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135 LAFAYETTE ST - BUILDING INSPECTION q� The Commonwealth of Massachusetts 4 Department of Public Safety hlassachusettsState Building Code, 80009)IVED Building Permit Application for any Building other)Ehrti 6lb>♦^�"b%Q �o fi fypwelling (This Section For Official Use Only) Budding Permit Number. Date Applied: Buildhgdffj�J�{' 12 A & 211 SECTION L LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) /3SiofrlVdIe . 5olel, Mn ,)19170 No.anti City/Town Zip Code Name of Building(if applicable) u , SECTION 2•PROPOSED WORK I Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Buildingja Repair❑ 1 Alteration ❑ 1 Addition O I Demolition ❑ (Please fill out and submit Appendix 1) i1 ChangeofUse ❑ Change of Occupancy ❑ 1 Other Specify:7RENOVATION, 7ADDITION, fl— Are building plans and/or construction documents being supplied as part of this Is an Independent Structural Engineering Peer Review requireJT Brief Description of Proposed Work:�12 Ug4 ra.4t �a r feyi on i . i nSECTION 3:COMPLETE THIS SECTION 1F EXISTING BUILDING UNDERGOING CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 31) O Existing Use Group(s): Propoacd Use Group(s): SECTION4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor,(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION S.USE GROUP(Check as applicat,le) A: Assembly A-1 O A-ZE1 Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business O E: Educational ❑ F: Facto F-t O-o F2❑ H. High Hazard H-1 O H-2 O.. .H-3 ❑ H4❑ H-5❑ 1: Institutional W O I-2❑ 1-3❑ I t❑ M: Mercantile❑ R. Residential R-10 R-2❑ R-3 O R4❑ S: Storage S•1 O S-2'0^ U: Utility❑ Special Use O and Please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ too IIA ❑ (Ili ❑ IIIAO 11180 IV ❑ VA VB Cl SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indenti(y Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: 41A I lid,ri,Comnussion Not Applicable O Is Structure within airport approach area? Is their review completed? or Consent to.Budd enclusal❑ 1 Yes❑ or No O 1 Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: <kcupant Load per Flour: Dots the building,contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 1 11 - W), } M (TC-0c 84 5*40 STfe?-' ,5ur}c (sm owlio )tea S8 Name(Print) U No.and Street City/Town Zip Property Owner Contact Information: INlllivc`+&ra „) WH&-&P0JA. 0C Title U Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip . to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.it of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. email address Registration Number Street Address City/Town Slate Zip Discipline Expiration Date 10.2 General Contractor 91ellbr&4-- t4ohfh-U6 icw Comp. y Name ,Z& HaA ly C 5 lot 9 S3 Name of Person Responsible for Construction License No. and Type if Applicable IN ah�fluieta `i�Civ� �'1IrtQka i 6. 0q3 Street Addiess City/Town State Zip &12�-IR14 (,cL- 66- 18/9 `k�l�aMai y�ei/harok; ln,v\ Telephone No. business telephone No. cell e-mailaddress SECTION 11:WORKER' "OMPENSA PON INSURANCA:AFFIDAVU M.G.L.c.152.9 25C 6 A Workers Compensation Insurance Affidavit from the Iv1A Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with.this application? Yes K No C3 SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost((Tom Item 6)_$ M6.TotalCost Budding $ Z Soo U�1 Building Permit Fee=Tohl Construction Cost x_(Insert here l $ SO 000 appropriate municipal factor)o$ 1 r2t 0. $ l (HVAC) $ Z.1 Soo Note:Minimum fee=$ (contac municipality) al Other $ U Enclose check payable to �r t $ l}0 �1 (contact municipality)and write check number here SECTION 13.SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I heby attest under the pains and penalties of perjury that all of the information contained in this application is true and ace ate the best of my knowledge and understanding. to H4mj— �u�cl',,74ea,/r-1k 6-7360. 1 9 G 'I I Please print and siggAr fa4Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval• .. Name Date Massachusetts -Department of public Safety. . Board of Building Regulations and Standards Constructioe Sapenisor License: CS_101953 14Rin HjGIIV)EW Sham MA 02843 + commissioner Expiration 04/20/2016 aco CERTIFICATE OF LIABILITY INSURANCE D7TE(MMIDD/1'YYY) lli. / 1 81612014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. 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 endorsements . PRODUCER NAMEACT Christina Jaeger Alliant Insurance Services, Inc., PHONE Exit, 617-535-7200 FAX . 617-535-7205 131 Oliver Street,4th Floor N. Boston MA 02110 EMAIL .cjaeger@alliant.com INSURERS AFFORDING COVERAGE NAIL It INSURER A:TWIn City Fire Insurance Company 29459 INSURED INSURERB:Starr Indemnity&Liability Company 38318 Dellbrook Construction LLC INSURER C:Navigators Insurance Company 42307 One Adams Place 859 Willard Street INSURER D:Allied World National Assurance Com 10690 Quincy MA 02169 INsupER E:Hartford Accident&Indemnity INSURER F: COVERAGES CERTIFICATE NUMBER:2048109695 REVISION NUMBER: THIS IS TO CERTIFY 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 INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR rypE OFADDLISUBRI POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MMIDDIYVYVJ fMMIDDNYYYI LIMITS D X COMMERCIAL GENERAL LIABILITY 03084515 11/2014 /1/2015 EACH OCCURRENCE $1,000,000 CLAIMS-MADE F] OCCUR PREMISETORENTEO PREMISES RENT occurrencel 8300,000 X XCU MED EXP(Any one person) $10,000 X Contractual PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $2.000.000 POLICY EX] PE' 1:1 LOC PRODUCTS-COMPIOPAGG 52,OOQ000 OTHER: Deductible $25,000 E AUTOMOBILE UABIUTY OBUENQT6583 /1/2014 /1/2015 (Ea accident) $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S HIRED AUTOS NON-OWNED PR PERW DAMAGE $ AUTOS Per accident 8 B UMBRELLA LIAB X OCCUR 1000021010 /1/2014 /1/2015 EACH OCCURRENCE $10,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $10,000,000 DED RETENTION$ I$ A WORKERS COMPENSATION OBWEQT6584 /1/2014 7/1/2015 PER OTH- X AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICERWEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-FA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 C Excess Liability NY14EXC7114561V /1/2014 /1/2015 Each Occurrence 15,000,000 Aggregate 15,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mare space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Dellbrook Construction LLC ACCORDANCE WITH THE POLICY PROVISIONS. One Adams Place 859 Willard Street AUTHORIZED REPRESENTATIVE Quincy MA 02169 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD m` The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibav Name(Business/Organizafion/Inaividual): Dp t . rook L f)ns4ror,41 o13 Address:0rP A`DAMS 4494G 9S9 wil�crrd S�retY City/State/Zip:liincy 41 fn O Phone#:_-Zgl - 55Y6 -/6 7s Are you an employer?Check the appropriate box: Type of project(required): 1.❑Ian a employer with employees(full md/orpart-time).* 7. ❑New construction 2.❑I am a,sole proprietor or parmetship and have no employees working for me in $ •`-ernodeling - 1�s"" . my capacity.[No workers'comp.insurance required] D r erl l .514 l 3.❑Into a homeowner doing all work myself[No workers'comp.insurance required:]t 9. ❑Demolition Uj f}tx 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I Will 10❑Building addition ensure that all contractors eitherhave workers'compensation insurance or are sole I I.Wlectrical repairs or additions proprietors with im employees. 12.Whimbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. These subcontractors have employees and have workers'comp.insuramot 13.Q Roof repairs 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other HI[IYG.- OTairs 152,§1(4),and we have no employees.[No workers'dump.insurance required.] on al Q(k(t(h arts, ors _ 1' 6_Crutar 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and slate whether in not those entities have - employees. If the sub-contractors have employees,they must provide their workers'-comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 13S IJCAV fA 5 fCe a City/State/Zip: .'5g1 GM M(N Ol 9 7 0 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un the ins and penalties ofperjury that the information provided above is true and correct. Simature: Date: t0iL/l S' Phone#: (7--31�0 -181 Official use only. Do not write in this area,to be completed by city or town official 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#: 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 and 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." 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 or 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 companies 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 pemrit not related to any business or commercial venture (i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02 1 1 4-20 1 7 Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia CITY OF SALEM MASSAa USEnS It } BUILDING DEPARTMENT 120 WASHMTON STREET,3'D FLOOR TEL.(978)745-9595 FAX(978)740.9846 KIIvIBERLEYDRISOOLL MAYOR THOMM STJP ERRE DIRECTOR OF PUBLicFROFERTY/Bum DING COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work] In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: �ti- EiVr�js,cvY (name of acility) /Ol shr t Zxbury / ,/A oz-IIq (address of facility) g t re of applicant Date '—� dart le*ntoorvv+v}_ I. CERTIFICATE OF LIABILITY INSURANCE s;512�1a. THIS CERTIFICATE US ISSUED AS A-MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. THIS CERTIFICATE OF:INSURANCE:DOES NOT CONSTITUTE A.CONTRACT-:BETWEEN THE ISSUING INSURER(S{, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,. IMPORTANT: It the certificate holder is an ADDITIONAL INSURED,the policy(ies)must beendorsed: 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.`, PRODUCER - CP"OpNTHAE CT Insurance Services, Inc., Nra, C_hi,is.t.,t,n_gJa.eee.. e.,.r,..� ...„„.,...-,tAax 131 Owe,'Sireet,4thFloor I 617 53A 12C.0 .Nm.617-o30 72C5 r-.GAIL uaeger aLlant com Boston MA 02110 .ACRRuSS...,__ram@ --- -,,,;,•.... a .,.,,.�,„,..„..�,__ ...<: INSURER{SI 0.FGO�tSinb COVERAOE�� ., eNAICR - .._...„ . _ . ....-. _. . ..:....... _.,.,-. .� . nsus RA Twin Ct�fjrt fturrance Compaq. 129459 iNsuaso ivsjaeae Starr Intlermtty&Lili61 ity Company 38318 De7lbrcok Construction LLC xsTrirac Navigators Irsuranc �Comparq 42307 One Adams Place. - -- - 859Wliard.Sdeet j INsuaeRo AAled VYorld National Assurance Cam 00E90 Quincy MA 02169 - lNstiaeBe Har`l9r d Accident& Inderrni,y IHSJRER P r x COVERAGES CERTIFICATE NUMBER:2048109695 REVISION:NUMBER:. juiS IS to CERIlrY'PIAT 1HE POLICIES OF INSURANCE LISTED BELOAI HAbE 8ELN SSUEU IO THE INSURED NAMED ED...AB.^.VL FOR THE PCJCY PERIOD INDICATED. NOTA,/'THSTA D NG:ANY R.,4UIP,E'MENT;TERM OR CONOITICN."Yt F ANY C04TRAG7 OiE OTHER=pOCt.MF,h7 r Yd$ RESP[Ci TO YnIICI1 hi15 G RTNM,ATE MAY 5E 'SSU D OR MAY PERTAIN HE IN UPANC Y CRDLD BY THE POLICIES JL CRiSLD H R IN IS S OBJECT TO ALL HE TLRW, tYSEdX.CL O-_N SAND ON.DIT IVNS Or SUCH POLICE& R"L"M"I S SF,'•tl N`N•M"A'Y AVE BE_EN.•.•-R EPDJ ECL fBf Y jP 1P OLICCYL P{X'NP B tPLQ4SURkNCkPoucyNUMECR OLrr LIP d ' r"' :'.:" •:::-- wCffYYY ii M1PnOtYfYYl r. LIMITS D IX,,..POMMLRCIAL GENERAL LIABILITY I t3O8-E:515 V1120'.4 �I',2015 3 U,Afi oCCURREN-il 11A00CCa 3 4 ( 'rFP,ht4S`it i 0 R J:Ci ( - r jb Alti$-WVn„ [y`,Orxup I { r - F RL,az}$}` Pa==ti 4et utX+.POO X x u #` arc x I n o��.Pa� T sicDoc ow us 4. Y s1,00a LTo 61'u.:,.-.Ga£u4[£UtCTYPCIEA rFF- i 4 GENERAL AOQP GA ;2ND COO POLc X :jCt:T i LOC i 7 I P i OR}P J AG °OOA u00 a, iANE3. --- ` i Ins,' .. iDetlaCible 4256+5N E AUTOMOBILE(ABILITY t I OBUENGF883 �F1112014 R t 2'7 a v N L 9 i^ S $ }, t Taro b 1 00^,000 I x<YYAL {esr�n r 3& I EJN Nt -.{JRX 2r9MSJM1) $ IAil,ONNEn :SC OD,i-@tJ p i BCD, tt LRY OP., c. )AuTuS :. . q w +M1ON cAN(5£Sb I q x "PRIrE Y04AGE *IIR6LA TS} .,._tA Ot - i 8 -UMBRELLAL(AS i X 'rt'E a i-TO00210IO OlIZO14 j1112G15 l i ,<Tfi I € t �Et,-TiD 02[.l �aQ:ROe O.I (iti a!A S LIAB X ERCE I I DE € s' ' (AU�RYC S s30,0aC daJ_ ( S ['JED i Rr FY T,OM1$ A I WORMERS COMPENSATION t'0]yyE(,`,?'gjgy EIV2014 �Arolb xIP I I AND EciPLOY£Rn LIAe:UTY YINt i. }TA R vr!RCFftt TCI a R Adbf."(Egii4V'e ` t- E E CH CCI H OCO C00 OF ICkRdEl3ee rXLLUCBII N INrA* r ,..,.._,. iN n0 Cory In Nni ` , s.Wry E, 11t A5an v,E 70E1 OW' J_SLd.-T'ILN of OPERATIONS 0oLo1UMn $1 W^Ooc C Exae%Liatlillfy IN`t1aEXG3114561V 7713U7@ jF1Y216 leachOc uence 15.000,0 0 3 ' G 'Aggregate 15,000,000. I DESCRIPTIOn OF OPERATIONS I LOCATIONS VEHICLES.(ACORO 101 AdditI0d31 Romorks Sahudulo,maybe af:at,hei 1?Iwo uI a.o a N w,od) EVIDENCE Of INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIESBE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE. WILL BE, DELIVERED IN Dellbfogk Construction LLC '` ACCORDANCEVATH THE POLICY PROVISIONS. One Aciams Place 859 Willard.Street AUTHOR¢ED REPRESENTATIVE Quincy MA.02189 Uc-.1:988-2014ACORDCORPORATION, All-rightsr@served. ACORD:25.(2014101) The.ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 M www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their ILL] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box Nl must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *.Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: 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 certify corder the pains and penalties ofperjury that the information provided above is true and correct. . S i mature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. 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#: 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 and 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." 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 or 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 companies 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 cur-rent 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Office 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. Offiee of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax# 617-727-7749' www.mass.gov/dia Details Page 1 of 1 no Oincia,twetsi;u of:ho Execunva Once of"ubitc Safety and Sect it;(F6PSSj Mass.Gov Home State Agendas ensee Details aaranhic Infnrmat'nn ull ame: ' A D E HAMATY Gender: \ALner Name: ddress: %ddress 2: ty: Hingham fate: MA ipcode: 02043 o nt : U 'ted tates icense o: CS-101953 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 3/21/2014 ssue Date: Expiration Date: 4/20/2016 License Status: Active Today's Date: 6/1 512 0 1 5 econdary License: oing Business As: Pocumentum han e: o Prerequisite Information iscipline No Discipline Information Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license id=290885& 6/15/2015