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0094 LAFAYETTE ST - BPA-06-663
e 1 /23/06 Dam a..a Is PP*MIV LooM h Les"Sm Of 94 Lafayette St. toNb oIn' ' ' 'I YM..No. 1s Popov LOUNd in bOarMlo>rp11AOM Y4k.No_ BUBJ"N MV APPLMTION FOIE penk UK ( ►(fit W* Mw aft) k* $Wft COMM a0k. &N" P" pLLMK V LLWTUMLr&COLqLsMVTOAvao aura w PFAM89M TO THE INSPECTOR OF BLU DINO&: The W dWIVIed hMltby 0*9 lOr a p&VA 10 bUld =Wft 101tM fOMowkl9 Owrlws NMM Strega REalty Tiust 94 Lafayette Street 97R 741 -0004 Ad*M& PINO Sal em_n M�� ], Afd*§WsN� Gray Architects, Inc . 9A Derby Square 978 745-4404 IlddnstAPIMN Sal m . MA 0197n IMICharda S - NWA Porter Engineering, Inc. 17 Wallis Street 978 531 -0581 Address& Fftm Peabody. MA 01 960 1 macs ftPapaoilOvlYYnp9 Restaurant Masonry & IIMo>r10101�11k9 Wood Frami na s sdMO n 1W hW ffA '1 h1o11n7 VMkQft DdM1~ Yes Ash~ Unknown $152 ,000 .00Ovuwr W A amLioM CS025859 am U'..t X of , ilowo UN THE Pf "w W mar OESCwP' M OF WM TO N DONE Prepare building for elevator and install same. New concrete foundation for elevator pit, new masonry elevator shaft and new elevator Machine Room. ��PET'TO+-.� Porter Engineering, Inc. P.O. Box 708 , Peabody No. APPLICATION FOR PIMIIT TO f2�-i p,- %moo r LOCATION Pr�wlrr IlNW%GT(M OF OLNLDOW email:Porterco@vedzon.net Since 1882 Tel.(978)531-0581 Fax(978)531.0580 ,. PORTER ENGINEERING; INC. General Contractors ^ 17 Wallis St.,P.O.Box 708 ALFRED J.DiMAMBRO Peabody,MA 01960.7708 I CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET. 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 Salem Building Department Debris Disposal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as Po defined b h' MGL Chapter III, S 150 A. Y The debris will be disposed of in: Graham Waste Service Cohassett, MA (Location of Facility) Signa a of Applicant Porter Engineering, Inc. 1 -23-06 Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information "' ' Please Print Legibly Porter, Engineering, Inc. Name (Business/Organization/Individual): Address: 17 Wallis Street P.O. Box 708 Peabody,-.MAx,-01 960 : ;dat 97.8-531 -0581„ . City/State/Zip: � Phone#. Are you an employer?Check the appropriate boa Type of project(required): 1.® I am a employer with 7 4. ❑ I'am a general coniractor and I 6.:❑New°construction ` employees(full and/or part-time).' have hired the subscontractors 2.ElI am a sole proprietor or partner- listed on the attached sheet : 7. Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. , 9. ❑ Bum7ding addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or.additions required.] t ,. iL ,t;, officers have exe clsed their` 3.ElI am a homeowner doing all work right of exemption per MGL` 11:❑ Plumbing'repairs or additions c. 152, 1 4 ,and we have no myself. [No workers comp. § O „ 12.❑ Roof repairs insurance required.] t employees. [No'workers'" ..1 _13.0 Other comp.insurance requred.l 'Any applicant that checks box#1 must also fill out the section below showing their;workens'compensation policy information' t Horneowners who submit this affidavit indicating they are doing all work and than hiie;outside contractors must subnrit a new affidavit indicating such tContractors that check this boa must attached an additional sheet showing the name of the sulrcontrictors and their worker;'comp:policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Eastern Insurance Group - AIG Ins. Insurance Company Name: WC89352711 1 /3/07 Policy#or Self-ins.Lic.#: Expiration Date: 94 Lafayette Street — Salem, MA., 01970 Job Site Address: City/State/Zip: 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 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 ceWfy under the pains and penalties of perjury that the information provided ab ire is true and correct Signatare: /� '� 4 Dater Phone#: S3/ V,S gy. Offwial use only. Do not write in this area,to be completed by city or town offilcial. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers,to provide workers' compensation for their employees.' Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, 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 having not more than three apartments dud who resides therein,or the occupant of the, dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL 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." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions 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." t ,F Applicants Please fill out the workers' compensation affidavit completely,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(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 confirmation of insurance coverage. Also be'sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit of license is being requested not the Department 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"' should enter their self-insurance license number on the appropriate 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 permit/license 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 new affidavit must be filled out each 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 The Office of Investigations would lilce 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-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia I� OATS)MMI001YYYY) PRODUCER <sDo>`333 CERTIFICAT FAX E-1214 OF88LIABILITY THISNSIURAINCED ASAMATfER OPINED MAT 006 ON EASTERN INSURANCE GROUP LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 WEST CENTRAL STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NATICK, MA 01760 INSURERS AFFORDING COVERAGE NAIC # INSURED EH Porter Construction Znc INSURERA: West American Insurance Co 17 Wallis Street INSURERS: Ohio Casualty Group Peabody, MA 01960 INSURERc: American Home Assurance 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. NSR' OD' TYPE OF INSURANCE POLICYEFFECTIVE POLICY EXPDATE W,IRATION POLICY NUMBERDATE Mminntyyj LIMITS GENERAL LIABILITY BKW0753179039 01/03/2006 01/03/2007 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S 100,000 CLAIMS MADE ❑OCCUR MED EXP(Any one person) 5 5,000 A PERSONAL&ADV INJURY S 1,000'000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000 POLICY FX1 PRO- R OC AUTOMOBILE LIABILITY BAW0653179039 01/03/2005 01/03/2006 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY S A (Per person) X HIRED AUTOS BODILY INJURY S X NON-0OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC 5 AUTO ONLY: AGG S EXCESSIUMBRELLA LIABILITY US00753179039 01/03/2006 01/03/2007 EACH OCCURRENCE S 1,000,000 X OCCUR O CLAIMS MADE AGGREGATE S 1,000,000 B S DEDUCTIBLE S RETENTION S S WORKERS COMPENSATION AND WC8935271 01/03/2006 01/03 0000] WC STATU-EMPLOYERS'LIABILITY C- ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000. OFFIOERIMEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE S 1,000,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 OTHER ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS MISCELLANEOUS WORK ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY S t OF ANY KING UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Roseman Fulham/PMA rtG `yy CORD 25(2001/08) ©ACORD CORPORATION 1988 ✓�ie l�omUnzo�auseal�. o�✓��ar�uaeCta t . BOARD OF BUILDING REGULATIONS t License: CONSTRUCTION SUPERVISOR Number: CS 025859 Birthdate: 0 7/1 511 9 3 6 Expires: 07/15/2007 Tr. no: 2001.0 Restricted: 00 ' ALFRED J DIMAMBRO 27 MEDFORDFORD, RD MA 02155 Commissioner E