292 LAFAYETTE ST - BUILDING INSPECTION (3) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL a
MAYOR 120 WASH NGTON STREET • SALEM,MASSACHUSETTS 01970
TEL:978-745-9595 ♦FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information y� �t L� �_ Please Print Lesibly
Name (Business/Organization/Individual): H(OI�Ff c&r-f �•,CyI�"S U9 . ZA)C
Address: (✓J I A ,9 L
City/State/Zip: � �I%ZiLt I-P"I of cl 20 Phone #: 7", 5 0,5--
Are you an employer?Check the appropriate box: Type of project(required):
1.[re 1 am a employer with )-- 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in an capacity. workers' comp. insurance.
Y P tY• 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
•Any applicant that checks box#I 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 most submit a new affidavit indicating such.
[Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. I? f r �7
Insurance Company Name: A�nn 1L'Y ` Z-1 -Y ec
Policy#or Self-ins. Lic.#:/n_. 1 //l' V//� /�y 9 )1 Expiration Date: '
Job Site Address: Q%oL l�(.LII-ct 4�y f—t� b i_- City/State/Zip: SCsl/�0 0t 976
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 der t e i a p n *es ofperiury that the information provided above is true and correct
Signatur Date: 31 R I
Phone#: I170 5'35r v O-fiLI3
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):
L 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 hue,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two oS 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."
i
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 perrilit/liccnse 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 afdavit must i,a shied aut aach
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 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
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
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TOOLS, SUPPLIES, AND SAFETY PRODUCTS FOR CONTRACTORS
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15 STILES STREET 305 FREEPORT STREET
NEW HAVEN, CT 06512 oti BOSTON, MASSACHUSETTS 02122
TEL: 203-469-0000 emirjch TEL: 617-287-2000
FAX: 203-466-5240 y FAX: 617-436-3304
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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rn:Y73-745-)595 1 F%x: ')7S-74G7846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 Ci`1R section 111.3
Debris, and the provisions ofNIGL c 40, S 54;
Building Permit a _ _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly Licensed waste disposal facility as define by v1GL c
I 11, S 150A.
The dyy�ebris will be transported by:
(n�mr of haular)
flic debris will be disposed of in
7a
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CA
R OF IN MATI
ICA ISSU AMA
PRoOvcoon R - D CONFERS NO RIOHTB UPON THE CERTIFICATE
H.J.KniYjIt International Insurance Agencies,Inc. 7!77!
TIi1B CERTIFICATE DOES NOT AMEND,POLITE"DCIES
OR
E COVERAGE AFFORDED BY THE POUCIEE BELOW.
Victory Road-Marina¢ay D"OMP FOQDinGy,MA 02121 Atlantic Charter Insurance Co an vDAC
BUI; Services CO.,Inc.AlpineProD�Y Olympic 11 Wilson Street Salem,MA 01970
TNIB L9 TO CERTIFY THAT THE POLICIES OF DIBURANCE LIBTV0 BELOW NAVE BEEN 194UEp7OTHE DiSURED NAMED vrIfH R"PE tIdVT FOR ETo wX cn THIS
POUCT D .
-B40WATED.NOTA RHBTANOTNO ANY REQUIREMENT,TERM OR COMMON OF ANY CONTRACT OR OTHER DOCUMINT
cERTIFIDATE MAY ae ISSUED OR MAY PERTAIN,THE INBURANCE AFFORDED BY THE POLICIES DESCRIBED XER[71116 SUBJECT TO ALL THE TERMS,
EnCLUSIOMO AND CONDITIONS OF SUCH POUCWS9 LIMITS BHDAERI MAY HAVE BEEN REDUCED BY PAID CLAIMS. UMITS
PQUCYNUMBOI POUCY�E�F'F�EnOrR�UE PQUCY OPIIIATION On TI1PVwem)
CO TYPE OF INSURANCE DATE RIWDORY) DATE WWOORTI
LTR BODILY INAIRY om f
GENERAL LNIBM1RY BODILY INJURY ADD S
COMPREHENSIVE FORM "OPmTYDAMAGEOCC i
PREM@,,a RATIONS PROPERTY DAMAGE AGO i
VNDBROROUND 516PD COMBBJEDOCC f-
,,,DB1011 B oa.APSE nA;tMo III A PD COMBINED AGO f
PIIOOUCTe.CAMPLETED OPER
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CONTRAGRIAL
INDEPENOEW ODKI UTORS
BROAD FORM PROPERTY DAMAGE
PERSONAL INJURY BODILY INJURY
µ"MOBR.2 UASHM (Pm Pm ) i
ANY AUTO BODILY INJURY
ALL OWNED AUTO 3(PRYAN Pero) (PerraWenU F
ALL OWNED AUTOS
(aBP Dun PNYab PaaeenOrG PROPENrY o GE T
HIRED AUTOS
BODILY INJURY A
NOI60WNED AUTOS - PRDPERIT OANAGE
GfRAGELIABILT' COMBINED f
FAGNOCAURRENCE S.
exC 56 UABIL"
AGGREGTE i '
UMBRELLA POW S
OTHER THAN UMBRELLA FORM STATUTORY LIMITS
woRlaR6 wePRI1F1LT1aH AnD WCV00754901 1/5/2008 1/5/2009
PAIPLOTFMB LUBILRY EACHACGDENT f 50D,000
DISEASE-POLICYUMIT f 500,000
DISEASE-EACHEMPLOYEE i 500.000
OTH[R
DESCRIPTION Of OPERAilON9lLDOAnOXBIVEnICIESWPICJAL ITIMS
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
12 DAYS WRTTTEN NOTICE TO THE CERTIMCATE HOLDER NAMED TO THE LEFT.
BUT FAILURETO MAIL SUCH NOTICE SMALL lMW5E NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE COMPANY,JTS AGENJ OR REPRESENTATIVES:':
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' ADrnoPasA RmwE6ENrAnvE
ACORD DATEOMNDOyyyy)
CERTIFICATE OF LIABILITY INSURANCE \
KNGVCER Phone. (TION]St10 Fee (elT)BSG t2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
KNIGHT INTERNATIONAL INSURANCE GROUP - ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
500 VICTORY ROAD HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
MARINA BAY .ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW_
- - QUINCY MA 02171,
I INSURERS AFFORDING COVERAGE NAIC 9
IN INSURER A: FIRST MERCURY INSURANCE CO.
ALPINE PROPERTY SERVICES CO.,INC_ INSURER B. SAFETY INSURANCE
11 WILSON STREET
SALEM MA 01870 INSURER C:
INSURER D: ^
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED SEIAW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD WDICATED, NOTWRHSTANOING
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 DESCRIBE➢HEREIN IS SUBJECT TO AJ-THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PNO CLAIMS-
ea URANCE r POLICY NUMBER w EREOTNE PoueYETPntAn LIMITS
LTA f IfX+ TYPEOFINS MTE NNN
GENERAL LIABiDTr FMMA00186 06114107 O6N4/08 EACH OCCURRENCE E T,000,000
X COMMERCW.GENERAL LUIBLLT' OAMAOETORENTEO S 50,000
PREwaEe(En amrpaN
CLAIMS MADE❑X OCCUR MEO-E (A^YOOaper ) S 1,000
A
-- PERSONAI.AADV WJURY $ _ 1.000,000
GENERALAGGREGATE E 2,000,000
GENL AGGREGATE LIMIT APPLIES PER
I'� PRODUCTS-COMP/OP AGG. S 11000.000
POLICY I A 1 JECT LOC
AUTOMOBILE UABILDv 27OZ651COM0o o1l09/OB 01/09109
COMBINEDLE LWR
ANY AUTO (Evxc _
AU °R°erA)V E 1,000,000
OWNED AUTOS tEa
BODILY INJURY
B I SCHEDULED AUTOS (P&pnsen) S
X HIREDAUTOS
X NON-OWNED AUTOS OODILY INJURY S
(PRr ex14en0
PROPERTY DAMAGE
RJ GARAGE LIABTY (PBram4Pn0
ANY AUTO AUTO ORLY-IJLACCIDENT S _
OTHERTHAN EAACC E
AUTO ONLY: AGG S
EXCESS UMBRELLA UABIUTY CUMAODD117 I 06/14/07 06/14/011 EACH OCCURRENCE S 5,000,000
X OCCUR �CLN WOE
OE
p I AGGREGATE S 5,000,000
DEDUCTIBLE I E
X RETENTION E 10.000, $
E
IWORRER9 COMPENSATION AND I vuC BTAiU. OTR
EMPLOYERS'UASLLRY TORV DAYT3
ANYPROPNETawNGNERIEX TofE E.L EACH ACCIDENT 5
OFFUMRIMEMPEa FJ.CLUDW7 _
ey�P,Pcacnx Aner EL.DISEASE-EAMAPLOYEE E
ePEOML PROVIegNB WIw E.L DIBEABE-POLICY IT E
OTHER:
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESI"CLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVORTO NAIL tO DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE
TO 00 SO SHALL IMPOSE ND OBLIGATION OR LIABILITY OF ANY HIND UPON THE INSURER
ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATNE
ACORO 25(2001/08) Certificate 9 - night � lJ
O ACORD CORPORATION 1988
- U//e '�nomvma�u�ed/,(/a oy
Board of Building Regulations and Standards License or registration valid individul use only
before the expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR Board of Building Regulatious and Standards
Registration: 154326 one Ashburton Place Rm 1301
Expiration: 2/27/2009 - Tr# 254379 Boston,Ma.62
Type; Private Corporation
ALPINE PROPERTY SERVICES CO,INC. r
. .. .. .. -. .STARROS .MOLTS OULAS - -
11 WILSON STREET otv ithout.signature -_--.._
SALEM, MA 01970 Administrator --
Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 154326
Type: Private Corporation
Expiration: 2/27/2009 Trtt 254379
ALPINE PROPERTY SERVICES CO, INC.
STARROS MOUTSOULAS
11 WILSON STREET
SALEM, MA 01970
Update Address and return card. Mark reason for change.
nPS-CA1 0 5OM-05106-PC6490 ❑ Address Renewal Employment Lost Card
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PL'131.IC PKO1'f:IZ'l'1
7
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APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS
IMPORTANT; A22licants must complete all items on this page
SITE INFORNIATT4, 1�[ // DI�51 �U�C�
Location Name "1 Building r 1
Property Address av l
Map#
Located in: Conservation Area Y/N Historic district Y/N
Use Groups
(check one)
Residential (3 or more Units) R2_
'type of improvement Residential (hotel/motel RI _
(check one) Assembly (churches) A I
New Building_ Assembly(nightclubs etc) A2 _
Addition Assembly(restaurants. recreation) A3
Alteration L'_ Business B
Repair/Replacement_ Educational E
Demolition Factory (moderate hazard) Fl
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard 11
Accessory Building Institutional (residential cave) I1
Other(describe) Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile 1%11
Storage (moderate hazard) SI _
Storage (low hazard) S2
OWNERSHIP INFORMATION(Please type or Print Clearly)
OWNER Name a h� 9t7Pi 1
Address a 4vv
Telephone �11 0) 0(9
DESCRIPTION OF WORK TO BE PF.RFOR:\IF.D
Tn51-0.i( 4�rJ15 ;n ancSE Floo ✓
ESTIMATED CONSTRUCTION COST 1 O 0
CL1t, -FIL-
CONTRACTOR INFORMATION
Name ` lying y`o" V `yiCE? an t
Address I IT J 70
Telephone 9 -
Cunstruction Supervisor's Lic #
Home Impro%ement Contractor # h y 3
ARCIIITEUVENGINEER INF'OILNIATION
Name
Address
Telephone
Mass. Registration #
.PERNIrr FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x,$A$1,000 + $5.00= 9 3. (?o
• ti`
a
COMMENTS
The undersigned does hereby attest that all information itatefflabove is true to the best
of my knowledge under the penalties of perjury
Signe
Date
Z
d
Q� \
9 � �
m
�1e notanm-R—'¢�f�. ..'flodarzC/I/mec7,i
Boar�olwfding RegulatioZ/and Standards
Construction Supervisor License
License: CS 80145
Birthdate: 10/26/1963
Expiration: 10/26/2009 Tr# 6205
9 Restriction: 00
GEORGE VASILIADES
515 LOWELL ST
PEABODY,MA 01960 Commissioner