90 LAFAYETTE ST - BUILDING INSPECTION CITY OF SALEM
7 PUBLIC PROPRERTY
DEPARTMENT
xnuaeRM DRtscotr.
WYOR l�..
IM WA20*TM SI M*ULEK MASSAC}iUS M 01970
TEL 978.745-9S" a FAX:978.740.9846
Workers' Compensallon Insurance Affidavit: BulldeyContraetonMectfldana ittmben
Applicant Information plea..,pti{ e
Name(BtsinesUOtpnitationtmvidaal): Vl')1 ••.�(�el 'e ✓'�,—� !�C 6, -L.C C.
Address:_ l7 .L y'o I� S� Sv ' /On
City/Statemp: S,tvnv> v; yL 4 0 f r�
Pltotu#:_ LI '7 6 z 1 S
Are yom as employer?Cheek the appropriate boXs
1.❑ I am a employer with 4. Q9I am A general contractor and IFRe
Projectegdred):
employees(hU and/or pameims).• have hired the sub-eontractors on
2.❑ I am a sole proprietor a partaa6 listed on the anached sheet.t ship and have no employes These sutb tuxa have working for me in any capacity. workers'co mp.insurance.[No workers' comp.inw=noe 5. ❑ We ate a corporation and its g adition
1e4Wred.] officers have exorcised their 10.C5Etectrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.Q Phtmbing repair or additionsmyself.(No works='comp. a152.11(41 and we have no
grans required]t employes.( �
No workers' 12• oof repairs
comp. . feQWred) 13.0 Other
;Any wvuaw row cheat bout at maw der ea as the a cdw below sbm*afdr wake•mV=.sy,e Play inaametlaa
tC�tbw eAwk wbo d&bbaa no aftd ��i8•at ma ikm me ouades eamaeta I nowt wbms.aw MI&A 6atia ft=CL
showhtg ft n®e of the s ubaw,yppe and their watksn comp.troy inlietmntlaa
injormarfaa ass as employe that It providint tverbn'eompensadoa insaroaee for my employees Below isthe polfry and Job rite
Insurance Company Name:_ eiI n <Z ,- ✓1 T�
Policy S or Self-ins.Lie.S 3 c W 9 S jo
Expiration Date•_ 1( 301 Ca k
lob Site Address: 9 0 �(Peg-P
City/State/Zip.
Attach a copy of the workers'compensation policy declaration Pap(showing the
Failure to secure coverageas g Policy number�ex;n=lmttnante}
required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to E 1,500.00 and/or one-year imprisonment,as well as civil MWtis in the form of a STOP WORK ORDER and a tine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the OtHce of
Investigations of the DU for insurance coverage verification.
Ida hereby certify ardor rho pains and penaldts of perJwrp that the Injormedoa provided above Is true and correct
Phone
/ a
oplat are only Do not write in this area,to be complefed by city or lown oJjlew
City or Town: Permit/Llcense f
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.CRY/Town Clerk 6.Other 4. Electrical Inspector S.Plumbing Inspector
Contact Person: Phone p:
Information and Instructions
Massachusetts General Laws chapter 152 requites an employers toy ovide the service oaf a�wther compeun nation for
their
conaad of hire.'
employem
Pursuant to this statute.an...doyee is defined""*..every person
express or implied,oral or written."
�corporation or other legal mtiry,or any two a mom
An enipfoye►is defined es"an individual,parmashtR ves of a deceased employer,or the
of the foregoing engaged in a joint 001708e,and including tha b�relifM n Toying employees- However the
receiver a•trustee of an imdtvidtia4 partnership,association or orbs legal
not mac than three apumanb and who resides therein.a then such
dwelling
owner of a dwelling house having m�maintwance.construction
or repair work m such dwelling house
atdwelling the
of smother who employs persons Shall not because of such employment be doamed m be an employer."
a on the grounds or building appurtenant
stets or teal neenalng agesoy shag wit"d the ban""K
MGL chapter 152.12SQ6)also states*""Ovary in the commonwealth for ant
to operate a buslaaa or to arotrser buildings���average required."
nsarral of a tlaas et p acceptable ensue of ampWaea wft the
applicant who has not produced e152,125C('n ststes"Neither the commonwealth nor a�of its t subdivisions
the insurance
Additionally,MGL chapter of public work until acceptable evidence of comp
liance
ester into any cmtnct Par the �presented S to the contacting&udW tY•"
ngdr�asr of this chapter
Applkasb
ion affidavit completely.by checking&a boxes that apply to your situation and.if
Please till out the wotkaa Conjr(a) a mees phone number(s)along with their catificate(a)Of Than the
neccssatY,supply sub-contracmds)nan a),addreae( ) abil with no employees
insurance. Limited Liability Companies(LLC)a Limited Liability parmenhips(If an LLC LI P) or LLP does have
members or Par1uBM ate not required to carry wod compensation be submitted
a policy is required. Be advised that this aff[davit may be submitted w the Department of Industrial
Of insurance coverage. Aloe be stir to sign and date the auldaviL The affidavit&b000m
Accidents for confirmation application for the permit or license is being requested,not the Department
be returned to the city or town that the the law or if you an required to obtain a workm
Industrial Accident. should You have any queffi�a regarding umbe
ffi the number listed below. Salfinsuted companies should enter that
compensation policy.please all the Department lino.
self-insurance Ham number on the
City or Tows OfDdsb at the bottom
Please be sure that the affidavit is complete and Printed legibly. The Department has provided a space to contact you regarding the _
of the affidavit for you to fill out number which will be useentd ere rthe Oaks of investigations Mefaenca number addition.an applicant
Please be sure to fill in the panni lications in any given year,need only submit one affidavit indicating current
that must submit multiple petmiMicense app
policy information(if necessary)and under"Job site Address"the applicant the city
or town may be provided to thhe or
Of the affidavit that has bean otRciolly stamped or marked by tY
town)."A copyr filtursperm or licenses. A new afdrvit most be filled out each
applicant a•proof that a valid affidavit is on file f a license or permit not related m any business a commercial venue
year.Where a home owner a citizen is obtaining is NOT required to complete this affidavit.
(i.e. a dog license or permit to bum laves ate.)said person
e of investigatio a would like to thank you in advance for your cooperation and should You have any questions.
The Offic
please do sot haitate to give us a call
The Department's address,tclephone and fax number.
The COMMMwealth of Massachusetts
DepaBment of industrial Accidents
Of&*d Investiptions
600 Washi080011 sheet
Boston,MA 02111
Tel. #617-727-4900 CM 406 of 1-877-MASSAFE
Fax M 617-727-7749
(revised 5-26-05 www.vwss.Vv/diA
XS BROKERS
INSURANCE BINDER
THE TERMS AND CONDITIONS OF THIS CONFIRMATION OF INSURANCE MAY NOT COMPLY WITH THE SPECIFICATIONS SUBMITTED
FOR CONSIDERATION. PLEASE READ THIS CONFIRMATION CAREFULLY AND COMPARE IT WITH ANY QUOTE AND SUBMISSION
DOCUMENTS AND REVIEW THE POLICY FORMS FOR THE ACTUAL COVERAGES PROVIDED.
IN ACCORDANCE WITH YOUR INSTRUCTIONS, AND IN RELIANCE UPON THE STATEMENTS MADE BY THE RETAIL BROKER IN THE
INSURED'S APPLICATION/SUBMISSION,WE HAVE OBTAINED INSURANCE AT YOUR REQUEST AS FOLLOWS:
DATE ISSUED: March 30, 2007
PRODUCER: Bernard M. Sullivan Ins. (RATS LLC)
981 Worcester Street
Wellesley, MA 02482
INSURED: RCG Builders, LLC
- - - attn: RCG LLC 4th & Broadway LLC
17 Ivaloo Street
Somerville, MA 02143
PRIMARY 1ST LOCATION: 17 Ivaloo Street , Somerville MA, 02143
INSURER: Essex Insurance Co AM Best rating: A
Non-Admitted
POLICY NO.: 3CW6956 RENEWAL OF:
POLICY PERIOD: 3/30/2007 TO 3/30/2008
COVERAGE: Commercial General Liability TERM: 12 Months
12:01 A.M.STANDARD TIME AT THE LOCATION ADDRESS OF THE NAMED INSURED.THIS INSURANCE BINDER WILL BE TERMINATED
AND SUPERSEDED UPON DELIVERY OF THE FORMAL POLICYIIES)ISSUED TO REPLACE IT.
LIMITS OF LIABILITY: $2,000,000 General Aggregate
$1,000,000 Products/Completed Operations Aggregate
$1,000,000 Personal &Advertising Injury Limit
$1,000.000 Each Occurrence Limit
$50,000 Damage To Rented Premises
$1,000 Medical Expense(any one person)
POLICY FORM: Occurrence
EXPOSURES: $4,000,000 Sales
DEDUCTIBLE: $1,000 Combined including LAE
PREMIUM: $20,000.00
Inspection Fee $125.00
TAXES: $800.00
TRIA PREMIUM: REJECTED
TOTAL: $20,925.00
ENDORSEMENTS / EXCLUSIONS:
ME001 Excludes Asbestos, Lead, Pollution, EPLI, Mold, Pun Dmgs, A&B, Animals,Athletic Participants, Internet
Exposures, Liquor, Breach of Contract, Cross Suits, Intellectual Property, Class Limitation, Contractual Liability Endst,
Limited Terrorism if purchased. Employee/leased worker&volunteer exclusion, Lessors Risk only endst.
ME002 Excludes Subsidence, Subcontractor Endst(sublimited coverage without COI's), Employees of Independent
Contractors Exclusion.
ME170 Premium Basis Edst
Premium is 100% Minimum& Deposit.
ME-043 Combination Contractors Endorsement(excl EIFS, movement of buildings or structures, underground utility
locator endst, roofing endst)
SUBJECT TO:
In order to BIND coverage, we need the attached Terrorism Disclosure form signed dated by the insured with the
appropriate"accept/reject box"selection made. Subject to the original signed, dated Application and Affidavit within 10
days of binding.
Subject to Inspection.
TERMS/ CONDITIONS:
25% MINIMUM EARNED PREMIUM AT INCEPTION.
ALL OTHER TERMS AND CONDITIONS APPLY PER FORM
COMMISSION: 10%
CANCELLATION: THIS POLICY IS SUBJECT TO THE CANCELLATION PROVISIONS AS FOUND IN THE POLICY(ES)OR CERTIFICATE(S)
CURRENTLY IN USE BY THE INSURER. THE INSURANCE EFFECTED UNDER THE INSURER'S BINDER CAN BE CANCELLED BY THE
INSURER (SUBJECT TO STATUTORY REGULATIONS)BY MAILING,TO THE INSURED AT THE ADDRESS STATED ON THE FACE OF THIS
CONFIRMATION OF INSURANCE, WRITTEN NOTICE STATING WHEN SUCH CANCELLATION SHALL BE EFFECTIVE.IN THE EVENT OF
CANCELLATION BY THE INSURED,THE EARNED PREMIUM WOULD BE SUBJECT TO THE MINIMUM PREMIUM IF APPLICABLE.
THIS CONFIRMATION OF INSURANCE IS ISSUED BASED UPON THE INSURER'S AGREEMENT TO BIND AND IS ISSUED BY THE
UNDERSIGNED WITHOUT ANY LIABILITY WHATSOEVER AS AN INSURER.
AS A REMINDER, you are not authorized to issue certificates that add or modify language in any way without
express XS Brokers approval first. Except when the certificate holder is automatically considered an additional
insured under the policy form,XS Brokers must be notified when adding any certificate holder as an "additional
insured", so that the proper endorsement can be issued. Certificate holders should never be added as an
"additional named insured"without express company approval.
PREMIUM PAYMENT IS DUE WITHIN THIRTY(30)DAYS FROM EFFECTIVE DATE UNLESS OTHERWISE STIPULATED.
Tony Constanzo
UNDERWRITING CONTACT
INSURED:RCG Builders, LLC
DATE ISSUED: March 30,2007
Created by:Tony Constanzo Reference#:0532056
CTTY OF SAuu
PUBLIC PROPE M
DEPAA'TUDPr
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BOARD OF BUILDING REGULATIONS
y License:,CONSTRUCTION SUPERVISOR
'* Number: CS 086143
BiRhdate: 1110111964
Expires: ivol/2007 Tr.no: 86143
Restricted: 00 .
= z MICHAEL G BERNIER
} 16 CHANDLER ST "0
NEWTON, MA 02458 Administrator
96 Lafayette Building Improvements
Assumptions
#Units 1
Gross Square Feet 16,992
Net Square Feet 14,443
Construction$/NSF $ 22.39
Division Label
Division 3 Concrete $25,922
Division 4 Masonry $19,439
Divion 5 Metals $50,700
Division 6 Wood and Plastics $5,780
Division 7 Thermal/Moisture Protection $57,120
Division 8 Doors and Windows $15,370
Division 9 Finishes $7,391
Division 10 Construction Specialties $0
Division 11 Equipment $0
Division 12 Furnishings $0
Division 13 Special Construction Systems $17,960
Division 14 Conveying Systems $73,000
Division 15 Mechanical $33,650
Division 16 Electrical $16,980
Construction Subtotal $323,312
90 Lafayette Construction Cost Total $323,312
EI I QF LE v ---
PUBLIC PROPERTY
DEPARTMENT
KI.%MERLFY ORLSCOLL
MAYOl 1721 WASHINGTON SMEE'r•SAUiK.%i&%A RLShTIS 01970
T7t 978-745-MS*FAx 978-740-9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
rSITENFORMATIOName: o S Building:
ddress:Is located in a; Conservation Area YIN Historic District YIN ` v
rJ
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land Lcn
Name: p L o1 e yi`�__ LLc
Address: Q ( o
( ? ✓c� l�� `sb_ pz Tz��
Telephone: t (I 6zS q 3( .5 �2 '� 1nz - 2�v,(
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing Z
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing 1r> ab
Approximate year of 92� ? Area per floor (so Renovated
construction or renovation
of existing building New
Rrief Description of Proposed Work: l /
-ern is r e .ii i
12,
Gy,� I-✓S� �'��?'/,e-l.eil � Yz-P�c�.>� , �.I�L�a� �717�a�l
Mail Permit to:
What is the current use of the Building? I�
Material of Building? 3�XR1,01 rY, If dwelling, how many units?
Will the Building Conform to Law? Asbestos? "/A
Architect's Name U2)y
Address and Phone 17 y✓ca�na �sy c lob
AA6 r 7 SR l 86 9 a
Mechanic's Name Y2'4-W 2V)10
Address and Phone �7 L✓�)�� `-b-
Construction Supervisors License# c,86143 HIC Registration# !ter T SRi gb��
Estimated Cost of Project Permit Fee Calculation
Permit Fee$ 35& + 00 Estimated Cost X$741000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields 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
specifications. Signed under penalty of perjury
Date _
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