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CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9848
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:
_110 s�S Co fi; G (Location of Facility) Sg
Signature of Applicant
' 4-
66
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigadons
600 Washington Street
Boston,MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information "` " Please Print Leidbly
Name (Business/organization/Individual): /� tom.: N c o..ti
Address: `J73 1125
City/State/Zip: 5,3 c�n Yri A- b 10 y° ` Phone#
Are you an employer?Check the appropriate boa ' Type of project(required):
I V I am a employer with� 4: ❑'I am a general contractor and I 6. ❑ New'constluction
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 ❑ 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_area corporation and its • 10.❑ Electrical repairs or.additions
required:] i .L officers have exercised their'
n 11. - Plumbing repairs or additions
3.❑ I am a homeowner doing all work right of exemption MGL` ❑ g eP
myself. [No workers' comp. c. 152,§1(4 ,and we have no
) 12;[rR6frepairs
insurance required:]t; employees. [No workers'`r.."F 13.13 Othet .
comp. insurance required.]""
*Any applicant that checks box#1 must also fill out the section below showing their workcn'compensation policy information
t Homeowners who submit this affidavit indicating they are doing all work and than hie outside contractors must submit a new affidavit indicating such
tContractors that check this box must attached eu additional sheet showing the name of the sub-contnictors 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 Company Name: A T'G-- `
Policy#or Self-ins. Lic. #: W C I 0$ -$6^ 7 Expiration Date: 4 1 o 1 ) O t,
Job Site Address: j 3 R- Pch e..a \ St J City/Statc/Zip: S a\c+-,.r, i'v'l 0. m 197 0
Attach a copy of the workers' compensation policy.declaration page(showing the policy number and expiration date).
Failure to segue 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certifny un�th�nder the pains and penalties of perjury that the information provided above Is true and correct:
Simature• Rr r-•— ti Dater I t$ z Io 6
Phone#: 9-2 ra.'?`W — Z 1 ot y
Official use only. Do not write in this area,to be completed by city orr town oJrcial.
City or Town: Permlt/Ucense#
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 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 employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged'm 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="'=
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 She 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 certificate(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 of 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 retumed to the city or town that the application for the permit o`' 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 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 permit/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 ihe-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 filled 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 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 www.mass.gov/dia
�0
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT. 311 FAX (978) 740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
L� Construction ❑ Moving
Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: 138 Federal Str t - C'otting-Smi h Assembly House
Name of Record Owner: Peabody Fssex Museum
Description of Work Proposed:
Repair/replace slate and copper roofing and repointing of chimneys and repair/repainting of roof balustrade
and accesshatch to replicate existing. No changes in color, material, design, location or outivard appearance.
Non-applicable due to being in kind maintenance/repair/replacement.
Dated: October 11. 2005 SALEM HIST C OMMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
01/12/2006 10; 09 976-741-7605 THE BURKE INS AGENCY PAGE 02
ACORD CERTIFICATE OF LIABILITY INSURAE A>H�°SUT DATEI Ni o
PRODUCER THIS CERT1FICpTEED AS A MATTER OF INFORMATION
ONLY AND CONFEIGHTS UPON THE CERTIFICATE
THE BUM INSURANCE AGENCY HOLDER.THIS CEE DOES NOT AMEND.EXTEND OR16 Srown Street ALTER THE COVEFORDED BY THE POLICIES BELOW.
Salem MA 01970
Phone: 978-741-7810 8ax: 979-741-7805 IINSURERS AFFORDING COVERAGE NAIC0
INSURED INSURERA' N, T. BAEDRY IRsDA = AGbnDY __
INSURER 811 AlbA L. TzcLecrinn EnsVwnoP
Amarican Steeple 8 TOWet CO. INGUREROi AMXAu�mGoen�[1oaaL GebuP
37� Essex Street INSURERD.
Salem MA 01970 —`
INSURER E .
COVERAGES
THE POLICIES OF INSURANCE LIS720 BELQ*HAVE 6EEN 53UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING
ANY RE^OUIREMF.NT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITK RESPECT TO WHICH THIS DERTIFICATE MAY BE ISSUED OR
MXf PERTAIN,THE INSURANCE AFFORDED SY TN=_POLICIES DESCRIRED MIENS IN IS SUBJECT TD ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AG^aREDATE LMTS SHOWN MAY HAVE SEEN REDUCED BY PAIO CLAIMS, ,
LT�R TYPE OF NSVRANCB —� POLICY NUMBER DA E MM DAK YMMO LW4TS
GENERAL LIABILITY EACH OCCURRENCE S 1 T OOO DH QQ
A I X �DONraRCIgLGENERnLL:AEIUTY NPP664569 D5/20J05 OS/20/06 pRE1.R9 (EoP«ufAE �)�Is300,000
J GI,AIMS MADE h I OCCUR i LIED EXP(MY gnu P B
PER80NAL SAOIJIWURY 141,DDD,DQQ
J.. GENERAL A"EGATE �31,000 000
40EN"4AGGREGATELNITAPPLIES PER
: P0.0DUCTS•COMMOPAOG 41,000,000
PQIICY 7 JECT 7 LUC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 4
IANY AUTO (Ee BbcIdMN
I
ALL OWNED AUT09 POORLY INJURY 5250000
8 X I SCHMULEDAUios 31051400002 12/16/05 12/16/06 (PwForm]
8 X_'HIRED AUTOS BI OOILYINJURY B 500000
$ X�NON.OW'NED AVTOS (PRr PccHSnli
I�I... PR�TY DAMAGE 8250000
(Per xWfthk1
GARAGE LUHBILITY AUTO ONLY•EA ACCIDENT S
ANYAUTO OTHERTMAN EAAOC S
AUTO ONLY, _
AGG I S
EXOESB'UMBRELLA LIABILITY I EACH OCCURRENCE S
rOCCUR CLAMS MADE AGGRECATB IS
I i I S
I DEDUCTIBLE --I—
• RETENTION
WORKERS CONPEWATION AMID LIMITS ER
EMPLOYERS'UABILITY
C gNyyPROPRIETORMARTNERM9ECUTIVE 14C1D6-B6-77 04/07J05 04J07/06 C.LEACMACCIDENTSSOD,Q _
OFFICERRUEMBER EXCLUDED? EL,DISEASE-EA EMPLOYEE 9 5 0 0,000
Ifr§660sCf�bn undbr
SPECIAL PROVISIONS below I E L.DISEASE-POLICY LIMIT s50 Q,000
OTHER
I
DEOCRIP'f10N OF OPERATION DCATIDN9l VEH10.E3l EXCLUSIOS ADDED BY ENMAsrMyNT16f4CIAL.PR0V1MNS
CERTIFICATE HOLDER CANCELLATION
MAMSS SHOULD ANY OF THE.ABOVE DESCRNnD POLICIES BE CANCELLED BEFORE TKE EXPIRATION
DATETNEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYSWRITTEN
PEABODY ESSEX MUSE"JM NOTICE TO THE CERTIPMATH HOLDER NAMED TO THE LEFT,BUT FAILURE TO DD 80 SHALL
Att: Bob Monk IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGIN TS OR
Eaaex 8keeet
Salem MA 01970 FERMENTATIVE&
AUTHORIZED BdTATNE
m mxE INS=cx + �_
AGORD 26(2001(06) 0A RD ORPORATION 1108