33 HAZEL ST - BUILDING INSPECTION (3) � � �--��'i a� �/'��i�
,
�� CITY OF SALEM
� ��� PUBLIC PROPRERTY
� ��..a
'� DEPART
MEN
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ai�m.RCFr uRtscx�u
M.�r<�
t�v7�vu.v:raH Srn�e7•
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a� ��oi9r
•rr�v�a,sys9s .F..x;v�ra.e.vx.e
VVurkerx' CompematioA Iasurance Atlid�vIt: Builders/Contractors/Electricians/Ptumben
A�mUcapt Informatioa Ptease Print Leeiblv
Vameid�U�n:um��n,�eN���u���i�:�eHs��w%�`o�, b b�..� �D rhe �a�%/�r-�-,
Addreav �S �f����G�l�PS% �( .
c��y�s��zp: ,/�ieve�cLX ltiln �►bop�u: "1'7P'-9a-1- ��sa '
.�rr you rn empbyer?Cbeek ths uppropriau Eox: '1`yps otprojxt(requlre�:
1.� I;un u empluynr wi�L 4. Q 1 am a gcm:rrl cowruwt aad I 6. � �ew corutruction
{.,.,�empluycex(full anJ/ur p:uo-tinu).• have hircJ che aub-cun�nc�on
2.QCf 1 am a sole propricu�r or partner. lisced un the attaehed�hca. � 7. ❑ Remodelin�
/ �ship and have no cmploycor Thae wb�eonvumrs have 8. �(kmolicion
�.•wking for m�:in any capuity. . workers'wmp, insuronoe. 9. Buildi
❑ na•rddition
ji (Ko worken'cwnp. inxurance 5. 0 We are a corpontion and ib !0. Elatrical r
rcquircd] ot7ieea have excrcl�uxl[heir ❑ epain or�dditions
,I 3.� I am a homeowner doin�all work rigdt of exemption pu MGL I 1.Q Plumbing cepain or adclitions
�I myxlf. (Ao woAccrs comp. c. 152.§I(4).and we havc no l2.� Ruofnpairs
i insutance requir�ed.) � �mployaeY. [1�o workers' 13.0 Other
Icomp. iawrance requircvl.J
•n�y�pplicuol tlrt chcclu bpy bl mu�t aIw lill wn�he ucliup IwWw�pwiay iAtu wurtai'cumyepwliuq pulicy iwfium�iwt
' 1 Wmm�wrsn wlw�upnyl tUis aflfdwi�indisuin�tl�ey a,e Juiuy oll wott a1y�p�y Si�e ppy�pp canuxfon mwl.ut�nu a neW alTiJsril inJiaYin�uk�.
�C�Hurxtw+�hu cAaslt�his bos mu,t ahachod un aWitiwW.Iwr�whuviry 4k nwq of Iho iuseontntton and�heir u�uAcmt'canp.pulicy infbrmatiue.
/um un rmployer thru lr pruvld)nx worken'compensadon L�rurancc jor uiy emp/uyecs. Below Is the pu/tay and Job siH
iii/uru/uliuR.
I Incurance Company Vame:
— ..... . _- ---
Policy Y ur SGIf-irm. Lic. H: -.-- . ___ F.�cpiruUon Date:
lob 5icc AdJrcss: Ci�yiSlutuZip:
�[tach a copy of the workers'compens�tlon pollcy declar•rtloa pake(s6owinR the polky number�nd c:piruiun date).
I�ui Iurc w�ccurc co�eraye as required unJrr Sw�ion 25A uf�(GL c. 152 eau lead to the impoaition of eriminal penaltin of a
, tinc up tu 51,500.0f)anJ/or ona tar im r�s��mnent �s wc11 yv civil •
-�
Y p �n�l�i�r in ihc form uf a STUP WORK URDER arnt a fine
oi up to�_50.00 a day �gumst ihe vwlamr. Ik advitcd thut a cupy uf thu sta�uu:nt mu be furw•rrdud ea ih
. r Y e UOict uf
Iq\'�111'•;ll{U115 UI ihc DIA �or in.urar.cc couen��• vcri"
o � hcatiun.
�
/Ju brrrby ce y un ei U�r pai r m�d p u!i r ujperjury thuf dre i��/brmallon provrdad u ve ' upe ui�J corrert
�;,.:,:,�„�� u�� � l i D �
,...
O/JJri�!au wr/�t /M�rol wriit In dJi ai�a.!u be cuw�p/eltd by dy or/own ofJlriuL
Ciryor 'Pmrn: __ PcrmitlL(cense�J
I�sufnk :\ulhuri�y (circle ouc): --- - _
t. IIo�rJ ��f Iterlth 2. ISuilding Dcp�rcm.nt l. City/fo�.n Clerk a. Electrical luspector 5. PlumGin� Inspector
4.Oihrr
CuntWcl Pc�son: __ Phonc N•
Information and Instructions
_ � .
hla�wchLLsctta Gcnoral[aws chapcu l i2 rrquitCx•rl!employen to provide workccs' co�npensation for t}�ir employas.
(4,cs�:�nt co chis suuute.an rwployts ia defuud as`...evay person ia che setvice uf another unlu any convxt of hire.
r„proas,u impli�d,orrl or wrictea"
An er�pfuj�n is detiaed as"m iidiividual,P�P��O°�00�°��io��o�her�egal entiry.or�uy two a more
ot�he foregoing eny�ged in a Joint rnteryrise.aad incluJin�{the legal represenw�ives oP a 1ece:�+e�!employer.or�he
re�:aiver or ecwuee oP m u�dividual.P��+P•as�ociaaou or orhec leeal enaey.emPleYini amployees. However du
s o0
ownu of a dwellias haae hsvin�na more th�n�hm apnruneaa and wia resides theeein.or the oauPant of ths
SwellinY 6ouu of ano�her who employs peraons w So m�iamam�r.conatrucrion or repair worlc oa wc6 JweUin�house
or
on�he n�or building appuetenant therew sEall not because of sucA employmeat 6e dcemed m be nn employer•"
S►a"
hiGL clwp�er 152, $23C(6)also st�[ea�u���every state or loeal Reemin$apeney sAaU ait6hold tAe issuasce or
renewa�of�licew°or P�rm1<<o operate�susiseas or to eoutruet buildiags h the eommonwerltY tor uy
rppllcaot wb Yas aet produeed aeeeptablt evWexe ot complluee witY t6e Insunset covera;e requtred."
A�1i[i�mnlly.MGL chapter 152.$25C(7)swrcs"'Neither the commonweal�h nor say oP its potitical subdivisioas ahall
mmr into any ca+tra�ta[he P�O�'��uf public work unal acceptable evidence uf cumplivace w i�h the insuronce
requiromen�s uf�Eis cA•rptar have been praented w the conaaetin�authoriry.»
�pplicauq
Ptease fill out ehe worken' compensacon aPFidavit completely.by checkinQ�he boxes rhat apply w your situarioe and,if
necessacy.yuPP�Y��O°�tot(s)name(s).ad�ressles)and P�n°°wnbu(s)along with dteir cerrificate(s)of
insurence. Limiced Liability ComPanies(LLC)or Limited Liability Partnerships ILLP)witb no employxs othec�han the
membeis or paMen,aie�ot K9��r��cazry worlcets' compensatien insara++��- �f aa LLC or LLP doa have
en�ployees.u policy is required Be advised thst�hia affidavit may be submined co the Depaztment of [ndustrisl
Acciderts for coafi+mation of inauranca covtraee. Also be sure to xi�n and daee the•rflidavi4 'I1ie atTidavit should
6e retumad to[ha ciry or rown th�t the application for the permit or license is being requasced, not the Deporhnent of
�n�u�aiut qc�iden�+. S6ould you have any yueariom rtgarding the law or if you are required w obwin a workers'
compeasacion policy,pleax call the Depactrnent at the number listed below. Self-insured companies should enter their
,eIP-insurance ticense numba on the a riate line.
Cily or Toan Ottklab
Plcase be suro tharthe affidavit is complrte and printed Icgibly. The Department has provided a sp'rcc at thn botWm.
uP�he affieJ•rvit far you to fill out in the evnnt the OtFce of Investigadons has ro conlact you rogardin�the applicant
Plcax: be suro co till in�ho p:rmiulkc�ue numlxr which will be used aa a reference number. [n adJirion.•sn applican[
thrt mu+t sub�nit multiple penniUlicense applicarioro in any given yeaz,need only sub�nit one a�davit indicating curtent
policy informatinn(if nectssary)a++d under"Job Site Address"ehe applicant should write"rll lae:a[iona in (���Y��
tuwnl."A copy of the•rflidavit dwt has bea^officiaUy stampeJ or muked by che ciry or town may be proviJcd to tht
spplicant as proof d+at a valid affiduvit is on file f'or future permiu or licenses. A new affidavit must be tilled out each
ytar. Where a home uwner or citizen is obtainin�a licee�ve or prnnit not relaeed to:wy business or commercial vennue
�i.e.a dug licen.0 or permi[to bum Ieavea ete.)said pusun u YO'C required[o complete this atfidavit.
l'he Oi tix uf Inves�i��tiuns wvuld like w �hank you in advunc¢ for yuur cooper��ion and,hou1J yuu h�ve:u�y questions,
plc��e Ju nut hesieate [o give us a call.
Thc Dcpanmrnt's address, [elephone nnd fax number.
The Commonweslth of Massachusetts
pepaRmeat of Industrial Accidents
OQlet at I�v�tioos
600 W�shingta►Strcet
Boston, MA 021 l l
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Rcvi.cd 5-26-US �r.�.gov/dia
, CITY OF SALEM
PUBLIC PROPRERTY
DF.P�t�rrr
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at��•• t'J."I.��N::AKi 7[�T�i�te�l.9ia�ll�t:r.r�1s::9.
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Coastsucdos Debrts Dispas� .�►1"Rdsvit
t�tuiral tbr ail�lanolitioa aud e�enovatioa worlc)
ia�aonianee w ith tlt� sixdt aditiae a[tM Stats Buildity Cod�,790 Cl►llt soctiaa t t 1.S
peb�i�,ud dw provisioeu of MGL e 40�9 SIC
euildin�P�nnit f1 u i�w�ad wi1��eondidos tfmt tbt de6�is rauldns hom
�his woh yhall bt diaposod of in s propaAy licensad w�a�dtapcual f4eiUty�s deMod!ry�l(�.e
l l l.! tlOA.
The debris wiU be tran�poesed by:
� � 7L �9 0 .� �
�aam.ot �af
fha:lcbri� will ba dispoted uYin :
r D�/
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�...l.:raa.oi Ca.:i.�y�
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, T� �o���� o���¢��
, ���� � BOARD OF BUILDING REGULATIONS
' n'.License: CONSTRUCTION SUPERVISOR�
� Number:�CS � 011369
B1rtFidate: 0412811950 � "
. . Expires;.04/26/2008 Tr.no: 23206 -
� . _... . ..__.. .... .. Restdcted;. 00 .�
� JOSEPH F FAHEY: �� � � / � .'
17 BAYVIEW CIR �-. . . �,.4.,- /y
SALEM. MA 01970 ComMss�oner .
� . � .. ' . . . . � . . . . .
" � - ✓/rc �anrnnonure� o�:.�tGiia:�¢c�rmr.F•ls .. _- . �_.. . _ ..... . . .• r. -i` ��.-. . +. . � . ., . -. '
�'� Bonrd of Building Regulatians and$tan�6xds' � LIC¢OS¢Or 1'¢giSteSti�n valid for individul use oniy
� �. HOME IMPROVEMENT CONTRACTQR � � before the cxpiratlan data If fonnd return to: �
Registretion: 108671 � �� BoarJ of Building RegulaUons and Standards- �
Expimtion: 8/20/2008 One Ashburton Place Rm 1301
. . , . . Bostan_Ma.02108
� .. Type: DBA � � . . . . . -
� JOE FAHEY BUIL�ERS . . - -� � ' � . '
� JosepA Fahey . .. . . - � � � . , � .:
tt BAWIEW CIR. . :._ �,^..�, '. _ - �...... ..
- � SALEM,MA 01970 . � � p�puty Adm{n�s"1u�ter�- T ot v id with ut s�goatur - . - -
� . .. . . �� , .
. .. . . . :. � �tr�::.. � : : � ...,. �• : .
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11/01l2007 08:37 781-933-8198 INSURANCE AGENCIES PAGE 01
ACUR� CERTIFICATE OF LIABILITY INSURANCE oare�Mrxoorcwvi
CON82 2 li O1 07
rRoouc�t � 7N1$CERRIFICATE 18 188UE�AS A MA7TER OF ENFORMA710N
I.oauon Shsuranca Ayency, Inc_ ONLYAND CONFERS NO WGH75 UPON THE CERTiFICATE
629 Il�ia Str��t HOLDER.TNIS CERTIFICA7E DOES NOT AMENO,E7(7EN0 OR
Poat pff iae Sos 232 JLL.TER TNE COVEIL4GE AFFURDEO gY 7'1iE POLICIES BELOW.
PJebura 8!A 01801-0332
Phone: 781-937-0�50 Faxs781-933-8198 INSt1RERSAFIFqtISINGCOVEIiAGE NAIClF
irvsurseo �NSIIftERA: y-�(��rwl satval xo�. cmpsny 18024
� INSVRER B:
COSISCY'13CE�011 571�1�9.rB IN&JRERC:
971d SOZUElOAY
15 8.i1SCL'06t AVp. iH$�1RFH0:
Bovarly M7► 01915
INSURER E:
COVERAGES
THf PO��C�E9 OF w$URANC���5PE�6EL0'�'HA�E BEEN ISSUEO TOTHE INSUR�[f HwMEC ABOVE FOH THE POLICY PERIOD IN�ICATEO.NOTNITISTAN�ING
ANY REOUIREMENT,TEftM ORCONDITION OF ANY CONTRACT OR OTHER OOCIIMENT W RH fiE9PECTTO WN�EH THi$CEROFICAIE M1NY BE IS9UEOOR
MAY PERTAIN,THE INSVRANCE AFFORDED BY TNE POLIQES OESCRIBED HEFiEIN IS SU&IECT TO AlL THE TEHMS,EXCLUSIONS ATIO CONOIilON3 OF SUC1i
POLICIES.AGGREGATE LIMITS SHOWN Mav Hnv�9fHN RED4CE0 BY PAIO CLA.IMS.
lTR NSR TYPEOFlNSVfiAHCE PadOYNYMOER pp� MM/P GATE MMT LI�B
I� GENERAI.UABIUTV EACNOCLURR6NCE S Z�I}OO�QOO
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