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90 LAFAYETTE ST - BUILDING INSPECTION (7)
CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT al�u a tDC 7.�sv::owiatsaT•iu:».ft.�vitt�u.t�1■�:ir '11a:r0!lfa�•rlts �f•�9747atY1W Construction Debris Disposat Affidavit (reyuiml Cot all demolition and renovation wort) in accordance w ith the snub edition of dw State Building Code.7Sf)CMR section 111.5 Debris,and the provisions of M- GL a 40s S A Building Permit to _ is issued with the condition drat the debris rmddns Rom phis wort shall be disposed of in a property licensed waste disposal facility as defined by%IGL a 1 11.S 130A The debris will be trutsported by: 5(Sb QZJO, Sj 1'� v aj inams at haWw) rho&-bds will be disposed of in : �} (n/am_r of rrughty) - � � ..w " CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT hlwnn'Rt F.Y lNtat:ULL 12C VA*&%4TcN S1iriT a SALEK►fAifL*A.7 is Ytyj%01973 TILL 97111.743.9595 a Fnz:9M74&9M Workers' Compensation Insurance Affidavit: Builders/Cantncton/Electricians/Plumben Applicant Information r� Le /_ Please Print gibly Name ttw.vnssroraanintitwlnJrvuA/nq: rS C.�9- ;u) ,C.,-40j Z—ZC_ Address:" 17 5,_V 1�- /07J -�, O 2-1 �3 CitylStamJZip: v i 1!'hone q: Are you as omptoyer7 Cheep the appropriate bent 'ty t{� pe or project(►Haired): 1.[31 am a employer with 4. (4 1 am a general contractor and 1 6. ❑New congruction ompluyaw(rull and/or part-time).• have hired the sub-contractors 2.❑ 1 am a sole propricter or partner- listed on the attached sheer. : 7. a Remodeling ship and have no employees Them sub-contactors have S. ❑Demolition working for tote in any capacity. workers'comp insurance. 9. ❑ Building addition (too workcea'camp. insurance S. ❑ we are a corporation and its El nquircd.) officers have exercised their !0.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.[] Plumbing repairs or additions myself. (No workers'comp. c. 152.144).and we have no 12.❑Roof repaint insurance required.) t cmployeea.(A'o workers' 13 Other Wi z-<�s�r comp. insurance rcquirtxl.] -Apr:,pph"al MN chucks boa e1 men also rs l tar On No,"helot their wohms'XXI wetpw m tithes ibmil a noLL 'I luaaewtttem who auhmil Min ttmtterh indka{uta Mry ate Juiy1 ttll testa attd rhea Alm otttfidm aeermr'amtm moo.uMnt a.taw antamwk iaata{it41 such. Comrxuwt the clialt this boa Mtge attadwd;m addithmal•hest wMwmg ON time ardw mb wt{eapm teed{bek wutkem'coati•policy MAXON" MMMM l am an employer that h providing workers'competrsadoa has'rance jar my employees Below Is the pansy and fob site injwm'tima Insurance Company Name:— Policy Ator Self-its. Lic.0: Expiration Date: 3 �iU�z'c Job Site Address: `l0 "_TQL-- <.L Citylstaterzip: 15;�__LDzu .%ftach a copy of the workers' compenlation policy declaration page(showing the policy number and expiration date). Ira;lure to secure coverage as required under Station 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a ring up ao S1.500.00 anWor one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a floe of up to S250.00 a day against the violator. lie advLscd that a copy of this siawmant may be forwarded to the Office of Io\Y.11hal{Unm ul dtc DIA for iosurartt covcnyc verification. l da hereby certify u/nlder the pains andpenakle f*rJury that the irofarmat/on provided above is sae and correct - tii•:,:ukkre' '-fed/� .�ZGti-�/ 1)ate 1 rF Z� ��_ UQIc%al aJe an/7C /0 mar write in rh[r area.to At complood by dry or town oJJ&•i'L City or Town: _.. Permitit.iccnse M __- lssuing Authority (circle ouc): 1. Board of lirallh 2. Building Department 3.City/rown Clerk J.Electrical Inspector 5. Plumbing Inspector 6. Other Contict Person: _ - . ___ Phone N• Information and Instructions plassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employaa. Pursuant to this snatute,an saspfeydte is defined as"...every person in the service of another under any contract of hive. rapiers or implied.oral or written." ..Lt ewpfeyer is defined as"ten individual.Partnership,amomabelk corparaben or other krgal entity,of any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer.or the association or other legal entity,employing employees. However the receiver dwellsUUM g o se huNUaving et met reship.' and who resides therein.a the occupant of the owner Ora dwelling house having not more rhea three apsrareest dwelling house of another who employs Persons to do maintenance,cuosnuction or repair work on such dwelling house or on the grounds or building appurtenant tberem shad not because of such employment be deemed to be an employer." MGL chapter 15Z 423C(6)also storm that"every sate or boreal Ikeusbag a`eney shall withhold the Issaasee or renewed of a decease or permit to opente a business or a construct buildings Is the commoawealth for say appnes who has net produced acceptable evidame of compliance with the insurance coverage required' af Additionally,MGL chapter 152,425CM stases-Neither the commonwealth not any of its political wbe ivisietes dull enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applieaets Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation and,if necessary.supply subeone actors)name(s)6 address(m)and phone number(s)along with their cortificaw(s)of insurannoe. 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 confinnstion of insurance coverall*. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or own that the application for the permit or license is being requested,not the Department of lndustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' at the number listed below. Self-insured companies should enter their compensation policy,please call the Department self-insurance license number on the apprcprute lime City or Tows 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitiliceuse 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 bat 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 ciuran is obtaining a license or permit not related to any business or commercial venture (i.e.it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. 1'hc Oniicc of investigation would like to thank you in advance for your cooperation and should you have any questions, pleuse du not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents OMOO of lavadpae" 600 WaddMISIott Street Boston,MA 02111 Tel. N 617-7274900 ext 406 or 1-977-MASSAFE Fax N 617-727-7749 Revised 5-26-05 www.mm.gov/dia oiand✓ S rds Board of Building Reg Construction Supervisor License License: CS 86143 FScplre"rj 111112009 Tr# 9354 sri P 1 i 1 M1 V., MICHAELG .. 68 JEWETT ST ` ' " � Commissioner NEWTON,MA 02458 k ACORD DATE(MM/DDP(YYY) CERTIFICATE OF LIABILITY INSURANCE 10/29/2007 PRODUCER (978)356-5511 FAX: (978)356-0214 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Bernard M. Sullivan Insurance AgencyONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 12 Market St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 568 Ipswich MA 01938 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Essex Insurance Co. XSB003 RCG Builders, LLC, DBA: C/O RCG LLC INSURER B 17 Ivaloo Street INSURER C: INSURER D' Somerville MA 02143 INSURER E'. VERAGES 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. MAY HAVE IJ REDUCED BY PAID INSR ADD-LINSRn POLICYTYPE OF INSURANCE POLICY NUMBER DATEJMMIDD/ ) PDATE MMIOLICY DYMN LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREM AMA3ES ea do.Er�nce $ 50,000 A CLAIMSMADE ❑X OCCUR 3CW6956 3/30/2007 3/30/2008 MED EXP(Any one persorn $ 1,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATELIM IT APPLIES PER: PRODUCTS-COMPIOP AGO $ 1,000,000 X POLICY JEGT Lee AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea aaident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIREDAUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per awiden) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSMMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND We STATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETORMARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERNEMBER EXCLUDED' E.L.DISEASE-EA EMPLOYEE$ Vyes, a under SPECIALAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATONSILOCAnONSNEHICUWEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Re: 90 Lafayette St Salem, um 01970; City of Salem is named as additional insured CERTIFICATE HOLDER CANCELLATION (978)356-8909 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Salem EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Bldg Inspector 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Salem, MA 01970 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE _ 1 J Lewis, Acct. Exec./ '. ACORD 26(2001108) ©ACORD CORPORATION 1988 IMCn7A,n,no,ncn Pannlnl� I IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) Gage z otz INS025(o me)oea EYI'Y-OFgXLEl� PUBLIC PROPERTY DEPARTMENT wraa tap m sneer•Sony Ws�aoasrra Otl70 710L.m7+5-95/6•FAM M746j9W APPLICATION FOR THB REPAIR. RZNOYATWX CONSTRUr_ ON_ DEriOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY ZMMG STRUCTURE OR BUILDING co SITE INFORMATION Locadon Name: D - l?luild4 Property Add- -- Property Is located in a;Conservation Ms YM HkWft DWM YIN 2.0 OWNERSHIP INFORMATION 2.9 Owner of LNW . Name: TOL _ Lr: c— Address: c-/o A�'C-76, L-L c- ! ? 43 Telephone: Gam! yr d 7-7 iJ3 3.0 COMPLETE THIS SECTION FOR WORK IN VVIENG BUILDINGS ONLY 1 Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing oD Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: in f '7_ J9 --- Mail Permit to; Kc—& What is tM current use of the Building? �� 2 Material of Buildk+g? — if dwomwo.how many units? Will ttta Buildtnp Confoee� '�-� S — Asbestos? N O AmhkmXs Name Address and Phone —� M@dAw .a ,,. RCS t�v!Z� Address and Phone l ? L✓a,L� a Consbuc&m supervisors License I , ! 3 HIC Registration It a Fee Calarlation EstYnabd Cod of Project 7J psrn�l f Estlmatad Cost X$7151000 Residential PennR Fee i --_ ESOMead Cost X$41/i100@ Comrnerdal- -- -- An Additional $5.00 Is added as an Administrative charge. Make aim that an fields are property and Ieyibly vrritten to avoid delays in processing. The undersigned does hereby apply for a Building pun*to build too Me above stated specifications. Signed under penally of perjury X Date Z ¢ d Ag S� I � �