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193 LAFAYETTE ST - BUILDING INSPECTION (2) !� CITY OF SALEM PUBLIC PROPRERTY r;4y. DEPARTMENT SustaFRIEV DRMXA L MAYos I=WA*iLwrON STREET a SALEM,MASSAU n.at'rn 01970 Tvi:97111-7439595 r Fax:978.740.9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .applicant Information Please Print Leeibly Name .Cl(_ Addreps:y r-zilx .�� s� � City/state/zip: -5/9-1 -Q' ,M)3L , D 1970 Phone N: 977— W'0 - ?72o Are you an employer?Check the appropriate box: 'rype of project(required): 1.P 1 am a employer with z 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full antYurport-time).• have hired the sub-contractors 2.❑ I am a sole proprictue or partner- listed on the attached sheet. : 7. ❑ Remodeling i ship and have no employees Then sub-conuactors have S. ❑Demolition s working for me in any capacity. workers' comp. insurance. 9. ❑ Budding addition (Ko worker'comp. insurance S. ❑ We are a corporation and in required.) officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. (No workers'comp. c. 152,§t(4),and we have no 12.0 Roof repairs insurance required.) t employees. (No workers' ffpp1l OtherjZ P- QoD f comp. insurance required 13. .] [4 'Ally applicant tlta chcain boa rl must also fill au the section itcluw Mowing than wmkaa'cumpentaafon Policy infiuttcuiuo '1 ive%nowttan who submit ibis amdwit indicating tAry as doing all work and then hits outside couractoa mail sutenit a paw alrndavit indicding Null. ;t'ontmsins thin Chats this boa Most anaehed an adifido n l Jmo showing the name of the WtFCena wtma and Ibeir waraea,comp.pul y intmmadw. l am an employer that Is providing workers'compensadon Lrsarance for my employees. Below is the policy and job site information _ r ImuranecComp211yVame:�l3.2t.rcn-t. Policy q or Self-ins.Lic.N:10 CI 3 3 1/ Expiration Date: r Job Site Addru-ss: ^J -L gtilt YI7-. C-i City/Swtu2ip:5/J/44. ,iywa 0/7?0- .%ttach a copy of the workers'compensation policy declaration Paige(showing the policy number and expiration date). Failure to s:cure coverage as required under Section 25A of.\1GL c. 152 can lead to the imposition of criminal penalties of a rune up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of lnvcsngations of tlic DIA for iniurarce covcragc verification. l do hereby certify under the pains and pen hies ofperjury that the information provided above is true and correct tii,�aaiure' ,� //'o.... Dater Phu:c a:- Gi 7Y- -2rO O/J&iol use only. !M not wrhe in this area,to be raripleted by dry of town officimi City or Tmrn: _. PermiVIJcenxe p Issuing Authority(circle one): -- " 1. hoard of health 2. Building Department 3.City/fawn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: _ Phone q: \ r Information and Instructions , Ntassachusets 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 him express or implied,oral or written." An gurpfoyer is defined as"an individual,partnership.associaam.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 uusm of as individual.prroxrship.association of otber legal cndty,employing employees. However the owner of a dwelling house having not mote 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 shad not because of such employment be deemed to be an employer." SILL chapter 152.42SC(6)also states that"every state or total licensing agency shall withhold the issuance or renewal of a neease or(hermit to operate a business or to construct buildings In the commonwealth for say applicant wise has net produced acceptable evidence of eompBana 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),addreas(es)and phone number(&)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,ace not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is requited 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 uIlidavit. Tlu 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 low 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 tine. City or Town Offlelab 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 ,,lease be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant that must subunit multiple permitilicense 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 he provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture i i.e. a dog license or permit to bun leaves ctc.)said person is NOT required to complete this affidavit. 1'he Oniix of htvestigations would like to thank you in advance for your cooperation and should you have any questions, plcube do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents O®ee of[evestipdoos 600 Washington Street Boston,MA 02111 Tel. # 617-7274900 ext 406 or 1-977-MASSAFE Fax fti 617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT \l,tl tt l2'W.%AdU.7:ONS 7EET O SAU N.at.\VIU:iII .ill]�i0�� TO:vn745.45" .FVL OM740-9M Construction Debris Disposat Affidavit (required for all demolition and renovation work) In accordswce with the sixth edition of the State Building Code, 7S0 CNIR section 111.5 Debris,and the provisions of M. GL c 40, S 54; Building{ Permit 0 .- . _ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 11 t, S 150A. The debris will be transported by: AJF-owv C or7it) s Ucn T"21ac% iname of hauler) me debris will be disposed of in ftz�r' b-s c Waste-... 'k �ddrCS, 0(t3C:{,tr) q-JI= 0'�7 -At, - CSR NIX DATE(MM/DD/YYYY) ACORD CERTIFICATE OF LIABILITY IIER. !SC 11C 9ASPE05 O5 16 07 THID AS A MATTER OF INFORMATION PRODUCER ONGHTS UPON THE CERTIFICATE John Walsh Ins Agency, Inc HOE DOES NOT AMEND,EXTEND ORALTORDED BY THE POLICIES BELOW.F 0 Box 4407Salem MA 01970-6407 - NAIC#Phone: 978-745-3300 Fax:978-745-9557INSURAGEINSURa Insurance Co.INSURED: INSURioaal Grout'INSURavelers As en Roofing Services Inc INSURSalemrMAcO1970#3INSUR COVERAGES SSUED TO THE INSURED NAMED ABOVE THE POLICIES OF INSURANCE TERM OR CONDITION OF HAVE V CONTRACT OR OTHER DOCUMENT W TH RESPECT TO WHICH(THIS CEIRTIFICATE MAY BE ISSUED OR DING ANY REQUIREMENT, MAY PERTAIN,THE INSURANCE AFFORDED F 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. P LIC EFrEvTNE pOui.,�FS.PIRATION LIMITS LT NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD DATE MMIDDM' EACH OCCURRENCE $ 1000000 GENERAL LIABILITY $ 100000 III A I I X COMMERCIAL GENERAL LIABILITY PAc6626014 12/31/06 12/31/07 PREMISES Ea oce MED EXP(Any onene person) $ 5 0 0 0 CLAIMS MADE X❑ OCCUR PERSONALBADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 PRODUCTS-COMP/OPAGG S 2000000 � N'L AGGREGATE LIMIT APPLIES PER: POLICY jECOT LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ S,000,OOO 12/31/07 (Eaaccitlent) ANY AUTO BA5356B217 12/31/06 I BODILY INJURY $ ALL OWNED AUTOS (Per person) B k% SCHEDULEDAUTOS BODILY INJURY S HIRED AUTOS (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) AUTO ONLY-EA ACCIDENT S GARAGE LIABILITY OTHER THAN EA ACC $ AUTOO ANY AUTO � AUTO ONLY: AGG $ EACH OCCURRENCE $ EXCESSIUMBRELLA LIABILITY AGGREGATE $ pOCCUR CLAIMS MADE S I I S DEDUCTIBLE RETENTION S - TORYLIMITS ER — WOPKERSJT(LdPENSATIONAN(> -. B EMPLOYERS'LIABILITY WC6932479 12/31/06 12/31/07 E.L.EACH ACCIDENT S1000000 ANY PROPRIETORIPARTNER/EXECUTIVE E.L.DISEASE-EA EMPLOYE $ 1000000 OFFICER/MEMBER EXCLUDED? If Syes.describePRO under E.L.DISEASE-POLICY LIMIT $ 1000000 S PECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 0001003 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 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. - AUTHORIZED REPRESENTATIVE, John J. Walsh Ina: A- c. Inc.. ©ACORD CORPORATION 1988 ACORD 25(2001108) ✓!te TJo�nmxO�wiva� o�✓ �tttee�a -• BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Numberi CS 054528 Birthdat®: 1V20/1959 Expires ,111120/2007 Tr. no: 9199.0 Restricted: 00. DAVID J BENSON 1 E LN G— DANVNVERS,S, MA 01923 ' Commissioner - � ✓�se V/MH/I/rblUl/P.6G(2 0�✓'�.aaAaf�i��detrd . Board of Building Regulations and Standards - HOME IMPROVEMENT CONTRACTOR Registration 118825 Ettpira6on _4f2612007 - h , TywpeL Pnvate Corporation E ; ASPEN ROOFING SE# lICSS,ING ,r DAVID BENSON i 4 FLORENCE ST _. fiALEM, MA 01970 Administrator f I f II 4� I PUBLIC PROPERTY DEPARTMENT u aas 13o WA2U GWW 8`M r.sum.,wgUaa:sr„s o1970 APPi�. CATION FOR TAE REPAIR. RENOVATI N CONSTRUCTION DEbIOLTTI V. OR CHANGLf OF USE OR OCCUPANCY FOR ANY EXISTII�IG STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: S Building: Property - - --- - — -- -- - - -- - --- -- - -- ---- - - Property is located in s:Cauarvallon Ares YIN HW"le Obeid Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: (lV- Vnc D o,- a l e- _ j Ra s-/7A- x Address: Telephone: i 3.0 COMPLETE THIS SECTION FOR WORK IN EXIS M BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New add Description of Proposed Work: jZc 9oor- FR os f eej-rLy c2 0/--. I"\ Ci�"luv..c- ,�r� sr�N� ��,✓ [2vu�` se�cL l2e Pc.p c..c, w�;� r.� ------ ---Mail Permit to: A3 P&,l Roo/'1/vs - 4/ What is the current use of the Building? LO /Ujo ,S Materiei of Building? N )c if If dwelling,how many units? Win tiw funding Conform to Law? Asbestos? ArdOtbas Name Address and Phone mochwWs Name 4-. P4y a - P + NC S Address and Phone Y Ft n c s r s�t� Yrio 9 7 7 L/o - F 9 3 C Consuudicn Supervisors Lk6nse# "' a SLS_DjHIC Registration f 117 Estimated Cost of Pr�jed= 0% Pennk Fee Caicula m Permit Fee Estimated Cost X$7/$1000 Residential _-- . Estimated Cost X$11/:1000 Commercid ------- An Additional$5.00 Is added as an Administrative charge. Make sure that all fields ens properly and legibly written to avoid delays in procesaing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury , Date `�Zla220ft 1 NI U' r. IZ4 }