam„ AS48.D. CERTIFICATE OF LIABILITY INSURANCE osio/20o PROD@ (978)535-7700 FAX (978)S35-8800 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION N A Consoles / CFR Ins Agency LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE lOO Cor orate Place, Ste 110 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR D,r P ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Peabody, MA 01960 INSURERS AFFORDING COVERAGE NAIC# INSURED Donald Greenleaf and Steven Greenleaf INSURERA: Essex Insurance Company DBA: Greenleaf Exteriors INSURER 8: 66 Bulfinch Road INSURERC: Lynn, MA 01902 INSURER D: INSURER ECOVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO'/ffCTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR kWL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POUCY EXPIRATION LIMITS 1URRrDATE tMN1IDDjV"f1 GENERAL LIABILITY PAC6690330 OS/11/2007 05/11/2008 EACH OCCURRENCE $ 500,00 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY $ 50,000 CLAIMS MADE � OCCUR MED EXP(Any one parson) $ 5,00 A PERSONAL B ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00 t POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMN a ANYAUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ HIRED AUTOS BODILY INJURY NONOWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: qGG $ EXCESSAIMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F_ICLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ 1 is WORKERS COMPENSATION AND WC STATU- OTHFR - EMPLOYERS UABIUTY E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ If ya5 describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS he Workers Compensation Certificate will be mailed directly by Granite State Insurance ompany under policy WC8745584 from 5/14/07 to 5/14/08. CERTIFICATE HOLDEk CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL City of Salem 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Salem City Hall BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 93 Washington Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Salem, MA 01970 AUTHORIZED REPRESENTATIVE A Nicholas Consoles PEG K ACORD 25(2001/08) FAX: (978)740-9846 ©ACORD CORPORATION 1988 F . -All framing memebers to be A.C.Q (Pressure teated). -All deckong and treads are to - be 5-Y4' Jatoba composite decking. -All Trim boards to be Azek wh[to trim. -Al fas eners and hardware to be Galvanized, stainless, or corrosion protected new lower A deck section ® existing deck to be rebuilt 14'6'xll'6' owner, Murphy address, existing house 3a Cleaveland rd. ext. drawing, floor plan date, 08/ 021 07 -All framing memebers to be A.C.Q (Pressure teated). _ -All deckong and treads are to be 5-Y4* Jatoba composite decking, -All Trim boards to be Azek wh I to trim. eners and hardware to be Galvanized, stainless, or corrosion protected 2 new lower deck section (� 14 25 9' ® existing deck to be rebuilt 14'6'xll'6' owner- Murphy addressi existing house 3a Cleaveland rd. ext. drawingt floor plan date) OB/ 02/ 07 0 owner! Murphy address: 3a cleaveland rd, ext, drawing "A" elevation date: 08/ 02/ 07 O owner; Murphy address: 3a deaveland rd ext. drawing: °B° elevation date: 08/ 021 07 owner: Murphy address: 3a cleaveland rd, ext. drawing; 'c° elevation date 08/ 02/ 07 owner- Murphy address, 3a Cleaveland rd. ext. drawing framing plan date, 08/ 021 07 owner, Murphy address, 3a Cleaveland rd. ext. drawing, upper level framing lan date, 08/ 021 07 owner, Murphy ILLLI addressi 3a Cleaveland rd, ext. drowing, lower level framing tan dates 08/ 02/ 07 I /rbYM�a br4 /pRYa gbMrt M�Iwb4rrt I I II I ua VbsYpbrrt MpYy /YYtlbbr rt69 /.YiY P.a r,r 1.e I / IIyp�111pp I/ybWobYrtM / MNV�[b MM ;owners ® -- ....... Murphy address 3a cleaveland rd, ext. / drawing) foundation --� plan • dates 08/ 02/ 07 CITY-OFF�AT.Eb PUBLIC PROPERTY DEPARTMENT .`rAra WASUNGIM l/./y/r ��Iwltwaserrs 01970 7U--M74i9N9S 0 FAZ V5.74094M APPLICATION FOR THE REPAIR. RENOVAT[ N CONSTRUCTION, DEMOLMON,OR C p R ANY FM STING STRUCTURE OR RUMpprG 1.0 SITE INFORMATION .. . Location Name: Building: ---- Property Address:--- - -- -- _- -- Properly Is loafed in S.Cww vadon Ares Y/N Historic District YM 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: 3 r� Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN MIXING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: C) Vie^ -- - _— -- --- -- _ --- - ---Mail Permit to: r, K Cled. Lu VLk MA . ©( Q O Z What is the current use of the Building? Material of Building? If dwelling,how many units? We the Building Conform to Law? Asbestos? Architect's Name l ) Address and Phon. (�e u1 5- Meshanies Name Address and Photo (n(n Construction Supervisors License S n HIC Registration a_/1 � EstmaW Cost of Project: L' D0 Perrnit Fee Ca Mtion Permit Fee$ Iy= Estimated Con X$7/$1000 Residential Estimated Cost.X S1t(:1000 CamnwcialAn Additional ib.00 is added as an Administrative Charge. Make sure that all fields are properly and legibly written to avoid delays in Processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of Perjury � Date g of � 3 3 s � � �.