39 LAFAYETTE PL - BUILDING INSPECTION FRAM MARK SOTRISH PHONE NO. 781 784 4384 Mar. 04 2009 09:50PM P2
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r SF_H R�3cJenuJl+SuhJ Fael Bamm A h.m« Insl�lluunn 4 s` -
'D ' rResiJeatinl Delnuhuun; s n -
r
`+`: r k ` 5 2 Reglsfered Name Improvement Contractor
r t
R[CRegist T - _ R strntion Number -- 'Y�.- 5
IiIC Colnpnny Nome w
r AJdtess y� '
4��lre`mvi -., x'2
r y SECTION 6'WORKERS'COMPENSATION_.INSURANCE AFFIDAVIT(M G L c 152 § ZSC(in)`
_:Workers Compen bttan Instu ace affid Vt mtut 6e comp eredarx s66mttted with this dpplicunun. Failure to pnivtde -
> thts uffidawt will result to theydemal of the Issuance of the bwiding permit rx t
_Signed AffidaVi�t�AMCOW7¢`S.�YCS'S+.• FArV[] 1�1',�;z'
ii rr�S SECTION 7a OWNFR AUTRORIZA ION TO BE COMPEETED WHENr n r
.,�� � HOR'NER;GGByA'GENT UR'CONTRACTOR`APPL�H3S FOR*BUIL�DaVG`PE=RMIT r tY y �' x
' ,us Owner of thesu
th blect property'heretiy
auorize F to ae[-oirmy behalf m all,matrers
relative to work nutnmzed by this'building,permit opplicntion
...: 'Sf lttrcafOwo«,:....t.:" ...-:__.r.. ;e_'n:. rc; ._'_ ,v:,: ..a:J: Dote.. •:_ -,..:...�x!9` ..,.' " ..
SECTION 7b OWNERt OR AUTHORIZED AGENT DECLARATION:.'
3r+ t ]'y� -' 4 +. t< -lj }-.: , le �� 't ) f ti✓33.. -h L p21 .Y. fit. - C t .� T
_ ,n sI� ,w>N+ - 4 J _- r ' .' = os Owner orAutho�ud AgenS)rereby declare,�*f _-- v .:
that tlteslatements and mforniMnn on the'foregomg applIm On;are sad accurate [o'the best of my knowledge and
a' ir
• Y,t �'e t r i I
= f 4t1 an Owtier who obtains o tiuilding pertntt to do lus/Fter own work or an owner who fore§ao unreg istere w d ntmttor
.'-�� (eo�tureglate�to the Home Improvement ContmctortHlC)-Program) wtil rtot have attess to thcurbrtrnuon
pmgrum at¢guararty fund under MFC)L c t142A Othertmportunt informnlion a`n the.HlC Progrum'a
K r CAnstr coon SupervtswtL censmg(CSL)can tx found in`7g0 CMR'Reguln(ions 1 lU R6 and 110_RS respn`hveiy r
3 .2 Whents6bstantiel W7wk is planned provide the mformmion below c
Tnrel flours mea(Sq Ft) Yt (mcludmg garage finished basemenNaurcs dell s iK pdr�hl
sGross'1�`VMg-0(en($q 5FL) h a a r r Hhbembie room iroutu { : .
Number of file laces
P � IHuriiber of 6edrooms�r' ` � '* `
r "; Numlieiof bathrooms°'" ; + � Number at:hatf/baths - - ' '
Type uF heanng'system a ' ' T . :Number of decks/poa)ies' yY
� T e 6finolin 3 em
-r 3 "Total,l'iojectSqutare Foamge may be sabsututed for 7otnt Project Cost , ; : ;r rt
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RAN Exp rai'0 N HOME IMPROVEMENT CONTRACTOR i
SNP ReBistra6on:. 106931
Exptraflon 712812010 ir# 0
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d� ,YPe: fri'vMdual
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MARK F. BOTAISH i �t 1 i
Mark.Botalsh
12 Glenview
Road , t
Sharon, MA 02067
T
4
RightFax N2-1 3/4/2009 6: 03 : 44 AM PAGE 2/002 Fax Server
ACORD. CERTIFICATE OF INSURANCE DATE(MMIDDIYY) 03-04-09
PRODUCER THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
SALHANEY INS AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
5264 WASHINGTON ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIESAFFORDING COVERAGE
WEST ROXBURY.MA 02132
COMPANY
268SH A AMERICAN ZURICH INSURANCE COMPANY
INSURED COMPANY
8
BOTAISH MARK F
COMPANY
12 GLENVIEW ROAD C
SHARON,MA 02067 COMPANY
D
COVERAGE
THIS 15 TOCERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN.THE NSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
LISTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS.
CO POLICY EPP POLICY EXP
LTR TYPEOFINSURANCE POLICY NUMBER DATE(MMODNY) DATE LIMITS
GENERAL LIABILITY GENERAL AGGREGATE S
COMMERCIAL GENERAL PRODUCTS-COMP%OP AGO. S
CLAIMSMADE OCCUR, PERSONAL88 ADV.INJURY S
OWNER'S$S CONTRACTOR'S PROT. EACH OCCURRENCE S
FIRE DAMAGE(Any onefre) S
MED.EXPENSE(Any ore parson) S
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT S
ALL OWNED AUTOS BODILY INJURY(Per Person) S
SCHEDULEAUTOS - BODILY INJURY(Per AC idsm) S
HIRED AUTOS PROPERTY DAMAGE S
NON-OWNED AUTOS
GARAGE LIABILITY
ANY AUTOS AUTO ONLY-EA ACCIDENT S
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGREGATE $ -
EXCESS LIABILITY
UMBRELLAFORM EACH OCCURRENCE $
OTHERTHAN UMBRELLA FORM AGGREGATE $
WORKER'S COMPENSATION AND
A EMPOLYER'S LIABILITY UB-0509M53P08 10-20-08 10620.09 STATUTORY LIMITS X
THE PROPRIETORI EACH ACCIDENT $ 1.000.000
PARTNERSlEXECUTIVE INCL DISEASE-POLICY LIMIT $ 1,OOQ000
OFFICERS ARE: X EXCL DISEASE•EACH EMPLOYEE $ 11000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIRESTRICTIONSJSPECIAL ITEMS
THIS REPLAOES ANY PRIOR CERTIFICATE ISSUED TO THE CERTTLTCAT-E HOLDER AFFECTING WORKERS COMP COVERAGE
THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR BOTAISH MARK F.
CERTIFICATE HOLDER CANCELLATION
SHOULD AM OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
STEVEN PARISEAU EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10
DAYS W RITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
39 LAFAYETTE PLACE FAILURE TO MAILSUCH NOTICE SHALL IMPOSE NOOSUGATION OR UASIUTYOF
ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
SALEM,MA 01970 AUTHORIZED REPRESENTATIVE
ACORD 2S5(3193) W A Bolinder
lS1B'f1LP&X JYL"J. 0/ Y/ cvva u. V , zi nil { .u.a. .+• ..•••- �••• --- --
ACORD. CERTIFICATE OF INSURANCE DATE(MMIDDSYY) 03.04-M
PRODUCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
SALHANEY INS AGCY HOLDER, THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
5264 WASHINGTON ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
WEST ROXBIURY.MA 02132
COMPANY
268SH A AMERICAN ZURICH INSLRANCE COMPANY
INSURED COMPANY
B
BOTAISH MARK F
COMPANY
12 GLENVIEW ROAD C
SHARON.MA 02067 COMPANY
D
COVERAGE
fl0G TOC6RMN THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,
NDTWTMTWMNO ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTACT W OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN.THE MSURWOE AFFORDED BY THE POLICIES DESCRIBED HERON IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF MUCH POLICES.
LIMITS SHOWN MAY HAVE BEEN REMCEO BY PAID CLAILIS.
DO POLICY MIFF POLIOY EXP
LTR TYPEOFINSURANCE POLICY NUMBER DATE(MMMIXYY) DATE LIMITS
GENERAL LIABILITY GENERAL AGGREGATE S
COMMERCIAL GENERAL PRODUCTS•COMPIOP AGO. S
CLAIMS MADE OCCUR. PERSONAL&&ADV,INJURY S
OWNERS S&CONTRACTOR'S PR07 EACH OCCURRENCE S
FIRE DAMAGE(Any om fire) S
MED.EXPENSE(Any om psrsen) S
AUTOMOBILE LIABIUTY
ANY AUTO COMBINED SINGLE LIMIT S
ALL OWNED AUTOS BODILY INJURY(Per Person) S
SOHEDULEAUTOS BODILY INJURY(Per AmIdem) S
HIRED AUTOS PROPERTY DAMAGE S
NON-OWNED AUTOS
GARAGE LIABILITY
ANY AUTOS AUTO ONLY•EA ACCIDENT S
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AOREGATE S
MICESS LABILITY
UMBRELLAFORM EACH OCCURRENCE S
OTHER THAN UMBRELLA FORM AGGREGATE $
WORKER'S COMPENSATION AND
A EMPOLYAWS LIABILITY U6.050W$30-06 10.20.08 10.20.09 STATUTORY LIMITS X
THE PROPRIETOR/ EACH ACCIDENT 3 11000,000
PARTNERSEXECU71VE INCL DISEASE•POLICY LIMIT $ 1.000,000
OFFICERS ARE: X EXCL DISEASE•EACH EMPLOYEE $ 110=000
OTHER
DESCRIPTION OF OPMATIONSILOCATIONS/VEWCLEWREBTRICTIONS/SPECIAL ITBMB
THIS REPLACES ANY PRIOR CERTIFICATE ISSURSD TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAOC
THE WORKPAS'COMPENSATfON POLICY DOES NOT PROVIDE COVERAGE FOR BOTAISH MARK F.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCPoBEC POLICIES 06 CANCELLED BEFORE THE
STEVEN PARISEAU EXPIRATION DATE THEREOF.THE ISSUNG COMPANY WILL ENDEAVOR TO MAIL 10
DAYS WRDTEN NOTICE TOME CERTIROATE HOLDER NAMED TOTHE LEFT.BUT
39 LAFAYETGE PLACE FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NOOEUOATIOH OR LIABILITY OF
AWKIND UPON THE COMPANY.ITS AGENTS OR REPRESENTATIVE&.
SALE-M,MA 01970 AUTHORIZED REPR99WA7IVE
AGORD 2M(3=) W A Bolinder
1 4
CITY OF SALEM
�;� PUBLIC PROPRERTY
DEPARTMENT
,,I,, n l \ 'At'( •91
U�•.•sI 12' W,NtnN,.I.).N StALLI • )ntr t<.bf.tsh.\t III .1 I I.J07:
11.1. ,711.7t i•tJ'15 a 1:tx 9711.74: Ix46
Workers' Cumpensation Insurunce IsIftdosit: liuilders/Contractors/Electrici ans/Flu mbers
Il 1 )licant Information Plerse Print I eeihly
/Syj
Name 111uwasyl�rganV.IitaNlnd,\ duull: l( I` . A
City,state.Zip S 11a />/� Vr/� - 020®Z Phone I!: j�J—2'0Z l3s/
.\rc)ou an employer:' Check the appropriate box: 7•)pe of project (required):
1.❑ 1 .un a employer with d. ❑ I an a general contractor and 1 6. ❑ New construction
cngslu)ccs(full +nd/ur part-un,c).' huvc hired the suh-contricturs 7. Q Remodeling
2. 1 .on a sole proprietor or partner- listed tin the anached sheet. i
�silip and have no cinployuc+ These sub-contractors have S. Q Demolition
\sorking for me in any capacity. \workers' comp. insurance. V. O pudding addition
No workers'cum 5. ❑ We are a cniporation and its
P insurance officers have exercised their 10.0 Electrical repairs or additions
I required.] 1 I. Plumbing se airs or additums
J.❑ I ant a homeowner doing all work right of cxempl d per MGL ❑ b P'
myself. (Ko workers' Lump. c. )52, j 1(4),and we have no 12.❑ Ruufnpairs
insurance required.] ) cinployces. iKo\workers' 13.0 Other
comp. inwrancc required.]
•wiq .,qJ,c+la ulat chccka box III mutt Abu IIII Wit the\ ,IWII INIuw S11Ywl,la Ih"r wurklni cun,pontasiwt lw1my uJiartutiurL
' I lumw,wran who\,flout this affidavit Indic+sing,hc)+re doing oil work+,W aren hire:utoudc colaxlon must-uhmis+new+Ir.liwlt,nJi",ng."It.
(,v,lrxhors thus check the box mlas+uwhed en ACJuiun+l stoat shuwiuy the nLtto of this sub.:onlrwlu and then%urkers•Limp.Imlay mfurm:mon
l anI UPI empluyrr that is proi,irlirrg workers'rarnpenartion hcrarance for illy employees. Below is the policy and fob site
alforalatialr. n�
f'714•erlrgk-2Nrie4
Imurancc Company Name: --- _. - ----------
Lt e c:'7�CL y p-0ff
1'olicv g ur Sclf-ins. Lie. H: l'vl .. . _ __ Enpirauun Date:
3�( Get\/4�/K�t I�<( CIty:SlatuZlp:
lob Site Ailtiress: l -�—
.\ttach it copy of llte workers' compensation policy declaration page (showing the policy ntuuber and expiration date).
I;adurc m,ccurc cowemge as required uodcr ScLliun 25A ul'VIOL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51.5na.00 and/ur one-year imprisumncnt,as \well as cswil penalllcs in the furor of a STOP WORK ORDER and a fine
.if up In i250.00 it Jay .Igainal the violator lic ado&,wd that a copy of the mulcmcnt may be Ibrwarded to the Office of
I n\;anq+unth ulalc UI,\ :or insw.u:cc.,n ctagc \a llicauon.
/Ju herchy t:rri/'v gaoler the prtlns and prno/Iic•v of perjary/hell the rut/urinrrllon province/abuvv is true and correct.
7LI) 2 /—yam
i)/Jiciul ust mdy. /)d nor grist in r/Ii, un•u, tube ruurp/<•rrJ by ciq,sir/asvn a//iciu/. -
(-iiv ur i own: _... _—. Per mitil.iec nsc 0
Iswuing \uilluriiv (circle noel:
I. Ib,arJ �,f Ilcalth !. ISuddin� Dcp.tnmcul 1. It itt.•1'ums Clerk J. Electrical luspcctor S. Plumbing luspcctor
6. Other _
('unlace Tenon: .. .. Phone it:
I
Information and Instructions
N I.% hu.etb Gcncral Laws chapter 152 icquires all emPlo)crs to provide workers' compensation for their entployces.
Pur.u.umt w t:us ,it uie, art rmphuiee is defined is - --%cry pet ion in the service of another under any Contract of hire,
:.pre» or implied, oral or written... .
An .,npluyer is defined as "in individual, partnership, association. Corporation or other legal cnttry, or any two or more
"r 11w torceou;g engaged it a joint cnterpnsc. and ptcluding the !cgal representatives of a deceased cmplu)cr, or the
receiver or trustee ul .ut wdrvidual, pair er,ihip,association or other legal conty, employing employees. However the
owner of dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelluig hou.ie of another who employs persons to do maintenance,cunstructitao or repair work on btich dwelling house
or on the--rounds or budding appurtenant thereto shall not because of such employment be deemed to be in rmplo)er."
\IGL 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."
Wilitwnally, %IGL chapter 152. 425C(7)stales"Neither the commonwealth nor any of its political subdivisions shall
enter into any cuntract for the performance of puhlie work until acceptable ev'idcnce urcompliance with the insurance
requiremcnis of this chapter have been presented to the contracting authority."
Applicants
Pleasc rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)nane(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
.\ccidents for conf)miation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Llepartment 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'rown Officials
Please he iure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of t e affidavit fur you to till out in the event the Office of Investigations has to contact you regarding the applicant.
I'Icabe be sure to till in the pcnniulicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitJlicense applications in any given year,need only submit one affidavit indicating current
policy intormation(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
vear. Where a hume owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dug license or permit to burn leaves ctc.)said person is NOT required to complete this atfidavit.
I he ()i)icc o(lincsti--atiuna wuuld Ii�c to dunk you in adv:utcc fur your Cooperation and should you ha�c .shy qucbltuni,
plea,--du nut hesitare to give us a call
fhc Ucp.uunem's address, telephone and fax number-
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. N 617-7274900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
a r.:.cd 5 `aui
www.mass.gov/din