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108 JEFFERSON AVE - BUILDING INSPECTION No. �'V� APPLICATION FOR PEMW TO LOCATION 4e - PERMIT GRANTED 19 INSPECTOR OF ®UILDMS IPI IS~�WM1194ND APPROVED BY T*E JMPZ==PRW TO A.FWW JREM GRANTED CITY OF_SALEM No. \ Or. wwd `� , . zarnp owha ft FYMaIc&AtI l?� y_pip ✓ iae�tioa of %U"wa /08 3 r-FFev,so,� in Pi"sly locate in Ale MN CWMW40 p AMO . YM No✓ Pemlit t0: SUILDING PERM APPLIUTION FOR: (Circe whioh~apply) Roof, RKW. IneWl SdMtp, ComtW peek, Shed, POW, RepairlRaplaoe, Dow. PLEASE FILL Otir LEOWLy i COMPLETELY TO AVOID DELAYS W PROCESSM TO THE INSPECTOR OF BUILDINGS.The UMWSW" '. hereby applies for a pwmk tojxt `a000r&-q.to tho.bbwinp Ownses Name ivs Ao c . Ad*m & Phone 8 i 111, m&kq m Ae S 46a- ( 51571 7Yj -/ e-cjo Amhiteot'a Name Address Q Phone ( 1 Meohanios Name 'De T,�n 61uz e,, w 5r c , ,j 3) ca .y 57- 7te�eL- Address A Phone c,y,JN rna o 5 z f7�1 Sg S 4 77 vnhrk b ft p.pow it tNi WW wWw a Now `8 Rtic� ter.�/:e� G N,�,a„0.for kww mknp weaa9 WE koft am m I to iow? AoO�Motq ,✓a E�nrNd cool t�yr Ua�w• 8wr • ue Ira Svditm Of AppYcant StO1iD UNOEA THE PENALTY' DESCRIPTION OF WORK TO 9E DONE OF T1lRY C.o rwyLesu Z)&-.a a F t 4-v oaJ r l 5 run-i N1 ✓�a,�-., 6u� c..� ir, � A� ��h-e �o�rt.,.J r � nl di 7V� 0j1//We �eZ✓wl 1]je4fs Ga.✓�� to / /c. MAIL PERMIT To. 3) Ci ///2< 157 Al fL f_Z Nam\ - --...- -. ----- - - - Department of Industrial Accidents Office oflnvestigadons 600 Washington Street Boston,MA 02111 www.mass.gov/dla -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (aunnesslorganization/tndividual): DeIulis Brothers Construction Co. , Inc. Address. 31 Collins Street Terrace City/State/Zip: Lynn, MA 01902 Phone#, 781-595-8677 Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 4. ❑ I am a general contractor and I 6, ❑New construction employees(full and/or part-time).* have hired the sub-wntractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical airs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I I-El Phmibing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp. insurance required] 13.❑ Other •My applicant that cheeks box p i most also fill out the section below showing their worla;ts'compensation policy infomrtioa t Homeowners who=lxmt this affidavit indicating they ate doing all work and then hive outside contractors must sulxtut a new affidavit todicating suck k-ontractora that check this box mart attached ao additiaoal abed showing the name of the sub-matraeton sod their workme'corm,policy infomianoa ram an employer that is providing workers'compensation Insurance for my employees. Below is the polky and fob sat Information, Insurance CoiMany Name: American Home Assurance Co Policy#or Self-ins.Lic. #: WC692-83-17 Expiration Date: 1/1/06 Job Site Address: 108 Jefferson Avenue City/State/Zip• Salem, MA 01970 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 cruninW penalties of a fine up to S 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. I do hereby certify unde�annakies of perjury that the Information provided above h true and correct Shmtore: Date: 8/23/05 Phone#: 781-595-8677 O,j/I'cid use only. Do not write in this area,to be completed by city or town o•,B9elaL City or Town: PermWLicenw# Issuing Authority(circle one): 1.Board of Heakh 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• Massachusetts General Laws chapter 152 requires all employers per n in theesservice oworkers' another under any co�c�lo�. Pursuant to this statute, an employ" is defined as"...every person express or implied,oral or written" An employer is defined as"an individual,partnership,association,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 baying>bt 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 suck dwelling house or on the grounds or building appurtenant thereto shall not bemuse of such employment be deemed to be an employer." MGL chapter 15Z §25C(6)also stasis 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 applicaat who has aot produced acceptable evidence of compliance with the Insurance coverage required." Additionally,MGL chapter 152,§25C( )states"Neither the commonwealth nor any of its political subdivisions shall of public work until acceptable evidence of compliance with the insurance enter into any contract for the performance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit compleuly,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(I.LP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or I.IB does have employees,a policy is required Be advised that ibis affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that due application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or ff you are required to obtain a workers' compensation policy,please call the Deparunent at the number listed below. Self insured companies should enter their self-insurance license number on the riate 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 fill in the permiUlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitticeme 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 Qr citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves eta)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 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 Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia I ofttlem, fttssor4usetts lid Public Propertp Department iiguilbing Department (One Salem green 508-743-9595 Ext. 300 Leo E. Tremblay Director of Public Property, Inspector of Building Zoning Enforcement Officer Section 116.0 DEMOLITION OF STRUCTURES Structures over fifty (50) years old must have approval of the SALEM HISTORICAL COMMISSION UTILITY DISCONNECTIONS REQUIRED Authorized Agent Date of Disconnection WATER: ,"ems 8 - 2 y-p�- ELECTRI CAL: GAS: SEWER: DIG SAFE NOMBER: 20oS 3 J b 7 1/eg Y PEST CONTROL: ***DOCUMENTATION OF ALL THE ABOVE MOST BE ATTACHED BEFORE*** ** PERMIT CAN BE ISSUED ** Fee for Demolition: $5.00 for application plus $2.00 per 100 square ft. gross area, minimum $15.00 V"r sr..:a `nip[ SFPR `29C In accordance with provisions of General Lai-is of the Commonwealth of Massachusetts and the Salem Fire Code, the following regulation governing the demolition of structures within the City of Salem shall be followed. This regulation is made in the interest of fire prevention, to prevent conditions which are or may become dangerous as a fire hazard, or are otherwise in violation of law. 1. Before a structure can be demolished, the Salem Fire Department shall conduct a preliminary demolition inspection , to ascertain any conditions which may require a fire watch or other preventive measures , to be taken before, during and/or after said demolition process. 2. A permit to demolish or remove a building or structure shall not be issued until said inspection has . been conducted, and a report of requirements necessary for prevention of fire and life safety hazards shall be obtained by the applicant for the permit. 3. The requirements outlined in the report shall become a part of the restrictions portion of the demolition permit issued by the Building Inspector, for compliance with the Code. 4. The inspection report shall include, but not necessarily be restricted to the following: A. Welding and cutting permit required. B. Fire watch to be maintained by a professional off-duty firefighter, with such equipment as determined by the head of the Fire Department. Per Order: Approved by : Cf 4 Iz�U • A Lieut. David J, ggl fnan, Salem Fire Mar al James F Chief Salem Fire Department (8/76) � _ .. y —n. '.\, v,..•�� ♦Y "K tS �/.�}' isi14. � llYn-;'�r...:.�a`n,�.r(.+�r.�zwyl 57 .,6o CMR: STATE BUILDING CODE COMMISSION r u ' SECTION 115.0 CONDITIONS OF PERMIT :I r -- t shall be a license to '$ y , erne 115.1 Compliance with code: The proceed with the work and shall not of thesprovisonsuofoths to violate, cancel or set aside tipuiat d by modification or legally �.I: > + ; ' except as specifically i J code, with Section 126.0 t ant e ord I - granted venation to act work shall conform to the ' 116.2 Compliance with Permit: All " �;j stamped m endorsed apPhcation and plans for which the permit has been issued and any approved amendments theret°' 115.3 Change in site plan: A lot or site shall not be changed, +.' unless a revised plan h Fsa . ;,�.•, increased or diminished in area from that shown on the official . site plan, as specified 1n Section by the necessary affidavit of showin4 such changes accompanied by roved. I i I �_• �r: owner or applicant shall have been filed and approved. :, � will not be required ff the Exception: A revised site plan reason of an official street opening. change is caused by _ "t or other public improvement. street widening 11i •I �r` . '�+, ?• ,� SECTION 116.0 DEMOLITION OF STRUCTURE or structure can 116.1 Service connections: Before a building the owner or agent shall notify all be demolished or I connections within the building or strue- ; utilities having serve sewer and other connec- . 3•.... E: `4 tore, such as: water. electric. 9aa. or structure �.�c.-. ture, A permit to demolish or remove a building ;�ry•'..� shall not be issued until a release is obtained from the utilities. :'' •.6 stating that their respective service connacators have and been re- n went, such as; meters and regul ant equip in a safe manner. moved or sealed and plugged I 116.2 Lot regulation: When a building or structure has been operation has not been demolished or remved the vacant building be filled with djacortnit •LF projected or apptro raded and maintained in conformity _ organic fill. 9 wed free from the accumulation ,- grades. The lot shall b. unsafe or hazardous conditionsot hwhicbL be a . :. of rubbish and all public; Pro a to any endanger the Afe or health of the P and the made to prevent the accumulation of water or damage t;. ' " foundations on the pr" ;Rea or the adjoining Property., erected in accord- necessary retaining walls end title 13. ante with the p I 1 rovisions of Arta ' �t SECTION 117.0 MOVED STRUCTURES code. I .� 117.1 General: structures Buildings andmoved into or within the jurisdiction shall comply visions of this ,' II �• 9/1/80 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDIYYYY) 07/08/2005 PRODUCER (978)887-4900 FAX (978)887-2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 16 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 457 Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC# INSURED DeIulis Brothers Construction Co. , Inc. INSURERA Acadia Insurance 31325 31 Collins St Terrace INSURERS: American Home Assurance Co Lynn, MA 01902-2205 INSURERC INSURER D: INSURER 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 kDDrLTYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR DATE MMIDDM/ DATE MMIDDMf GENERAL LIABILITY CPA130127615 07/01/2005 07/01/2006 EACH OCCURRENCE $ 1,000,00c X COMMERCIAL GENERAL LIABILITY DAMAGE AMA PREMSET Ea oNnurance TED $ 250,00( CLAIMS MADE a OCCUR MED EXP(Any one person) $ 5,00 A PERSONAL 8 ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,00( POLICY n PROECT LOC J AUTOMOBILE LIABILITY MAA1301277 14 07/01/2005 07/01/2006 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,00( ALL OWNED AUTOS BODILY INJURY $ A X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLAUABILITY CUA1301278-14 07/01/2005 07/01/2006 EACH OCCURRENCE $ 10,000,00( X OCCUR ❑ CLAIMS MADE AGGREGATE $ 10,000,001 A $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC692-83-17 01/01/2005 01/01/2006 1 STAU ORYLMITSI JOTHER EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,001 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-FA EMPLOYE S PRO $ 1,000,OOI yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-PoLICY LIMIT $ 1,000,001 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL City of Salem 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Building Dept BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 120 Washington St OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Salem, MA 01970 AUTHORIZED REPRESENTATIVE Peter Sennott/LA ACORD 25(2001108) ©ACORD CORPORATION 198 CITY OF SALRMV MASSACHUSETTS PUDUC PROPERTY DEPARTMENT I aC WASNINGTON aTl M. 3*0 FLOOR OA,aN.MA OI 970 TaL (970)7/0-01198I=. 300 PAX (076) 740.9"6 STANLCY A U80VICl. JR MAYOR DISPOSAL OF DEW D AMAM b accardaaa with the peoviaim of Imo,a 4Q M 4 I W&n0Wb dp that as a C=&dOR Of Buildio�Perm.f .ad ddWk fQW tieB fiom the Owdmeum activity Bo UDW by this BuMN Pamit sbal be dhpoaad*tin a propaly bleeoeed solil4wwo dbgmd BciWq n defined by 1XL a UL SISM Zbdebria Win bediapaedo(at: 12 Swampscott Road, Salem, MA LOCM iaa OfFeeiiity � 8/23/05 Sisoatuee of Permit Applieaot Daa (PLEASB PRW CLEARLY) mformatioo. Antonio Pacitti Name of Peewit Applieaot DeIulis Brothers Construction Co. , Inc. Film Name`if soy 31 Collins .Street Texrace Lynn, MA 01902 Add(eaa.City R St o The above SMM require that debris from the demoliUM reoovgwo,rehab or other altaadon ofbuildiop or StrtKIUM be disposed in a rValy-kaaad 50h&waste disposal faahty M defined by WX cIq S 1 SOA, Md the buiI j pamita or license arc to Md"d the location of the facility. f 08/02/2005 12:33 9787414872 FACILITIES DEPT PAGE 02/03 ._.-... ...-.. 14:Ud FAX HF8(414S83 SSIIBC,LLP to 002/UU;i SE,RAPINI, SERAFINI, DARLING & CORRENTI, LLP 'T"ORN[YS AT LAW 69 f EOERAL STRCET SAX-EM, MA55ACMUZETTS 01070 JOHn R. BeRA/1NI. GR. T4LRPWOMe RRRAMMI, JR. 070-74 -0912 JOMn E- DARLING 761-581-E743 JOSCFN C.CORRFPM TELECOPIFIR 076-741.460a July 25, 2005 VIA TEL99OUER and HIR9T CLASS MAIL David B. Wright, Esquire North Shore Medical Center 31 Highland Avenue Salem, Massachusetts 01970 Re: Application for Waiver of Demolition Delay Ordinance lag Jefferson Avenue Dear David: Enclosed please find the Salem Historical Commission Waiver dated July 21, 2005. call.If you have any questions, please do not hesitate to give me a Ve truly yours, o h C. Correnti JCC:dl Enclosure cc: John A. Christoforo 08/02/2005 12:33 9787414872 FACILITIES DEPT PAGE 03/03 . . . . . ... YYUY LLI IwIj VVV/VVJ Salem Historical Commission 120 WASHINGTON STREET,SALEM,MASSACHUSETTS a1970 (97a)745.9595 FXT 311 FAX)o78)74o-04o4 WAIUR OF UM DEMOLITION DELAY O ANCE It is hereby certified that the Salem Historical Commission has waived the Demolition Delay Ordinance for the proposed demolition as described below, as per the requirements set forth in the Historic District's Act(M.O.L. CIL 40C)and the Salem Historic Districts Ordinance, Address of Property: 108 Jefferson Avenue Name of Record Owner: Salem Hospital Description of Demolition Work proposed: Demolition of warehouse. Dated: 1/O5 _ SALEM HISTORICAL COMMISSION g3 -a-VIL THIS IS NOT A DEMOLITION PERMIT'. pleasebe sure to obtain the appropriate permits fr of Buildings(or any other necessary permits or approvals)prior to commencing work, CITY OF SALEM r FIRE DEPARTMENT •. FIRE PREVENTION BUREAU s Salem, Manacchunttts01970 PERMIT Date) In accordance with the provisions of Chapter 148, G. L as provided in Section 10A this permtt is, led to Name (run mm.of p.noo.Wm w Co w.Im araal.d P mw) to conduct demolition operations per Salem Fire Code . State clearly Massachusetts Fire Prevention Regulations and purposes for Code. Massachusetts State Building which permit o is granted Restrictions: As per Mass. State Codes and City of Salem Ordinances. Clearance fmn Salem Historic Comnission. at Iah• leeatlm b• •1eN1 and m.. er d..eAM Is weL oaas•r to pe.1d• ad • Id•atlW a a.be al leeeml Fee Paid �o a e n 5? n (SlpnaNn of elnelal a.mlag p.nmlt) This permit will.expire44)" Ao0-ir- c� ;e< C z i �- Irw.) ow- (TICS PEDW MUST BE CONSPICUOUSLY POSTED UPON THE PREMISES.) 'aq Form #29C 08/23/2005 16:00 9787414872 FACILITIES DEPT PAGE 02/05 _. ._ .. 12:48 PM KEYSPAN FAX NO, 978 927 7459 P. U1/UZ SPAN Delivery ':.ew England Operations �- RIVER STREET wtrRLY, MA. MIS Jonathan Keys From: George Lovell -.-... 978-74DA729 pate: Tuesday,Aug6st23,2005 �artc: 978-354-2275 Phone: 787-466-5782 - '-` 108 Jefferson Ave.,Salem Fax:: 97"27.7459 _*;gent F[3 or Review M Please Comment ❑Please Reply ❑Please Recycle. ^Metter attached. f i I ;j 08/23/2005 16:00 9787414872 FACILITIES DEPT PAGE 03/05 TUE 12;48 PN KEYSPAN FAX N0, 978 927 7459 r, uuuc New England Operations •? �_=- North Shore Division ts �ll 44 River Street y Beverly, Me. 0191 E -! ust 23,200E a,r is in regards to 109 Jefferson Ave.,Salent. Please be advised that the gas service wilding has been cut ofiin the street. 1 c any questions or concerns you can call me at 781-466.5782. vot :, C•nordinntor ^7-n Shore Divisions This is a confidential message,Intended sold for the tson to whom It Is addressed. If you receive this sag , Y pc m:ssag¢in zrror,pla�se forward i t to the cornet person,or back to us at fax 978-927.7459 08/23/2005 16:00 9787414872 FACILITIES DEPT PAGE 04/05 :cT c005 10:04 AM FR BEU BUSINESS SERVICESF4 2273 To 91978740472E P.01 ,;ett 'Electric Nwlonal erta coma*W Fax: 978-524-2273 C1-70 , -7q0 , -}7Z6 Douglas E.Wagner ^'n a:: FS/ZZ/0S— _,abject: €ter-Mi L .D (S 1ce i ind wver WE ON E:f n Ay 44 Pover VS•Ireel Sevedy,mA 01915 97M4.2252 F=97&524.2273 08/23/2005 16:00 9787414872 FACILITIES DEPT PAGE 05/05 G 27 2005 10:04 AM FR 'EEV BUSINESS SERVICE524 2270 TO si S787404728 PAS P.02 ' %11�e/2025 IWO 17MS937848 0e1UL19 31�05 ! (� t ofjF11Et2i. != Public prnptrto ftr rwras �aa�o� �epartmetd Wn�fis�m 6rtea $n9-i33=9S95 FJCI. 390 Leo E. Tremblay ti .cLor of Public PropenY ..; sector of Building i:r:rg Enforcement Officer . _ rrasozzxzos aF sza�ocxoaas strucraras aver fifty (50) years old mast have approval of thn SAM laxnmcns. cot wszos t11>Zlzx nssCx>otla Ant:hax-ised rtnt Pace of nii 0cancrtua X Ham: sas: g i VZ SAVE XMIRK ' E� -etm CaMOL: � *"p000!'ID.Pf Tj()R o8 Am Ti ! ABM OAST as ATTAGM MWW0 4�e ke PERMT W BE loam Fee for pewl=i,on: t5.D0 for appl.leatiom plus 42•00 per 100 a t ft. pvss area, siusam W.00 Ri./"AVI TA/ AIA H rNnn�a /,ia�rS ''W� :x� TOTAL PRGE . 02 : „ Pest Control Service Agreement B & B PEST CONTROL 7636 29 School Street SAUGUS, MASSACHUSETTS 01906 (781) 599-4317 CUSTOMER SERVICE LOCATION STREET �/ /o ��" • CITY.STATESVZIP / PERSON TO RE CONTACTED SERVICE PHONE N PHONE TYPE OF PROPERTY TOBESERVICED GATE SERVICE BEGINS EXPIRATION DATE RENEWAL SERVICE TO RE PERFORMED A dsr /.f 2oa S� 0A-� ei✓ ❑ ❑MONTHLY ❑QUARTERLY OTHER L PESTS T CONTROLLED: �'Xd D�Ts ---- ----�0 .----- f�FE.tSe.,/-Cc�.i- -.. �"IL�..� M.c..P t------ ----- SPECIAL INSTRUCTIONS: ?` ®e-d U A<- s'?"''� -`8" �P--_a ., � w � T� -------------- ------------ TERMS AND CONDITIONS'. D.✓ �G/� ,S�,� is ,�� d��%.H� � SERVICE GUARANTEE: We agree to apply chemicals to control above-named pests in accordance with terms and conditions of this Service Agreement. All labor and materials will be furnished to provide the most efficient pest control and maximum safety required by federal, state and city regulations. SERVICE RENEWAL:This agreement shall be for an initial period of one year, and will renew itself annually unless either party cancels this agreement by giving thirty days written notice before any expiration date. ANNUAL BY / 6 AGREEMENTCHARGE $ \ // 1�O/ 7`4 1 -- COMPAN DATE INITIAL SERVICE CHARGE $ (Au Rrz IS nRe! KfMONTHLY/QUARTERLY PAYMENTS $ DATE $ (AUTHORIZED SIG ORE) ____________________________ Department of Industrial Accidents Of ee of Investigations 600 Washington Street Boston,MA 02111 wrv»cmassgou/di& Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le¢ibly Namepusizk�stiowbdividaaq: DeIulis Brothers Construction Co. , Inc. Address. 31 Collins Street Terrace City/State/Zip: Lynn, MA 01902 phone#, 781-595-8677 Are you an employer?Check the appropriate bos: Type of Project(required): 1.® I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).• have hired the 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling ship and have no employees These sub-coutractots have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. y ❑ Building addition [No workers'comp.insurance 5. ❑ We an a corporation acid its 10.❑ Electrical repairs or additions req�.] officers have exercised their 3.❑ I am a boin"M doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' cow. a 152,j 1(4),and we have no 12.❑ Roof repairs insmaoce required.]t employees. [No work' 13.0 Other comp.iffillrartCe required.] 'Any applicat ibet checlia box#r mut also fill out the section below abowing ffiev wurlaes'compm®tion policy information: t Homeowneta wbo submit We efdavit milieatma they am dome as wmk mod then biro outside oontr ictom must sprout a new affidavit indicating suck tContracomm the check this lox most attached an additional sheet showing Poe now of the sub-conttactme sad their workam'limy.policy information. lam an employer the is providing workers'compensation braunmefor my employees Below hi the poft and job slat Information. Insurance Company Name: American Home Assurance Co Policy#or Self ins.Lis #: WC692-83-17 Expiration Date: 1/1/06 Job Site Address: 108 Jefferson Avenue City/Statc24: Salem, MA 01970 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 imprisonrxat, 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. I do hereby serif j�and PAW ./-1,,/,nobles ofperjsuy that the hrfwmadon provUed above is true and correex Sismature: Date. 8/23/05 Phone#: 781-595-8677 O,Q?eial use o* Do not wrbe in this area,to be completed by city or town oA9eiai City or Town: PermiVUeense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/fowa Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: