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50 FREEDOM HOLW - BUILDING INSPECTION (4) Is Mrpwv tow"In Yam_�� iL"Ams b pwpsly IooslM In ;� MOssaMslrloAwal Y��N° DNq pW&VF APPLIrAUM Pqft. PON"UK��OMMrwK� � PAOL NOW on 'ol. ' Fool. PUTAK F"auT u nLY a cmns V TO AYao WLAVS w N° TO THE ur6PEdriOR OF BU1LD"L Do �► #a*" for a PO MA p bwld aooadinp w tlr toYowirp Qnows NLTA Sa Addms i Phowrr Matfsoft Noma Address A Phone . Medmics Now Address i Phone rA Q'"`� No is is pupoa wa.N a ar t .*owe br now NAM man?-'�"�---_- MIII ? ICJ A isWprlad sosl —�—,�'-- OlyUo�w�• N sCS ©�&)3� , . xo pp�p T1iE PiMAL'n ; 4 DEiciil rnoN OF WogK To of DONE AV v iy P Y}n mill, 0 4A2 MAIL ERWT T' A" �ayuw aidr� I-4l APPLICATION FOR PwAwiro xC may, LiOCA71ON PEF"T GRANTED eu�orros . CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 40 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. UIOYICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 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. Theen debris will be disposed of in: `I/i 11m n ` J1�tG�C (Location of Facility) �I'�ilslc� Signature of pplicant �06 Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass•gov/d e Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Ptumbera Applicant Information /) Please Print Leeibly Name (Rusinsanrpniiz�zation/Indivia4 ►!I_► M Address: tXp� � srn Aire c City/State/zip: L�V1tn l�Ll Phone# Are you an employer?Check thi sipproprlate bogs' ' Type ofprof project(required); 1.❑ I am a employer with 4: all am a general contractor and 1 6. ❑New coustm is employces(fail and/or part-time).' have hired the sub=contracrors 2.❑ 1 am a sole proprietor or partaer- listed on the attached sheet t 7. Remodeling ship and have w employees These sub-contractors have 8. ❑ Demolition working for me in any,capacity. workers' comp.msurance, g• Q Building addition [No workers' comp,insurance . 5. ❑ We ate a corporatism and its' regaind}: officers have aexecued their 10.❑ Electrical repairs or additions 3.❑ I am a homeownor.doing all work right of exeirti dt'-per MGL 11.0 Phmrbmg repairs or additions myself. [No wmkcW,comp; c. 152,§1(4i and we hive no 12,0 Roof rcpafre insurance squired:)t. emPloYens [P[o worker's' 13.❑ Other comp.ms uranci regtiaed j` •Any applicmt that cheeta box All mutt also 511 antbe section below ehowme 1Le¢,. •cottq�easetjon po Y infoemtion t Homeowners wbo submit tbia''affi&vit kdicetins they ass"a all work and lben him outside contractors moat submit a new d5&vit k&catina such, 1Contractors that check this boi`mnat attached-an eddi6onel sheet showma the nowr fthc subcaetie end the¢workers'comp,policy mforrtrelion. I ant all'employerthat is providhr;worktrs'eompensation buurarretjor my ediptoyies Mow Is 91m po&7 and job site inforaaat" nn Insurance Company Name: �/Xw5 . Policy#or Self-ins.Lic. #: 1 JT Expiration Date: S w 0 t Job Site Address: City/State/Zip 546 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 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. 1 do hereby cerd under the pains andpenaUss ofperJury that the informadon provided above u true and correct Si D : a 141 job Phone#: Qateid use only. Do not write in thb one,to be completed by elly orMM o f7elaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Heakh 2.Building Department 3.Cky/Pown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone# Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide worker ompensation for their other under employees. Pursuant to this statute, an enrploYes is defined as"...cvuyPetson in the service q, express or implied,oral or written" An employes is-timed,as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged n a joint enterprise,and including the legal rcpresentativen of a deceased ees. Hex,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` s Persons todo maintenance,construction or repair work on such dwelling house dwelling burst of another who emnpby thereto shall not because of such amploYmcnt be deemed>a be as employer" or on the grounds or building appurtenant 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 of any of its political subdivisions sitar enter into any contract for die 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 of necessary,supply sub-contractors)uame(s�address(es)and Phone numbcr(s)along with their certificate(s)employees other Co antes(LLC)or Limited t iabniry Partnerships(LLP)with o employees other than the insurance. Limited Liability workers' compensation insurance. If an LLC'or LLP does have members or partners, are not required to carry 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 aflidavN. The affidavit should be returned to the city or town that the application for the permit license i w or if you requested,not the uired m obtain pworkers'rtnt of Industrial Accidens, Should You have any ment a t regarding compensation policy;Please call the Department at the nnmber,listod below. Self insured companies should enter their Self-insurance license member on the ate 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 applicauL Please be sure to 6n in the pemnivlicense number which will be used as a reference number. In submit n ffidavion,an applicant indi g current that must submit multiple permit/license applications in any givenyear, policy information(if necessary).and under"Job Site Address"the applicant should write"all locations inor town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provide-to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be fined out each year.Where a home owner or ci6M is obtaining a license or permit of related to any business or commercial venture . (ie. a dog license or permit to bum 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 of 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 585-216-6180 2/14/2006 9:02 AM PAGE 3/003 Paychex Inc TO:BR II�AN COMPANY :�ry� t+� tiLI�w +t f K l�yy 1k��! Lf ��k1tf� ACORN kw (T1VF,. :171'R��� � �IM■7 :FYI�t:V balE(MM/DOlYYI ..:. .; .. >: . . A2/14/06 . . ...:..::. .......:..' ..::................... . PRgDUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PAYCHEX AGENCY, INC. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1175 JOHN STREET ALIER THE COVERAGE AFFORDED BY THE POLICIES WEST HENRIETTA, NY 14586 COMPANIES AFFORDING COVERAGE COMPANY A GUARD INSURANCE INSURED COMPANY BTM BUILDERS INC B 22 EASTERN AVENUE LYNN, MA 01902- COMPANY C COMPANY D OyFRA#E5' -. .. . .. .o: _ ... THIS IS TO CERTIFY THAT 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,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Co TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE IMMIUDIYY) RAT E(MMIDDIYY) GENERAL LIABILITY GENERAL AGGREGATE 3 COMMERCIAL GENERAL LIABILITY PRODUCTS COMPIDP AGG L �LAIMS MADE[=)OCCUR PERSONAL&ADV INJURY 3 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE 3 FIRE DAMAGE(My one liAl 3 MED EXP IAny ono Pusan) 3 AUTOMOBILE UABILITY ANY AUTO COMBINED SINGLE LIMIT S ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY I (Pa Pelson) HIRED AUTOS BODILY INJURY 3 NON-0WNED AUTOS IPer a«menM PROPERTY DAMAGE 3 GARAGE LIABILITY AUTO ONLY EA ACCIDENT S ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT 3 AGGREGATE 3 EXCESS LIABILITY EACH OCCURRENCE 3 UMBRELLA FORM AGGREGATE 3 OTHER THAN UMBRELLA FORM 3 WORLER'S COMPENSATION AND X WCSIATU OiH A EMPLOYERS'LIABILITY EL EACH ACCIDENT S iD0,00D.00 THE PROPRIETOR/ s INCL PARTNERSAXECU VE ® BTWC649746 --. 08/10/05 - 08/10/06 EL DISEASE Poucvunsrz s 500,00000 OFFICERS PRE: EXCL EL DISEASE-EA EMPLOYEE 3 100.00D.OD OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS CERTIFICATE ISSUED AS EVIDENCE ONLY. CEfFT1HCATEi#lOE#)R. CANGEf LACION .:.il .. ' SHOULD ANY OF THE ABOVE DESC IGED POLICIES BE CANCELLED BEFORE THE EAST COAST PROPERTIES EXPIRATION DATE THEREOF.THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERF IFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES, AU IZEESENTATIV ............................................................................................... 'ACORD2551:1.195)' mAC:URDCORPOH4.TI0N198Ei:_: Jul 14 05 03: 32p p. l A(�D CERTIFICATE OF LIABILITY INSURANCE DATE iiiz 05 PaODucER (781)S81-6300 FAX (781)581-9070 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Quinn of.-Lynn Ins Corp Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 152 Lynnway Suite 1D HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 789 Lynn, MA 01903 INSURERS AFFORDING COVERAGE NAIC II INSURED Brian Maguire INSURERA: Safety Insurance Group 39454 22 Eastern Ave INSURERS: Lynn, MA 01902 INSURER Ci INSURER D: UiSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN( 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. INSR ADVI TYPE OF INSURANCE POLICY NUMBERPOLICYEFFECTIVE MUCYEXPIRATION LIMITS GENERAL LIABILITY OPOOOOS627 04/27/2005 04/27/2006 FACHOCCURRENCE S 1 ODO 00 X COMMERCIALGENERALLIABILITY DAMAGE TO RENTED E CLAMS MADE �X OCCUR MED EXP(Any aria Mmm) E A PERSONAL A ADV INJURY E GENERAL AGGREGATE E 2,000,00 G EN'L AGGREGATE UNIT APPLIES PER: PRODUCTS-COMP/OP AGG E 17 POLICY JELL 71 LOC AUTOYDBILEUABIUTY 394SSS2 08/02/2004 08/02/2005 COMSINEDSINGLEUMIT ANYAUTO (EA eccitlemj E ALL OWNED AUTOS BODILY INJURY A X SCHEDULED AUTOS (Per PB1Onj S 100,00 HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Per wodem) 300,00 PROPERTY DAMAGE E (Peracmdem) 100,00 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTOONLY: AGC. S EXCESSNMBRELLA LIABILITY EACH OCCURRENCE § OCCUR CLAIMS MADE AGGREGATE E E DEDUCTIBLE S RETENTION § E WORKERS COMPENSATION AND WC STATU- DTI+ EMPLOYERS'LIABILTTY S.)G.4 ANY PROPRIETOFVPARTNERIEXECUTNE E.L.EACH ACCIDENT E OFFICEWMEMBER EXCLUDED? H yyaBsS 6050be - E.L.DISEASE-EA EMPLOYE $ OTHERLPROVISIQY$pgew E.L.DISEASE-POLICY LIMA E OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ERTIFICATE HOLDER -CANrELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR UASIUTY OF ANY KIND UPON THE INSURER, 0 REPRESENTATIVES • AUTHORQEDREPRESENTA L ACORD 25(2001/08) ®ACORD CORPORATION 1988