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73 GROVE ST - BUILDING INSPECTION
poi_p: cUT�r 1i: LU ri117GD10LG C A POWEPS RANDOLPH PAGE 01/01 n>.>:{ncr A1G trc-c DACC3rcUVI 11:UJ: U1 su9 11AUL VUJ/VUJ ra.x merv¢r ACORD. CERTIFICATE OF INSURANCE DATE(MNWDIYI') 0E-2e-C7 PRODUCER THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO PoOHT9 UPON THE CERTIFICATE C APOWERS&SONS LLP HOLDER. THIS CERTIFICATE GOES NOT AMEND,EXTEND OR 233 NOW IF MAIN STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. RAXDOLPH,MA 023158 COMPANIES AFFORDING COVERAGE - COMPANY 233NS A AMXRICAN7.LR)CFTINSL'RANCF.:COI7PANY INSURED COMPANY s NJ.OHADO DUARTE 14 ALBION ST COMPANY C SALEM.MA 01070 COMPANY b COVERAGE THSISTO OFRTFYTHATTH6 POLICIES of MSURAHCE U3TFII BFWW NAYp EeEN IS!LR0 TOTHE lItlNRED NA DAROYE MR THE POLICY PERM INOICA ,,NOTMTKTANNhd uYRkONUIRIMM'FDTRRUCMMlRO R HOP ANYEpFN 0Cu RE.R�Ci TORO AI THE�T'EGRMB R,OId R1161 ICHRm Mi1CMY UkM0HOINORMAv WTNR�R'ENMUCkbEYE PAIDCLAIYR Go POLICY EPP P CY SEP LTR TYPE OF INSURANCE ►p.ICYNUMBER DATC(MMIDOMT DATEINMIDDIWI LIMRS OEpERAL LIAINLITY GENERALAGCRSGATE 6 COMMERCIAL GENERAL UAILITY PRODUCTTIPCOMPAOPAGG. S CLAIMS MADE OCCUR. PERSONAL99ADV,INJURY 3 OWNER'S A&CONTRACTORS PROT, mm OCCURRENCE / FIRE DAMADE(Any at THe) S AUTOMOBILE WABLrtY- HIED,EXPENSE(ADy me p.N ) S ANYAUTO - CCMRNED LIMIT 3 ' AU.OWNED AUTOS BCDILY INJURY(Per Pe DIM) D SCHEDULE AUTOS SOCILY INJURY(POATLeI " S HIRED AUTOS PROPERTY DAMAGE s NOWOMMIED AUTOS GARAGE LIABILITY ANYAUTOS AUTO ONLY.EA ACCIDENT S OTHER THAN AUTO ONLY' . EACH ACCIDENT AGREOATE S EXCESS I IRS LSTY UMBRELLA FORM EACH OCCURRENCE S OTHER THAN UMBRELLA FORM AGGREGATE S 4 WORRER9 COMPERSATIDN AND A EMPOLYERS LIABILITY UR�7739AOOA-07 07-2"7 DT-2E-09 STATUTORY LIMITS X THE PROPRIETOR/ EACH ACCIDENT S 100,000 PARTN6Rr4)MCUTNE INCL OISWOE•POLICY LLMIT $ S00,000 OFFICERS ARE: X SXCL DISEASE-EACH EMPLOYEE S 100,000 OTHER DESCRIPTION OF OPBRATIONSAACATIONSAMMICLESIPESTRICTIOLISSPECIAL ITEMS TR)S XEPLACL4 ANY PRIOXCESTT rATE INUED TO rXECEI7MCATE MOLDER APTECTINO WDRXFAS COMP COVERAGE. TRF,WORXERS'CMUP ATTOVPOLTCYDOWROTMOVyECOVrAAGEIbRMACEADC DUARIM. CERTIFICATE HOLDER CANCRLLATION 6HIX OMY OFT ASO�DESCRIBED POLICIES 33 CANCELLM NPICkSTHE l.I'IY OF PEABODY RXFRNATON GATE THEREOF,TiiE 1',ONNO CWPANV'NfiL ENDEAVOR TONM 1D DAYO WRITT NOTCE TO THE CERYP-ICATE HOER.O NAMED TO THELS*T,BUT 24 LOWEI.L ST EN=AAURCTOMM SUCH NOTICE R &L iNPCSE NO OWISATION OR LIARLDY OF MY MIND UPONTNE COVPMY,RE AS ENTS OR REPRESEHTFTTA3. PBABODY.MA Oi960 AUTHCRIIBD REPRESENTATIVE W A Bolinder ACORD 2S.6(Z" CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT w tUnr RUY DRIWOLL MAyoR Ir.WAil lL\GTOfe STREET•SAIEM.MASSAClf *..T1,s019M MtL-978-743-9595 4 FAX:9M7449846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anolicant Information Please Print Letlibly NlMe tausinWOrgani:ationtlndivtdual): D U/ IIRZ�P_ " A G/1/APO C,,r tV,FRAL LONTAA C./U' R Address: / G/ A G B I t 0 N cS% .S/>- L,&--A,10 City:StardZip:Sa4e1_T'/f/, 0/9T0 Phone tl:_I L?-2141 —G/t5 L2 Are you an employer? Cheek the appropriate boa: Type of project(required): 11.Wan a employer with -�' 4. © 1 am a general contractor and 1 6, ❑ New construction employees(full and/or part-tine).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. : 7• ;S R' emodelmg ship and have no employees These sub-contractors have S. ( ]Demolition workingfor me in an capacity. workers'comp. insurance. Ya9. ❑ Building addition [No workers'comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions rcquircei] officers have cxcrcirsxi their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. (No workers'comp. C. 152.§1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp, insurance required.] •:Uty applicant that chucks box 01 must afro lilt ow the section lr:luw awwiog olRtir wurkoxs'companadiwt policy inf ant aium ' I1,ane twnen who submit this affidavit indicating they arc doing dl wont and them hire outside contmetors nowt.ubtnit anew arridavil indicating etch. C,ruracUrs that check this box none attached an additional ahcel showing the natue of the rab-contractors and their workers'comp.policy information. /urn air employer that Is providing workers'compensadon insurance for trty ettrpluyees. Below is the polity and job site information. Insurance Company Name: / Policy k or Self-ins. Lie. #: U.6 ?7 36'_4 4 0._-d 7 Expiration Date: 07- 2 'p- D k lob Site Address: I S �rA we S Sv /r n Citylslutcyzip: .�cQ /o c �_/� Ot 97'r 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.IGL c. 152 can lead to the imposition of criminal penalties of a tin.:up to S1.500.00 and/or one-year imprisonment,as well as civil pcnallics in the form of STOP WORK ORDER and a fine of up to S250.00 a day against the violator. lie advised that a copy of this slatement may be forwarded to the Office of Imesngations oi'thc DIA for insurance coverage verification. l do hereby c/erriify under he )ains umd penul ies ofperjury that the information provided above is true and correct tii,•n:m ref ICJ O 9�/ 9/67 �7 71e- 9fA.2, OJfc ial use only. Do no/write in Ndr area,to be coatideled by city or town official City or Town: Permit/License# Issuing Authority(circle one): -- - 1. board urucaith 2. Building Department J. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: __ - _ _-- Phonc N: 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 bite, eaptess or implied,oral or written." .An emploJ+er is defined as"an individual,partnership,associatitn.corporation or other legal entity,or any two or more Of the foregoing engaged in 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 compnance 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 w ith 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 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 uflidaviL 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 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 till 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 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 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 bum leaves etc.)said person is NOT required to complete this affidavit. I'hc Oflicc 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 Invesdipi Ions 600 Washington Street Boston, MA 02111 Tel. #617-7274900 ext 406 or 1-977-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ..ya•rter• �a..�tl IX �.�9ev::Jt►f1ELT iuF»,tL�vatt:u.l�la:.9 Tra:��•tyil!�f.�7t:97sJ�0.9sN Construction Debris Disp"af Affidavit (required rot ail lemolition and renovation work) In accordance with the sixdt edition oohs State Building Cody 7S0 CMR section 111.11 ocbds,and the provisions of M. GL a 40.S A suildinS Permit N _ is isated with the condition that the debris resulting}boss this work shall be disposed of in a pooperly licensed waste disposal fboility as defined by%1GL e ItL.3MA. The debris will be transported by: roam+�r h2Wdd rhe&-bds will be disposed of in tname ur farilrty) EITStOfr PUBLIC P'j ROPERTY DEPARTMF,NT awal rr ti.bvv Wras 130WASUNGWOI air•1ALKKwsuaHL3rrisot+70 11n:M746-9SU•PAZ M7404M A_PpLICATION FOR THE REPAUL SNOYATION, CONDUCTION, DE,riOLiTiON.OIR_CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Nance :3--;�5 f31-/ t a— Property A"CiLtroolc--- roue S i Z- lf-l�v property Y located In a:Conservation Are@ Y/N HWAft ObVid YIN 2.0 OWNERSHIP INFORMATION 11 Owner of Land _ Name: --S-OS C GY r t i Address: '/3 r a u-0 Si- Safen 3.0 COMPLETE THIS SECTION FOR WORK IN MaSnW 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 8def Description of Proposed Work: -r%ar by dernc ILT%s-Nr4 ulRlls �remoytr� Plasle��. t?zrncd�l kl- khen, bm +11,oc)— J , a bEearqms a�d i; J ro claws a dGc<r. --- -- ---Mail Permit to: 6 cp l'o r re :'a C e o 0t use 01 the Building? What is tt►e Current � . Materiel of Building? L,-,n d of M dwel6rp,how rtwry units? Will do Building Conform to Law? Asbestos? At b l�cc�s �e Mar�, p rL AddraW and FIMO d' 4/h 6h S/• W a/o Msehanie's Karns Address and Phone Ca, n Supervisors L cwm S 7 3� � 3 y-- HIC Registratlon //-z t /� Esdmaled Cost of Project Par"Fee_Calwlstion Permit Fee i 3SQ' D a Estimated Cast X$7/:1000 Resldentiai Es*natsd Cost X:11/:100A Commwchll An AddUfonel =s.00 is added as an Administradve charge. Make sure that all fields are properly and legibly written to avoid delays in procesetng. The undersigned does hereby apply for a Building pgm*to build two the-above stated spwAce*M& Signed under penalty of perjury - Date /9 G M bl A F � ins G� v