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63 FLINT ST - BUILDING INSPECTION I lftMBMWV*EfKA&*ND &PPROVED BY ME ampxX B POOR 7DA PEW AWO GRANTED CITY OF_SALEM ow I2 0(0•85 Yr 1 Wiliiel9„ Of YN Nois plowtv ucaud in X 1�lLios �0?J �� 11 7l • cwmn wlpn mn? Yok.No X BWLDW PERWT APPI WATION FOR: Parma to: (ChW whichever VW) Roof, Reroof, n" Osoll. Shed, , k?.S PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID YS IN PROCESSM TO THE INSPECTOR OF SUNA W&- The mWsWad hereby aXWu for a pprmd to buNd a000rdtnp to the fo WWQ Owners Name b--4 4 kArcli vi 3 Plea sm c+ - satm m 14- Address SPhone j21-e. 1Ae�Plea .t, Clem, Mr4 ca?81744 5501 MW%oWs Now MIX,+ W WU/ }4r-Gct`f Ub Address & Phone _ PA fX 3R4• IZockgpt MA:. 07$1 546 74&3 Msdenics Name C n1n'�u�t I GcreraV �asti ec DV' I Address & Phone �' OW420,Fart AhJper Pn D 1816 UL°I t q 'Nzq� "mavopApmaWhop Petal mama'IwImw I�G�21 l S1?4 U s an&*,lor how amr%man?N(�_ WE b Aft come to law?_ h Aft"? t a Csfr uarw s N A us me+r IA cs UOz!�7 of t n UNDER THE PENALTY PlygY DESt:RI TWN OF WORK TO BE DOME MAIL PERMIT AN& , No. APPLICATION FOR PE l TO 4or ReA.-I (,14, LOCATION to -3 PERMIT GRANTED 2. =4t L INSP6 q F BUIL. W—G ' � i J CITY OF SALEM, MASSACHUSETTS • 4s PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVIC2, JR. TELEPHONE: 978-748-9593 EXT. 380 MAYOR FAX: 978-740-9846 Salem Buildina 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: �F S'�L� �^� �u5 (Location of Facility) Fme bd e4 Sk add, M'h� Signature of Applicant Date The Commonivealth of Massachusetts Dcpartment of Industrial Accidents �ell 600 Washington Street, Floor Boston,Mass 02111 VV��Workers'Compensadon Insurance Affidavit•.Bniltbng/Plumbmg/Electncal Contractors A- licant mIoimatioe. —�- .: —• — , - -Please PRIN'f7 ,- _ , name: KhPi9/9Y address: city Apo del✓t.4t state ,�� /� gin' d/0'/O phone# f7,F ',K work site location(full address): \ ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ lam an employer providing workers'compensation for my employees working on this job. company name: address: city: phone#: insurance co. poHff I am a sole proprie[ general contractor r homeowner(circle one) and have hired the contractors listed below who have the following workers'co ensa on pot . company name. ^? 7. c M• Do L addresr. ,/!�/"f�f��,,...p�tl N,,// / A,-A eK city: �f/UQOtJC �. /iN 0���6 phone#: ipsurance tro. 6 Q�'N �' _°' policv# w c zoo y company name: address: city: phone#: insurance co. Mucv# - Anuh.addttloualshattlt _:.,�.. t-i:�,a30ic Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or oae years'imprisaimeat as well as dve peaakks is the form of a STOP WORK ORDER mad a nee of$100.00 a day against me. I understand that a copy of thn statement may be f ed to the Office of Investigations of the DIA for coverage verification. I do hereby certify under d penalties of erlury that the Ltformadon 'dud above is true and correct Signature Date Primnsmc 41�44hglfgAflyl bout# 'f78''Y7Y' f-2Y6 it ot6cial a c only do not write in this area to be completed by city or town official e ie ae city or towa: permitNceau# ❑Building Department re so ❑Llceming Board Ce ❑cbeck if immediate response is required i ❑Selectmen's Office 6 » ❑Health Department ea ar contact person: pboae#; ❑Ofbcr U�swr mml fie CITY OF SALEM, MASSACHUSETTS BOARD OF APPEAL 1--id-E.", MA ITO WASNINGTON STREET, 3RD FLOOR CLERK'S OFFICE SALEM, MASSACHUSETTS 01970 TELEPHONE: 97 a-745-9595 FAx: 979-740-9e4e 700b FEB 22 A IO: 24 DECISION ON THE PlriTION OF G PETER RENAULT REQUESTING A VARIANCE FOR THE PROPERTY LOCATED AT 7 GRANITE STREET R-2 A heating on this petition was held on February 8, 2006 with the following Board Members present;Nina Cohen,Richard Dionne,Nicholas Helides, Bonnie Belair and Edward Moriarty. Notice of the hearing was sent to abutters and others and notices of the hearing were properly published in the Salem Evening News in accordance with Massachusetts General Laws Chapter 40A. The petitioner is requesting a Variance fiom side yard setback to construct a 22 x 24 single story addition for the property located at 7 Granite Street located in an R-2 zone. The Variances,which have been requested,may be granted upon a finding by this Board that: a. Special conditions and circumstances exist which especially affect the land, building or structure involved and which are not generally affecting other lands, buildings and structures involve. b. Literal enforcement of the provisions of the Zoning Ordinance would involve substantial hardship,financial or otherwise,to the petitioners. c. Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent of the district of the purpose of the Ordinance. The Board of Appeal,after careful consideration of the evidence presented at the hearing, and after viewing the plane,makes the following findings of fact: 1. The petitioner Peter Renault appeared and represented himself at the hearing. 2. Petitioner requests a variance fiom a side yard setback to construct a single story addition for his family who needs the additional room. 3. Plans were submitted to the Board showing the proposed addition 4. The addition will be a single story 24 x 22. 5. There was no opposition to this petition y un;t,tatuty 0f i HE PETiTiON Or G.PE i rfc RriAULT REQUESTING A VARIANCE FOR THE PROPERTY LOCATED AT 7 GRANITE STREET R-2 page two On the basis of the above findings of fact,and on,the evidence presented the Board of Appeals finds as follows; 1. Special conditions exist when especially affect the subject property but not he District. 2. Literal enforcement of the provisions of the Zoning ordinance would involve substantial hardship to the petitioner. 3. Desirable relief can be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent of the district or the purpose of the Ordinance. Therefore,the Zoning Board of Appeal voted 5 in favor and 0 in opposition to grant the Variances requested,subject to the following conditions: T. Petitioner shall comply with all city and state stature,ordinance,codes and regulations. 2. Petitioner shall obtain approval from any City Board or Commission having jurisdiction,including but not limited to the Planning Board- 3. All requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 4, petitioner shall obtain a building permit prior to beginning any construction. 5. A Certificate of Occupancy shall be obtained. 6. All construction shall be done according to plans submitted to and approved by the Building Commissioner,with plans to be amended to reduce the size of the second floor by eliminating the outside deck adjacent to the parking area and setting the second floor back an additional four(4)feet from the property HBO shared with the McGrath family.The amended plans and new construction cannot exceed the footprint or height of the demolished structure 7. Exterior finishes of the new construction shall be in harmony with the existing structure. 8. The residence shall remain a single family dwelling. 9. Petitioner shall obtain approval from any City Board or Commission having jurisdiction,but not limited to the Planning Board. DECISION OF THE PETITION OF G.PETER RENAULT REQUESTING A VARIANCE FOR THE PROPERTY LOCATED AT 7 GRANITE STREET R-2 page three VARIANCE GRANTED February 8,2006 'chard Dionne �C/k-� Board of Appeal A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK Appeal from this decision,if any, shall be made pursuant to Section 17 of the Massachusetts General Laws Chapter 40A,and shall be filed within 20 days date of filing of this decision in the office of the City Clerk Pursuant to Massachusetts General Laws Chapter 40A,Section 11.the Variance or Special Permit granted herein shall riot take effect until a copy of the decision bearing the certificate of the City Clerk that 20 days have elapsed and no appeal has been Sled,or that,if such appeal has been Sled,that is has been dismissed or denied is recorded in the South Essex Registry of Deeds and indexed under the name of the owner of record or is recorded and noted on the owner's Certificate of Title. Board of Appeal P J.L. WARD CONSTRUCTIONi ` DESIGN&REMODELING SOLUTIONS 3�1"d&"ftft a ?4 no 0191'S T: 978.921.2752 F: 978.921.4580 HIC: 139222 MA LIC: 063821 ****PROPOSAL"*` 1 YEAR WARRANTY ON ALL WORKMANSHIP PROPOSAL SUBMITTED TO: Proposal # 020906-2 Peter and Diane Renault Date: March 6, 2006 7 Granite Street Salem MA 01970 Page: 1 of 4 Dear Peter and Diane, We respectfully submit our revised proposal # 020906-2 for the family room, master bedroom master bathroom addition project at 7 Granite Street Salem, MA, as per plans submitted by J.L. Ward Construction Inc. Permits and Plans: The permits for this project are included We have allowed $ 700.00 for this fee. This does not include variances or special permit fees. If required, any additional fees are the responsibility of the Owner. Excavation & Foundation: We will excavate for the new addition as follows: We will excavate five feet below grade to allow for the foundation / crawl space which will support the new structure as per the plans. We will form and pour a 12" x 20" footing and form and pour a 10" concrete wall according to the plans. We will backfill as required around the foundation. We will supply approximately four (4) inches of crushed gravel and four (4) inches of `pours S4M�l�w� concrete for the basement floor which will be trowelled smooth. 7e'-'- /" EXCAVATION ALLOWANCE: $3,600.00. FOUNDATION ALLOWANCE: $4,455.00. Demolition: We will remove and properly dispose of the following items: We will remove the necessary portions of the existingrear wall at the kitchen and den to allow for the proposed familyroom renovations. We will remove the existing siding on the entire exterior of the existing dwelling to allow for the new vinyl siding. WASTE REMOVAL ALLOWANCE: $900.00. N Page 2 Framing: We will frame the new addition as follows: We will supply and install foam sill seal to the foundation capped with a 2 x 6 pressure treat sill. We will then supply and install a triple 1 3/4" x 11 7/8" x 24' LVL center girt with 2 x 10 KD floor joist 16" on center sheathed with 3/4" tongue and groove plywood sub flooring, nailed and secured to the joist with construction adhesive. The exterior walls will be framed using 2" X 4" KD. studs 16" oc. and sheathed with 1/2" CDX exterior grade plywood. The roof will consist of a roof truss roof rafter system, sheathed with 5/8" CDX exterior grade plywood. The interior walls will be laid out according to the plans and framed with 2" X 4" KD. Studs. We will frame a new porch at the side of the dwelling as per plans. We will use pressure treated lumber for the framing of the side porch and steps. Roofing: We will install Ice and Water shield to the entire surface of the new roof. We will install 8" aluminum drip edge to the entire perimeter of the new roof area. We will shingle the roof using three —tab roof shingles (25 yr). color to match existing, secured to the roof using galvanized roof nails. We will properly flash where the new meets the existing to insure a weather tight seal. We will also install COBRA VENT ridge vent. Windows and Exterior Doors: We will install the windows and exterior doors as per the plans to match as close to existing as possible. We have allowed for vinyl Windows and a vinyl sliding door. The windows are White vinyl exterior and interior with no grilles. Hardware is white and full screens are included. WINDOW ALLOWANCE: $ 1,860.00 EXTERIOR DOOR AND HARDWARE ALLOWANCE: $ 771.00 Siding, Gutters and Exterior Trim: We will install TYVEK house wrap and apply 3/8" fan-fold insulated backer board to the addition and the exterior of the entire existina dwelling. We will supply and install Wolverine American Legend vinyl siding to the exterior. We will supply and install aluminum coil stock to the exterior trim to include rakes and fascia. White aluminum gutters and downspouts will be installed at the soffits of the addition. The side porch and steps will be trimed out with pre-primed pine, the handrails and balusters will be cedar and the decking material will be correct deck. SIDING COSTS LABOR $ MATERIALS: $11,110.00. Plumbing &Heating: We will supply all pipe fitting and labor for the master bath and laundry on the first floor. We will tie into existing sewer/septic lines. We will run a new vent for the laundry and bath area. We will supply a separate zone with approximately fifty feet of base board heat to to the new addition as required and tie into the existing Forced Hot Water furnace. We will re-route the existing sump pump drainage system away from the newly renovated area. We will install the bathroom fixtures as per plans. HEATING ALLOWANCE: $1,850.00, PLUMBING ALLOWANCE: $3,000.00, NEO- ANGLE SHOWER WITH DOOR & DRAIN $ 950.00. Page 3 Electrical: We will supply and install fourteen (14) wall receptacles to code, one (1) GFI receptacle in the bathroom, one (1) washer receptacle, one (1) 220 amp dryer receptacle, one (1) exhaust fan/ light combo in the bathroom, one (1) vanity light supplied by owners, two (2) closet lights, We will install the wiring and flush mount boxes for the owner supplied track lighting which we will install, Two (2) exterior lights one (1) at the side slider and one (1) flood light at the rear, We will supply and install the necessary switches for the lighting as described above. If required by the City of Salem we will supply and install seven (7) hard wired 3% photo-electric with battery back up smoke detectors. ELECTRICAL ALLOWANCE: $$4,000.00. �� vw wws Insulation: y We will install R-13 fiberglass insulation in the walls of the new addition. We will supply R-30 fiberglass insulation in the floor. We will supply R-30 fiberglass insulation with to the ceiling areas. Walls and Ceilings: We will install V blueboard and skim coat plaster to the walls and ceilings of the new addition. The plaster finish will be smooth and we will blend with existing to match as closely as possible where patching or tying into existing is required. Interior Doors and Trim: We will supply and install the Interior trim, base molding, door and window casing to the newly renovated areas we will match the existing trim to the best of our ability. We will supply and install the interior doors as per the plans. Floors: We will install new flooring to the family room and master bedroom. We have estimated for a pre-finished engineered flooring for the family room and master bedroom and file for the master bath and laundry. FLOORING ALLOWANCE: $3,192.00. TILE BY OWNERS. Painting & Finishing: By others. Clean up: We will provide daily clean up and we will remove and properly dispose of all construction related waste leaving the home broom clean at the completion of the project. Pre-Completion Checklist: Homeowner and Contractor will review all work performed to insure that the project has been completed as specified. Any remaining details will be part of this checklist. On completion of these checklist items, the contract will be complete and final payment will be due. Any issue that arises that is not listed in the pre-completion checklist will be treated as warranty work and will not impact the final payment. Page 4 TOTAL COSTS FOR ALL ITEMS LISTED OVE $80 ✓ cfv"Ctt(g' awYL'rs ( ( PAYMENT SCHEDULE: 30�0�O WITH ACCEPTANCE OF CONSTRUCTION AGREEMENT $12,559.00 PRIOR TO COMMENCEMENT OF EXCAVATION $17950.00 PRIOR TO COMMENCEMENT OF FRAMING $17:576 PRIOR TO COMMENCEMENT OF INSULATION $17,118.00 PRIOR TO COMMENCEMENT OF INTERIOR TRIM $17,118.00 WITH ACCEPTANCE OF PRE-COMPLETION CHECKLIST $ 2,281.00 AT COMPLETION OF CHECKLIST $ 2,280.00 ACCEPTANCE OF PROPOSAL: The enclosed prices, specifications and conditions are satisfactory and hereby accepted. J.L. Ward Inc. and Company are authorized to do the work as specified. Payment will be made as outlined above. This proposal is valid for 15 days from the date specified. Signed and Sealed: AZ ✓ Date: i nt/Agent Signed and Sealed. Date: 6 0 6 Signed and Sealed:ta� �sra�- Date: 3 1 0"o -*All material is guaranteed to be as specified. All work to be completed in accordance to Mass State Building Code. Any alteration or deviation from submitted specifications,involving extra cost will be executed only upon written orders;and will become an extra charge over and above this estimate.All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary Insurance. Our workers are fully covered by Workman's Compensation Insurance. BOARD OF BUILDING REGULATIONS �i( - - License; CONSTRUCTION SUPERVISOR i -- -gPynevnoruriaa<".� .,°� � Number, CS 063821 .. _ Board of 11o0dineRegs"IDus �o�R BiNitdaLe: 09/1G/1959 VmEw CONTRACTOR ©spires:09/1612M6 Tr.no: 2712.0 - - HOME IMPRO - --- �. R�kdrntion: 13gm — - R�icterl:.08- Expiration: 612 2007 JEFFREY L WARD ,4 Type- Pilau ,non 50 GLIDDEN STREET.: �„� i/ BEVERLY, MA 01915 Commissioner JJ_WARD CONSTRUCTION,INC- JEFFREY WARD - 50 GILODEN ST• Ad000iArator - --- BEVERLY,MA 01915 oo-ss,000 demiosea saac8 (MGL C.112 S.6oL) Lkense orm valid individd use only 1A-MawnY0* expiration date ff found return to: tG-t&2 FamBy_Fiomes before theand Standards Failure to possess a cement ed6on of the Board of BuMrM Re b 130 Massacnusees State OaudMg Catle One Ashbartun Place a nose for revocation of this fim`se. Boston,Ma.02108 r JfQ �• ,/ � _6 (8881 CENTER' 3gM7233 7 l 1 DIG SAFE CALL `� otvali withontsignature _ _ - AGORD CERTIFICATE OF LIABILITY INSURANCE 10/2/0" saonuaYl rm CHRnfwATE IS DHI®ASA MATUR43FIMMATIDN Phil R.Lchaxd i Aasociatea ONLYANDC REMNONGKIS UPONTHECRUFICATE 491 maple Street NGU)ER1FQSf:6UF=TE0=PWAYBQE MOR ALTER THECMEMGEAFM=9R7HEP0L C10 BLOW. Suite 102 Daulvoxa, M& 01923 9ffiLWMAFFQfW=C0VEMGE NAIL• I®uR® NSINaIA AI6 J.L. Ward Conutracticn Inc. NSURt110 50 Glidden st Ba Iy, m 01915 P'�mwo MWR91E ---- COVERAGES THE POJGES OF INSURANCE USI®BB.OW HAVE BEEN ISSUED TO THE oR91RED NAMED ABOVE FOR THE POUCY PERIOD INDICIOM.NOTWITHSTANDING ART REOHOREMENN.TERN OR CONDRION OF ANY CONTRACTOR OTHER DOCUMENT WTIH RESPECT TO WHICH THIS CM11RCATE WAY BE ISSUED OR WAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERON IS SUBJECT TD ALL THE TERNS.ENCUJSIONS AND CONOITRONS OF SUCH POUCIES.AGEREGIRTE IUYWTS SHOWN WAY HAVE BEEN REDUCED BY PAID CLAW FOUCYLV® POU wmlRE WNW/JIPPIw4N lam �ALLIABAIA FiTCM OCCURRBfLE f caRmRCNLSBRfnALllAnav cRalrsEa�mAw s 1 Ia SNIDE I IDa.TIR uWaw ao s — PERSg1ALGADWaA1RY s GEC AG(i1E6 W i GHfLAT�tEGATEWOMPl6P9! IRDOUCIS•COIOYOPARG s .... Pout' MM IM nRDuou"LLM'un cORTRRmsouaK NR s ANYAUTO (EA—O A OIW W AUTOS IN00L� T SOMWNWAUTOS IRT®A11TOs �rw�URv R NO10O1WODAUTOS9 PRprtRTYDAUAoe s (IaaRluiO uARATERfIRAJTY AMONLY-FAALCOBR s ANYAUTO OfHENTHAN FAACC 7 - . AIROONLY. AEG .i. EMO�URS"LVeu TACNaecurmEfCE s OCIAIR CWIS YAOF AOGTEGUT: P i OW114TBIE s RETBRWN s bq s wOiRNSO0Nfa19Rfal Alfa 7 TR A awolowlmmuff 109305734 7/28/05 7/28/06 ELEApAC00GHT s 100,000 "a mo ELOMUWE-Rlmt s 100.000 T °v0sin0' ELD16H10E-POUCY11W s 500,000 s�oALWaWsufsm. oTIUR OfATlI1wNOFOIwIfOw116f1ACATgM6fY91tlSl ESLIBORS�BYEMOOI>OE�ITfs®AL iRalesb/6 CERFWICATEHOLIR CANCELLATON ` suaanANTOFT1wwmYEaISTN®WUgFdDEUNent�BBDRETNEFA9tA1fON OATETRBI®F.T�Ilm1NC P1YNNfsIwLL wlpWgRTONII< S.J—RATswR.nal NOICETOTIWfJB[TWTI:IOEEIMtOBt NNNW 10 TMESETY.uaTFNBAElOD0606HNA. IYOfENOOR1B1OwM0 IBIW 7 R9An31TOO11 REitoom� AlIT11�N�TX. ACORO S(ZQ0VBB) ` O ACORDCORPORATIOs11Bee ACOBQ. CERTIFICATE OF LIABILITY INSURANCE 10/25/2005 yy�R THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Circle Business Insurance Agency Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 247 Newbury St. ALTER THE COVERAGE AFFORDED BY THE POLWJ0 BELOW. Danvers, MA 01923 978-777-7030 INSURERS AFFORDING COVERAGE NAICM VASUED J.L. Ward Construction Inc INsuERA SCOTTSDALS INSURANCE CO. IrER�rs e: 50 Glidden St HEIR c Beverly, NA 01915 INSURERD 978-921-2752 MIREII E: COVERAGES THE POUCIESOF 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 POUCIES.AGGREGATE LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS- IF POLICY HAIBER OAlE EFFECTIVE Y DATE M OUYY ILION LNUTS LTa TYPE a-asPYa+cE EacHacaLeENCE f 1,000,000 GEfFRAL LPBRIT( f 50,000 X COMMERCWL GENERK LMBLLITY PREMISES If$Acar ) OAA mAOE �X occva MEDOP(ANryanoA�Al s 5,000 A S1131559 06/18/05 06/18/06 PERSO"iIALNuunY s 1,000,000 DENEROLADOREGaTE s 2,000,000 PROOLICTS.COMPIOP f 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: PO.ICY LOC AUTOMOBRELWBLLITY COdBI EOSINBLELIMIT f (Ea 8=o ) IETENTION O NFDAUTOS (BOOMYYNJJRY S AEDA ITOS ITIOS BODLYINARY f (PeraotleN) NEDAUTOS ( n f ALHOON.Y-FAA.00IDENT f SILITY HO OTI RNN EAALC f A HOONLY' �G f RELIA WSILM EACH OCOIFa7FfK'E f AGGREGATECTIBLETION f VVORKERSCO.>PEMS TIONAM TORYL0.11TS ER EWtOYERS'LIABILIW E L.EACH ACCIDENT I A"IR�fENRAYRI1ERh�WINE E.L.OSEASE-EAEMPLOYEE 5 GiFrl7Zf00FB DciuomT ITyns.EawiGau1=1 EL.DISEASE-POLICY LIMIT f SPECIAL PROVIS W LS Oelaw OTTER DESORPTWNOFOPEPATIOS/LOCAM S/VEHICLES/EXCUISMMADDEDBYENDORSEW-W/SPECIALPRONSIOS CERTIFICATE HOLDER CANCELLATION SHOILD ANY OF TIE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE L%ST NG MU ER WILL ENDEAVOR TO MAIL 10 DAYS WTITIEN NOTICE TO THE CERTIFICATE HOLDER MANED TO THE LEFT.BUT FAILURE TO DO SO SHALL 0.POSE M OBLIGATION OR LIABILUY OF ANY KIM UPON TIE IT49JTER.RS AGENTS O2 REPRESEHIATNES. AUTHORIZED REPIENTA 10/25/05 ®ACORD CORPORATION 1988 ACOR025(200008) 77tts CommotrtveoltlY oflifgssoehusetts" Deporhnent oflnduadd Accidents O,0?ea ojhiviesd�tons . . 600 Waddisatow stKa Boston,MA 02111 wwwMasxsewad Workers'Compensadon Insurance Affidavit. BaBderalContradonMedridamMumbers AnDHeant ht9jantim Plesse Print UgM Name / • �Ji4c�dI�ll/US72/�T�F'o�J �/!JG . Address: S D ��•G/ � i� CitylStattdZia ice✓ L �/ Phan Are yore as es,100 rT Cheek thr` `aPproPcift boat' ` Type dpreieet(required): 1.®I am a employer wiih '-13 4: [2 1 am a general con6apor and I 6. ❑New constructim ewk"=(hn=&orpwt-dmlo havelikedtkesukkisnaesm 2. 1 am a Bole pmprietor or partna- listed on this attached abeeL t 7. ❑ Remodeling ship and have no employed These Bub-co11traAon have S. ❑ Demolition woddw far ma is a w capecity. conlLmsmance. 9. [j Building addition [No worker'comp,insurance . 5. ❑ We are a corporatioa add ib' • 10.0 Etegrial tepsirs or additions officer bare eiuis$d their nq •I-� 3.❑ I am a homeow>rs.doing aft work right ofeae>Kiptsp'p'r MGZ' 11.Q Phmubmgrepairs or addition mysez[No wodww comp: t« 152,41(a an$al aU"'ao 12.Q tioofMPi msuraooenquiredj t, employees.[A(o,wyakai`, . 13.�OBttr Camp.insurance jjju d r •Any apptics4rt chub box at alit do Ile outgo nodoe below��aak,�al�' yoli�y mSo�mdoa t Homsowons colon reboot ob sfs avtt iodieatea se doing s4 wark nod tan lifooddd.oogdKt6es iWoubuitanewd5dwhiodiontingsuch tCoaeuaas Bat ebskaisbsa'tst stLsched s addidaosi sbssr sbo ar o.sera..obaoetia�ld..na�e+.wo�ta.•coma poft infimrsidoo. -wen atr enwbydrdhar h p vyfA g xw*ers'eompmsatloa 6rmww farm mipke t =don b cite psJL7=d fob silo '"leraa" Insurance CoagmyNama Policy#or Selgim.Lfe, #: Expiration Date 2 0,6 lob Site Addt=s 7 ��� Ctty/StatrlZip:Xi%ice? // GYr� Attack a copy of the workere compensation policy dceLrstloo page(showtag the pulley number and expL aunt,date). Fat7me to secure coverage as nqued under Section 23A of MGL c. 152 can lead to the inposidon oftaimmal penalties of a time rep to S 1,500.00 and/or one-year hgffbonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of cep to S250A0 a day against the viobdur. Be advised that a copy of this statement may be fbtwulded to the Office of Investigations of the DIA for ioaoraam coverage vesitleadon. I do #r daprhm and pmaNa ofper/ury that then lnfw=adon provide!above h are and earrea i p 20 G6 O,aleld au add Do no wrba In fhb area,to be eoawkfet by eAy arranw of/kiaL Clty or Town: PermWilanse# Issuing Authority(circle one): 1.Board of Haltk L Building Department 3.Cityflbwa Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions for to 152 ragmen an emPlQDt�si to P`'ov � their employer Massaelmacuts General Lawn chap in the aavrce .f another tads any coaum ofbim Pursuant 10 this steute. an a pbyee is defined as"...every'Peesou cx�rcss of implied,oral of wriva. An >t defined as"us individual.Partnership,asweiatioe.ompoeation dr other legal or � es m a two or more . . enterptis%and iaobtd>�the l� a of a deceased. Or ft or�� siagcogera asaoaiation of orbs h V entity.d ern CM4 *0 Q of an individost,P steel who resides maei4 of'thtt" owner of a dwelling boast having not mom thus throe ms such&x1ling Lame dwelling boost of anotba who employs persona to do maintenance,aonsnuctioa or Te woe# or an the grounds nsbtu7ding appurtenant thento Shan sot became of each employment be deemed in be as employer." MGL chapter 152,125C(6)*0 states that"every date or loci neeadag agency shall wkbhold the Issoaaee or renewal d a Hceiase or permit to aP a bashers or to eosstntet bdldteW la the causn"wean for aaq aPPHCmd errs has not produced aeceP�"Idsatt of(compliance with the insnnaee eaidcd m required." " Additionally,M���154125C(7)states"Neither the commnweslm rot any of ifs Ponrical soLdiviaions sham eala into any coottsct for the pafoemance ofpublic wort mud acceptable evidence of compliance with the msnrance requirements of this chapter ban bees presemed a the coadt 9ftSnlLontX" APPlkaats _ . �svu completely,by checking the boos that apply b YOU utaadon nod.if Please fi4 tot the workers'compensation s with their ca0ficAe(a)of necessary,sOPP,Y sob contrsctmt(s)nsmc(a�addressmit d j¢phone mmcbersh along with no employes other thus the m turpom Limited Liability m a=Or a compensation 1D8 ° n LLC or LLF doer have members or Psi an�m4�Be advised that this afdavlt maybe submitted to the Departateot of brdoetrial emplol+�a policy fi is of insarna coverage. Also bt'are to dp sad date the stadavk- The affidavit should b emanne fcc or license is being m pamCd,got the Department of be rearmed to the city or town dirt a e Any questions for the pet rft�law or ifyou are required to obtain a workers' IndmuialAaidats. SbOg1d yin 'e should enter their ccmpcasatioapolieyq plate o the te d the nmrtba liatod below. Solt=insnsed companies self-inaurusee fioeam> lift City or Tows Oftldak u to and printed legibly. The Department has provided a space at the bottom Please be same that the affidavit is comp _ of the affidavit for You to pill out in the event office of be used as a refaemce number. In addition,as aPphcaor Please be sum m fill inthe pamA/hceme lications in any given year,mad only submit one affidavit indicating current that mat submit multiple petmit/6canst V? Address" should write"afi locations in (cuY or sad mesa rob S policy information(if ne davit ) marked ... or town may be provided to the town}"A OOPY time affidavit met has ben Officially tnacupcd t►t. . . ...bY . applicam as proof that a valid affidavit is on flit for shame permits or licenses. A new affidavit nodbe tilled otrt each e of permit not related to any business of commercial vcnWe year.When a borne owner or cittem is obtaining a license perso n is NOT required b complete this affidavit. (Le.a dog license or permit to barn leaves etc)sag The Office of Invesuptions would I&c to thank you in advance for your cooperation and should you,bave any questions, please do out hesitate to give us a call The Department's address,telephone and in n mbw. The Commonwealth of Massachusetts Department of Industrial Accidents Oda of InvesdPdow 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26.05 wwwmass.gov/dia CITY OF SALEM9 MASSACHUSETTS • ' PUBLIC PROPERTY DEPARTMENT 120 WASNINGTON STREET. 3RO FLOOR SALEM. MASSACNUSETTE 01970 STANLEY J. USMICE, JR. TELEPHONE: 979-745-9595 EXT. 360 MAVOR FAX: 978-740.9846 Salem Building Dena rtment p9hris Mwosal 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: (Location of Facility)_ La 0 Si f <� p licant 06 Date