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22 FLINT ST - BUILDING INSPECTION w SS/ 6 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT m%uwntF.Y URMULL M.%Ytla 12C VA4iu%GTmSTaear•SA IZM.1tt4tAt7 n.:tF7'1J 0197Z TILL 978•74S•9593 •FAX:97L740.9846 Workers' Compensation Insurance Affidavit Bu11derWContractors/Elertrtcfans/Plumbers AD In Ica_gt Information Please Print Lesibly NaMC tOuunss/OgpnintioWlndlvidmi): 44,e ,0411/ 7`gw&&� Addrcss- City/Stmlzip: lone Are you as employer?Cheek the appropriate box FONew project(regatred): 1.❑ 1 am a employer with 4. Q 1 am a general contractor and Itruction employees(full and/or p rt-tine).' have hired the sub-comnctm 2s 1am a sole proprietor or partner. listed oo the attached seet t ingship and have no amploylem Them stnb•eontrseters haw onwaiting to me in any capacity. workers'comp. insuranea, addition (no workers'camp. insurance S. ❑ We are a corporation and its !0. Electrical required] officers have exercised their ❑ repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.Q Plumbing repairs or additions myself.(No workers*comp. e. 152,y 1(4),and we have no 12.❑Roof repairs insurance required.( r cmployeas. [No workers' 13.Q Other comp. imsuraax requirodJ i Any wph"al tlrt chucks boa at mast also fill rut the sect,"bulaw slowing lkeir wwkauo cumPn Wiwi putmy iaauntaiva llwnw,wnwa who submit Min aledevit indicating d"am Jomg to work arse tam him wit"Communism mate•uAnk a maw aaideril imtdi°aing irk. 'C. r%vM th f that Chuck e bm most teat shed as additlanal slam dmwtng Me name,Grain, ed th teeir wumkese'comp.paltry mtaama lee. /oar an mnployer that fs providing workers'compensaden Luarance for my imp/oydet 8410w is the policy and job site injursrutwa Insurance Company Name: �� ✓!.l_L✓ Policy 4 or Sclrins. Lie. A: IYr��•T r Expiration Date: S J' - Job Site Address:_ —i,? CitylsiatuZip: Attach a copy of the workers'compensation policy declaration polls(showing the policy number and ex ration date). Failure w wcum coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal pensities ors fine up to S1.500.00 and/or one-year itnprisontncnt.is weld as civil penalties in the form of a STOP WORK ORDER and a fine ,'full to 5250.00 a day against the violator. lie advulcd that a copy urthis statement tray be forwarded to the Office Of Im rangawnts OI'thc DIA ror lnlurance covcra3e vcrlticatlon. !do inrn by rcnijy am a ran nd prnallks ujperfary that//a injormW/on provided mr w 1 true and correct. O/JkAd am're oni3e Donor write in thls area,to be romp/ded by city or town o/ ej(d City or 'fawn: PcrmiVlJccase 11 Issuing Aulhurily (circle one): _— 1. IA,ard of Health 2. Building Dcpartincat J. Cityifoon Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other if C,nllucl Person: _ Phone p: Information and Instructions \lassachusetts General Laws chapter 152 requites all employers provide eetvice workers'anti compensation n for their contract hire. IOYem Pursuant to this statute.an ew/royee is defined as"...every person empress or implied,oral or written." .kn eadeyer is defined d"an individuaL partnership,assecnathaa corporation or other legal entity,o any two or mom Of the foregoing engaged in a joint enterprise.and including the legal representatives of a deceased employer.or the association or other legal entity.employing employees. However the receiver or trustee of an individual,pattecibip. ments and who resides therein.or the occupant of the owner of a dwelling house having not more than three apart dwelling house of another who employs persons to do mainremance,construction or repair work on such dwelling house or on the grounds a building appurtenant thetew shad not because of such employment be deemed to be an employer. AtGL chapter 1 S2.¢2SC(6)also states that"every Nab or local Wen=hg apt ey_shag withbold the b(suanee or Operate a business or to construct ImUdinp lo the commonwealth far any renewal of•licence or permit b opt with the���coverage required.' applkaut wbe has am predeced acceptable evidence of co=PU&N" Additionally.MGL chapter 152,;23C(7)states"Neither the commonwealth tier any of its political subilivisiooa shall enter into amy contras for the performamce of public wort until acceptable evidence of compliance with the insurance requirements of this chapter have bees 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•eont acrot(s)name(s),addre*cs)and phone number(s)along with their cortificatc(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$1 0a is heind rs the aMdaviL The nested, not the Departmentdavitshould be returned to din city or town that the application for the permit g requested, Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain u 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 Offic" Pieaae 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 applica please be sure to till in the purmit/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 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 t i.e permit.a dog license or pert to burn leaves etc.)said person is NOT required to complete this affidavit. I'hc of Investhations would "c to thank you in advance for your cooperation and should you have any questions, please du not hesitate to give us a call. The Departments address,telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents OWN of lavesoptleaa 600 Washington.Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-977-MASSAFE Fax 0 617-727-7749 2cvi.cd 5-26-05 www.mm.gov/ilia CrrY OF SALEM PUBLIC PROPRERTY DEPARTNONT LL�u s i'1'IaeN::Jr:f.�ttT 0Ulc%>AIAW:w*c1b'dwie. Ttit:YOW�19lb /.�1C I W4&04 Construction Debris Disposat Affidavit (required rot all demolition and rmtovation watt) In=wdswA with the sixth edition otdw Stsae Building Cods.790 Cl►IR section It L S pelvis.and the provisions of M. CL c 40.S 54 8uildin{Psmtit d _ _ is issued with the candttion that the debris rerAwng item t With as defined %lGL e this work shall be disposed of in a properly licensed wssa d sposal ty by t 11.s 15OA. The debris will he transported by: (name or heated rho:k-bris wilt be disposed orn : (arise�r rac,t,ty) 111311 lz4 CONTRACT No. 450 generaCContractors and DeveCopers 55 1/2 Rear Walnut Street Peabody, MA 01960 Tel: 978-977-7425 Fax: 978-977-2427 Re: 1. Liability Insurance Issuance 2. Personal injury release 3. Performance contract agreement 4. Change orders 5. Lien release Job site and owner's name 72 FLINT STREET --SALEM,MA. Subcontractor DEBRIS REMOVAL CO. CEL DEMO License No. 017047 Address AS STATED 1. Liability Insurance Co. and coverage wAVERLY INS Co. $1-3 , 000 , 000 . 00 Owner,renter, architect It is agreed between all parties signing this document that they and/or any people brought on the job site by them will carry their own insurance for liability and personal injury and that they are on the job site at their own risk and cannot hold the General Contractor or his subcontractors responsible for injury caused to them,or site damage caused by them. 2. It is hereby agreed between Garfall & Moore, General Contractors, and the above named subcontractor, that any workmen brought on the job to perform any duties or deliveries will be covered by workmens compensation insurance or any other type of disability insurance, and to release Garfall & Moore and the owner of the property where the work is to be performed from any legal or financial obligations if one of the workers is injured. 3. Performance contract agreement Jobdescription 1--REMOVAL OF FIRE DAMAGED ROOF AND .SIDE OF HOLDING TANK STRUCTURE 2 .-LEAVE AND RE-ENFORCE SIDEWALLS TO 42" HIGH WITH A LOCKED DOOR FOR EGRESS 3 .-REMOVE ALL DEBRIS BY COVERED 10YD. DUMP TRUCK It is hereby agreed between Garfall & Moore, General Contractors and ZI9N RFTT TV MPP that the above-described job will be started on 3 DAYS AFTER ISSUANCE QF pFuraTapd completed by T nr)Av FnT.LowTNc� or a penalty of 10% per day for every day over the agreed-upon completion date will be deducted from the final balance due. If any other subcontractor does not fulfill his/her performance contract and delays your completion date, the 10% per day will be paid by them from their final payment and added onto your final payment. Any stock or equipment supplied by the owner that is not on the job site on the date you specify will cause a delay penalty of your per-day labor downtime and will be paid direct to you from the principal, and a new completion date will be negotiated. All work done by you and your employees must pass all city, state, and federal codes, architectural inspections, general contractor's inspection, and client's approval before rough and final inspection payments are made. Any mistakes or poor workmanship caused by you and/or your employees will be corrected so as to pass all inspections. Any additional work or unforseen constructural problem and their corrections must be cleared first by the general contractor, architect, and the owner on a separate contract atRcost-plus basis. Any corrections of mistakes or miscalculations inherent in architectural-stamped plans will be the financial responsibility of the owner and the architect, and a separate cost-plus contract will be negotiated. In case of any exterior weather conditions (inclement weather that causes downtime), the downtime will be added to the completion date. 4. Change orders All change orders will be priced outside of the orginal contract price, with payment in full upon completion of each change order. The amount of time to compelte each change order will be added to the original completion time of the main contract. 5. Lien release It is hereby agreed that any disputes between the subcontractor N/A and Garfall & Moore, General Contractors, will be resolved by the above-mentioned parties, and will not involveZION REALTY CORP. , and that no legal action can be brought against them by the subcontractor, except in the case of unjustifiable non-payment to Garfall &Moore, General Contractors. Total Price of Contract $ 14 , 000 . 00 Deposit $ 7 , 000 . 00 lst inspection $ 2nd inspection $ Final inspection $ 7 , 000 . 00 Signed: ete�all,GenckALCjgWa16Ror Subcontractor y - Owner or Repres alive Architect & 3/-dam Date This is a legal document. ANC ORD CERTIFICATE OF LIABILITY INSURANCE CSR FM DATE(MM/DDIYYYY) GARFA-1 10 29 07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Waverley' Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 493 Trapelo Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Belmont MA 02478- Phone: 617-484-5216 Fax:617-489-4626 INSURERS AFFORDING COVERAGE NAIL# INSURED ?s INSURER A'. Hanover Insurance Company 22292 { t INSURER. Essex Insurance Company Garfall:l& Moore INSURERC' Peter Garfall 55 1/2 Rear Walnut Street INSURER D: Peabody MA 01960 INSURER E' COVERAGES 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 ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN5RPOLICY NUMBER POLICY EFFECTIVEC EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE DATE MMIDDNV DATE MM/ODM' GENERAL LIABILITY EACH OCCURRENCE $ 1, 000,000 B X COMMERCIAL GENERAL LIABILITY 3CU5545 05/23/07 05/23/06 'PREMISES(Ea occurence) $ 50r000 CLAIMS MADE 1XI OCCUR MED EXP(Any one person) $ 1, 000 PERSONAL B ADV INJURY $ 1,000,000 GENERALAGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO $ 1,000,000 POLICY PRO 1-1 LOC ECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ A ANY AUTO AMN6061016-06 12/17/06 12/17/07 (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULEDAUTOS (Per parson) $ 250, 000 X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ 500,000 PROPERTY DAMAGE $ 250i 000 (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO THAN EA ACC $ AUTO ON AUTO ONLY'. qGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—ICLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND I TORVLIMITS ER EMPLOYERS'LIABILITY CH ACCIDENT ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EA $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If Yes describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Job: Demo of holding tank CERTIFICATE HOLDER CANCELLATION ZIONREA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Zion Realty Corp IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 72 Flint Street REPRESENTATIVES. Salem MA AUTHORIZED REP ESENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR ._ c Number:.CS 017047 Birthdate..10/07/1942 F=t Expires:.10/07/2007 Tr. nor 7057.0 ' Restricted: 00 PETER J GARFALL t 55 1/2 R WALNUT S PEABODY, MA 01960 - �° Commissioner �\ ��E 't�0-YIY/)LdItF�/('.CLUiL RL✓f��00(1C�LF,/eG(OYV•• Hoard of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR RegistrationC 118894 Expiration:. 5/3/2009 Tr# 128762 Type: Partnership GARFALL& MOORE GEN CONTR PETER GARFALL 55 112 REAR WALNUT ST. PEABODY, MA 01960 �-- Administrator i T , NUMBER DRIVER'S LICENSE �J t 080342929 s , DATE OF BIRTH CUBS REST HEIGHT SEX 10-07-1942 D e 0.01 MEXPIRES 10-07-2007 f GARFALL f PETER J .a: I 18 HOLDEN RD APT 1 'oiaoB _ BE MA^`?Ey? 02978-22278-2222 F!PIICPR TMENT wws 13o rr . sftAftWMmne �:sret+�+fN.eyefW746 " APp11.ICATION FOR TB= REPAIR. RENOVATION. CONMUC agM DE.KOLTI'ION.QR CAANCE Of CSZ OR OCCCIPA_Nrv_ Fno ._tW Y2g!37'M IITRQCTURZ OR BUIidMG 1.0 SRE INFORMATION LQCE*M NameC - - �y �u� Ste _ PrgwV Is bealsd In a.ConwvMbn Am@ Hkftft DIsm Y 2.0 OWNERSHIP INFORMATION 2.t Owner of Land Name: Addresc Telephorw � -/ LOCOMPLETE THIS SECTION FOR WORK IN EY13LNG BIALONGS ONLY Addition ExlsdnS Renovation Number of Storl" Renovated FA: Use Now �,tiV e year of Aroa per flow (at) Renovated n of renovation uilding New iption of Proposed Work: 7 4- 7-0 � `7� S/Gli 7-U /his-�,� ov✓/dv<-v,�< • - --- - -----Mail Permit to: - - - d tlfe parent use at Me ou"M? Materhl d 8ut�dkgl' E dWelwq. + basiNMkV u? VW the @ugt0 Conforf Is lam Assbestos?ArdAsd's Noma l Addr«s and PhOW M*&An 'a Name Addrasa and Phone _ HiC Rapisadon d om CsbuoWn Supervisors�mN ay Estimdsd Coat atProjsd� Perm Ree Cala+Wton Permit Fee c Estimated Cant X$741000 Residential - -- - - Estimated Coat X f11/1111008 CmwwddV -An AddNwd=6AQ In added M an AdmYrbbatl s cl n Make sure Mat an Melds are PtOPOdY NO 189"writtsn 10 avold delays In W=sssirq. The wndosWad does hereby apply fOr a Building Pwn*to hM to Me above sestsd spsd sfty . Sipmed under pa+allY of pw*m Date �I s 0 a � F