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90 LAFAYETTE ST - BUILDING INSPECTION (8) E E CPPY OF SALEM PUBLIC PROPRERTY DEPARTMENT �,Ms\l 6f' {3A`IL �l�u. t�`1.cst(Lv::Jt.i 7EtT•iu:s•.��sK»u.cn\'.:9 T1tt:,n,�wtlts�f.�97{'7�6'MN Construction Debris Disposat AfAdavit (required fat all demolition aid renovation work) in=onlanee with the sixth edition of the State Building Cody.790 CUR section It t.S Debris and the provisions ofMGL c 44 S A Building Permit• _ is ismed wi*the condition that the debris resulting Harr this wet shall be disposed of in a propaaty licensed waste disposal facility as defined by 1dGL c tlt.SiSOA. The debris will be transported by: roam.ac haulm) rho&-bris will be disposed of in : luanr ui r'acd(ty) ..ltd CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT wmlWItt r.Y nnbrta.LL M sYc>s l2r WAAe.V:7 IPI Sttttmr•Sun w,MAULAc7 n_.[YY%01973 AL.M74S."9S •FAX:9M740.9ee6 Workers' Compensation Insurance Affidavit: Builders/Contraetors/Electrldansn%mbe» AnallCant Information Please Print Legibly Name ttluvnessrortanintiowlmhvuhnp: RC-6- LL-e. Address: )'7 L >'��roo sy))� ),PW aZ,7L4 '< Citylststedzip: !'hone#: G 1 7 Are yen an empleyer7 Cbeek the appropriate be= f 1.0 6.1 am a employer with 4.El am a gestural contractor and 1 (-ol project(required): � �� etnployaw(rull and/or part-tine).• have hired the sub-contractors New ronstrtsetien 2.0 1 am a sole proprietor or partner- listed on the attached short t 7. ❑Remodeling ship and have no employees These sub conttsewrs have g. 0 Demolition working for mL in any capacity- workers'comp. insurance. q, 0 Building addition (too workers'comp. insurance S. 0 We am it corporation and its r-quin-Al officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repair%or additions myself.(No workers'comp. C. 152,§1(4),and we have no 12.El Ruofrt:pairs insurance required.) t employees.LNo workers' comp. insurance mquirtxLj 13.®OtherC hTe l �S 'Any.ppt cant tt n elkebe boa el neat also rim uu tha aactim h�iuw aawieg t6etr tvurkete wwpaswLte pwwy ia6umW tens 't tustwwttan who subotil Hie aaldavu indisatotg fry ate""at watt awe than hbe wastes contmoors meal submit a new amdevil ittdtading such. =C',mtrxwn thet cMea this box nu es smelted au adt itiwW AM Jawing Hs notes of He mb connataan see their wuthan'costs.policy Wfunn edtr l um an employer that Is providing workers'comprissadon huraronce jar my employees Below Is the policy and Job rite i'llarmatfwa, Insurance Company Namr. _ _ Policy 4 or Self-its. Lie.#: / _... _ .---- Expiration Date: Job Site Address: qD 2W t-4,e C4 CityiStata2ip:_ .%track a copy of Ilto 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 ri nc op ro S 1.500.00 and/or one-year imprisonment,is well as civil penalties in the form of a STOP WORK ORDER and a fine ofup to S250.00 a day against the violator. ale advised that a copy urthis statement maybe forwarded io the Office of lu..angmuuts of thu DIA for insurance covcn.,c verification. l do hereby cerrIfy Aulder the pains arc naltbs ofper/pry that the in/ormallon provided above is true and correct Dater, Pit, is 6 / 7 S O/Jkid ttse only. 00 nay write/a rib area,to be compfete✓by clay or tower a/jletat Ciry or 'Town: _ . Permit/License Al Issuing Aulburily(circle onc): 1. Doard of Health 2. building Department 3.Cilytrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: _ Phone q: Information and Instructions Massachusetts Gcneral Laws chapter 152 requires all employers to provide workers' compensation for their empbyees. Pursuant to this statute,an ejapt a is defused as`...every person in the service of another under any contract of hire, eapmss or implied,oral or written" .%n errFfoyer is defined me"an individual,pare msbip.associauoa6 corporation air other legal entity,Or any two err mote of the foregoing engaged in a joint enterprise.and including the legal representatives of a deceased employer,or the receiver or tcustes of an individua4 partnership.association of other legal entity.employing employees. However the owner of a dwelling houm having not more than these apartments and who resides therein,or the occupant of dw dwelling house of another who employs Persons to do maintenance.cunsruction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not license of Rich employment be deemed to be an employer." MGL chapter 132. ¢23C(6)also stares that'-avert'state or local licessfng ageary AM withhold the Issuaave er reaewal of a Iteetste or permit to operate a business or to eoastruct buildings is the con mosweahh for say applksat"be has act produced acceptable evideaee of compliance with the insurame coverage regtdred." Additionally.MGL chapter 152,$25CM states"Neither,the commonwealth not any of its political sublihitioas shall 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." Applteasts Please fill out the workers'compensation afldavit completely.by checking the boxes that apply to your situation and,if necessary.supply cub.eoneraator(s)nxrne(s),addresses)and phone number(s)along with their certificate(:)of insurance. Limited Liability Companies(LLG7 or Limited Liability Partnerships(LLP)with no employees other than the members or partners,we not required to carry workers'compensation insarewc. if au LLC or LLP doer 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 aMdavIL 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 Inluuurial Accidents. Should you have any questions regarding the low or if you are required to obtain a workers' compensation policy.pleats 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 Oflkials 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 applicane Please be sure to till in the pernittlicense 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 now affidavit must be filled out eacb 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. fhc Oi rice 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 Offte of Iawstlpttioala 600 Washington Skeet Boston,MA 02111 TO. N 617-7274900 ext 406 or 1-977-MASSAFE Fax 0 617-727-7749 Rcvi%cd 5-26-05 www.maw.gov/tilt BOARD OF BUILDING REGULATIONS Licenser CONSTRUCTION SUPERVISOR i Number: CS 086143 Birthdate: 11/01/1964 Explies:,11/01/2007 Tr. no: 86143 - _ — -- Restricted: 00 MICHAELG BERNIER i a -16 CHANDLER ST D, NEWTON, MA 02458 Administrator - ACORD CERTIFICATE OF LIABILITY INSURANCE 10//2972 o' PRODUCER (978)356-5511 FAX: (978)356-0214 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bernard M. Sullivan Insurance Agency 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: NSU RER D: Somerville MA 02143 INSURER E DOVERAGES 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. G T H N REDUCED YP PAID QINBR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MMIDD/YY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES ea ocaEenoe $ 50,000 A CLAIMS MADE [XI OCCUR 3Cw6956 3/30/2007 3/30/2008 MED EXP(Any one erser $ 1,000 PERSONAL B ADV NJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGRFGATF LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY JECT LCC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accitlenp ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIREDAUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accitlen0 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAA C $ AUTO ONLY I AGO $ "CESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE $ S DEDUCTIBLE $ RETENTION S $ WC STATU- SLR EMPLOYWORKERS COMPENSATION ON AND IM T R EMPLOYERS LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFLCER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE$ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S OTHER DESCRIPTION OF OPER nONSILOCAMONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Re: 90 Lafayette St Salem, MA 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 J Lewis, Acct. Exec./ ACORD 25(2001108) ©ACORD CORPORATION 1988 INClNA.m nm nn., .—I^r 9 Cr "7 PUBLIC PROPERTY DEPARTMENT MAYOR . ,apw snsar♦sw,�4Kuaas.�,s ot.'ro ma+s.sas.FAs:rna+a9w AppLLCAnM FOR THE REPAIR. RENOVATION_ C0NCTgUCTiON, DE.rIOLITION.OR CAANGL OF USE OR OCCUPANCY FOR ANY ZXLvLl C STRUCTURE OR BUIQ.DINC- 1.0 SITt INFORMATION Location Name: `�D /A q4j k So,-,V—\ (319'70 PropwV Is boated In a;Conservation Ares YM HWAft Dlatrlet YIN _ 2.0 OWNERSHIP INFORMATION 2.1 Owner of Lanai _ Name: To 2- LLLG Address: 9 O 1 ovr� e e S Telephone: i 7 5 9 z Z &a COMPLETE THIS SECTION FOR WORK IN E70182lDILi BUILDINGS ONLY Addition Existing 2- Renovation Number of Stories Renovated Change in Use New Demolition lusting Approximate year of floor (sfl Renovated construction or renovation 1 7 t d 1:7 of existing building New Met Description of Proposed Work: RA I�csa_ ,r-M-� 6 w 4w-) eE-Pb 2 - Y�'Co �rlsr-� ✓-� �-��c�-t (ter r,�l � a -- ---Mail Permit to: gC-(=, i ao WrnS S .vr,� - - - What is the current use of the BuiWUV? Material of Buldin g? y4ASStr1 Y i _ if dwenhi%how many units? tic) Ww ti+e CO^r0^^to Law?�� S Asbestos? ArehitecCs Name Address and Phone ( t Mechank's Names A Address and Phone 1-r/ iv e, 1�o '� �'-v y I a� �� ✓� �-c-- YLvIC ��� .� Construction gupenisore L mn"r c�6b I LI 3 HIC ReyistratiOn 0 Estimated af Proms 2� oo U Per"Fee Cakxdsdon Permit Fee av Estimated Cost X s7/i1000 Residential - - Estimated Cost X i11/i1000 Cartunardal --- An Additional$5.00 is added as an Administrative charge. Make curs that all flews are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated speck;ations, Signed under penalty of perjury Date r zv v _ I 5 A 06 0 r