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303R LAFAYETTE - BUILDING INSPECTION -- ErrYroF- Y PUBLIC PROPERTY DEPARTMENT � Ii1.�aYO�ftr �� 130 V/AwuwTcw y��yu,,,b �a®e970 YN cogmucam DSyIOGITION. IR CHANGE OF ITSE OR OCCCnw, "L FOR;,� sLaQ'r'**1G 2MIQ 1.0 SITS INFORMATION Location Now ' Fropsrtf Is kteetsd In a;COMMatlon Am YIN H eft OkMd YM 2.0 OWNERSHIP INFORMATION M Owner of Land Name: PE �7T ,4�'t= 2- Address ly 3.0 COMPLETE THIS SECTION FOR WORK IN EYLSIWrs BUILDINGS ONLY Addition Fisting Retwvat(on Number of Stories Renovated Change in Use New DemolitiOn Existing 4~o4brats year d Area per flow (at) Renovated construction or renovation Of existing building New Hoe!0eScription of Proposed Work: -rN s PP, Jj 30 Cs,",/I-c LAy(!-r) -Mail Permit to: vuhat is ttis currant use of dw auiwhv,? WE LLT-N G- / a dwsWi&how many unil'7 mataiw of sum? wo o p Asbasim? wo U+s Buidrq IrAw"m 10 uws? Archhods Nw" A,ddreW MA Phor O modwdes Nan•. �. art s o�� i 9� -Sao7 Addrow and � df iHi y9 zv io Z EX h� Cam ism Lisa S 87[a03 c/( a9 Hr. RagMtrsUon Es�madse Cost ad Ro" Parrrx Fss CakulMlon •d Cod X$71$1000 RNwsrdid PamR FN i Estlma8d Cast X S"I$'O06 Cwmrmda4 -- — M AddNkmai SB.ao is added as an Admwdowatlw dw%PL Make sun emd au Revs am properly and legibly written to avow delays in pnm"sinp. The undo vWad do"hereby ap*far a BuiwU►g Permijwlu O sp*cMcatlon& signed under Penally of pw1 " Date Z/ �I 06 s � � 1 I y CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ntMURIFY LNUS :OLL NAYtta 12C WAsee.%s:T0Kft ar At SAtiat,111A4iACle.:Q'1'IS01970 'rya:97eJ43.95" a F.ax:9MY40.9946 Workers' Compensation Insurance AfAdavit: Builders/Contractors/Electriciaas/PIumbers Applicant Information Please Print Legibly Name luaainess/oryrtizuiawtmhvudtan:�O Address:_ QG, g0}, H 0&,- C ity/Stamizip: V E A Q�op \). Vy1 A none m. Are you an employer'Cheek the a ro 4 boss PP 'ryp.of project(required): 1.Q 1 am a employer with 4.)V I am a general contactor and 1 6. Q New construction employtma(full and/or p rt-time).• have hired the sub-eomractors 2.0 1 am a sole proprietor or partner. tinted on the attached sheet : 7. ❑ Remodeling ship and have no employs" Then wbaomractors have V. Q Demolition svttrking for me in any capacity. workers'comp. insurance. 9. Q gh-Fkiigg addition (No workers,comp. insurance 5. Q We ate a corporation and its 10.❑Eleetrieal repairs or additions required.) officers have exercise!their 3.0 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself.(No workers'comp. c. 152,41(4),and we have no 12.0 Roof repairs insurance required.) t employees[A'o workers' 13.❑Outer comp. inwrance required.] •Ant Whwn that ch Cka has el men aho till ua the sectim below dbawiag ttnea wwtoW eumvmra8uw pull y inionn liaa 'i Iwtwtwtwn who wOmit thin atedsvit indicating ary an daisy as work and not hie asilde eamtm m nw o.Went a new amdwd i"'Aing am►. -C racttxs AN that this box mat anachod an additional AM%bowing the notes of the rub-wntraaaA and their wurkpe'camp.policy int6neatim /um an entp/oye►that b provfdlag workers'compeaeadoa httaraaee jar toy employees Below Is the pallay and Job site iajurmatiow. Imsurance Company Name: Policy 4 or Self-its. Lic.0: _-. Expiration Date: lob Site Address, Cllyislawzlp: Attach it copy oi the workers'compcns2t8nn policy declaration page(Showing the policy number and cspiratiom date). Failure to sacure coverage as requited under SeAion 25A uf.IGL c. 152 can lead to the imposition of criminal penalties of a f nor up to S 1,500.00 and/or one-year imprisonment,is well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Ile adviscd that a copy of this siatca wnt may be furwarded to the Office of luvcan.-auons of ate DIA for insurance covcra.,c verification. /do hereby rem u tJer pains mtd h bar the iajarmutloa presided above is true and correct Date- ,Q#ktd ase ante DO coot write/a ebb area,to be campkird by dry of town o,07t•1ml City or Town: __. Permit/I.1cease Issuing Authurily(circle ona): 1. Board of Itrallb 2. Building Department J.City/fowu Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Of her Contact Person: _ Phone q: Information and Instructions 7 Afassachtuctts General Laws chapter 152 requires all employers to provide workers'compensation for their employees Pursuant to this statute,an OmPtOytt is defined as'..every person in the service of another under any contact of hire, C%Press or implied,oral or written.' An e.s Oiiyer is defined as"an individt"parmorabipi.Association.corporation or other k d entity,of any two or more of the foregoing engaged in a joint auetprssi,Aid including the legal representatives of a deceased employer.or the usoeiatioa or other legal entity.employing employes However the receiver a trustee of o se having of mo partnership.' and who resides therein or the occupant of the owner of a dwelling hours having net mote than thturo apartments dwelling house of another who employs Persona to do maintenance.construction of repair wont on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." btGL chapter 152.42SC(6)also states that"every state or legal Ifeensing agestey shill withhold the issues"or renewal of a license or permits to operate a business at to construct buildings Is the commonwealth for any appUeaN who has site produced seeeptable evidence of compliance with the insursnee coverage requfrad." Additionally.MGL chapter 152,§23CM states"NeNher the cormuctrweahb nor any of its political odmBvisiom shall enter into any contract for the perforawnce of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applkssts Please fill out the workers'compensation affidavit completely.by cdecit &the boxes that apply to your situation and.if necessary.supply sub.cont actors)nxme(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLL7 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 employes.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 alga and date the affidavit. The affudovit should be returned to the city or town that the application for the permit or license is being requested not time Department of leWusmiul 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 Tows 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 purmit/licetise number which will be used as a reference number. In addition,an applicant that must subunit 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 tilled out each year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture i i.e.a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I'hc Oi nice of lnvestiyations would like to thank you in advance for your cooperation and should you have any questions, p least do nut hesitate to give us a Call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts DepaMent of Industrial Accidents ota t of lovestlptlena 600 Washington Street Bost^ MA 02111 Tel. # 617-7274900 ext 406 or 1-977-MASSAFE Fax N 617-727-7749 2cviscd 5-26-05 www.niaw.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPAR't'vmm ..ural at•'�+YL Ttit:`�7ai't9q�f.�9AJ�0.lW Construction Debris Dispos>at Affidavit (required for all demolition aid t+enovadom worst) in xeoniattee with the sixth edition oaths State Building Cods.DSO C16IR section t 11.5 Debris.&rA the provisions o(vtGL.a 40.9 5* Building Permit 0 _ _ is issttdd with the coidition that the debris moiling ftm this wort shall be disposed of in a property licensed waste disposal tbcility as deSnod by %4GL c t 11. 3 ISOA. The debris will be transported by: _ tname of haWa) - rho dcbds will be disposed of in : t u�une ur•tu�tay) 4, John Pantapas P.O. Box 4065 Peabody, MA 01961 Phone: (978) 808-8207 CUSTOMER: Ka L14ET21E JOB ADDRESS: STREET: qQ39 LA 12,Pq Yt'7fE sT. CITY,STATE,ZIP:S/,/,eyp, , MA PHONE: JOB PHONE: John Pantapas proposes to famish the materials and labor necessary to complete the following: ®G�ev4�� -t cNEe,k A�1 Gx$sT��v G- cw7Te/�r � QR�n'r F2onT �x$sT$� � G-u7T�Rs, gook CuEra v4 frox, 33 `;7, 30 /9��1�� 5[„�rvslP - Pe✓h es/ . & o�,T�,� Qvjid�y I I EveN 4� v9ry rl irY !c sY TOTAL PRICE: �d TERMS: i arO,0 Q UE UAnvvv Ae4v&,-,-� A c 700 °O U o✓�9 e CUSTOMER NAME SUBM _ SIGNATURE S NA RE DATE �� MAY-29-08 03:OOPM FROWEI A'STEVENS CO 1781-397-7672 T-911 P 001/001 F-700 ... ... . ...... . ....... . . .. . .. . .. . ACORD GER'TI�ICATE q.� LIAB LITY WSVf�ANCE 05 2oioa PRODUCER THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION E A STEVENS CO INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 389 MAIN ST BOX 188 COMPANIES AFFORDING COVERAGE MALDEN MA 02148-5076 COMPANY A CENTRAL INSURANCE INSURED COMPANY -'•-. --- JOHN PANTAPAS B COMPANY P O BOX 4065 G _ PEA13ODY Mk 01960 COMPANY D G4Y�ftA4�S _. _ 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. CO TYPE OF INSURANCE POLICY'NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTA 13ATE(MWDDIYY) DATE(MWOOWY) GENERALUABILITY 7989264 12 23 07 12 23 08 GENERAL AGGREGATE s2 000L000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPIOP AGG S2 , 000 , 60 O CLAIMS MADE 7 OCCUR PERSONAL S ADV INJURY $1 , 000 , 000 OWNER'S L CONTRACTOR'S PACT I EACH OCCURRENCE $1 , 000 , 000 FIRE DAMAGE(My e c I'M) S SO , OOO MED CXP(MYena Parenl S 5, OD0 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO _ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (PP, S HIRED AUTOS BODILY INJURY NON OWNED AUTOS (PA,KCIDBDD $ PROPERTY DAMAGE S GgRAGE LIABILITY _AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT S AGGREGATE S _EXCESS LIABILITY EACH OCCURRENCE S _ UMBAELU FORM AGGREGATE OTHER THAN UMBRELLA FORM S A IH WORKERS COMPENSATION AND pY,LIMITS EA EMPLOYERS-LIABILITY EL EACH ACCIDENT $ THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT S PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE S OTHER DESCRIPTION OF OPERATIONSILOCATIONSNENICLE$,SPECIAL ITEMS .CERTIFICATE NOAbER :`:,: ? :.;. : :';.: .• .. '"-CANCELLA7YON :;'- -'+.' . , ', SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE RAY PELLETIER EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL .1_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEA. 3 03 R LAFAYETTE STREET BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY SALEM MA 01970 OF ANY KIND UPON THE AMPANY. ITS AGENT& OR REPRESENTAT)YE9. AUTHORIZED REPRESENTATNf / F.M. CLIFFOB6]U4rTj� AC6RD.45;9'(1/9$) ;.'_ . . . �:�- .' °' ' =QB AGORD•�CORPOWIT,IDN 1.988 ACORD be CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) o5/21/2008 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PARENTE INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 94 LYNN STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PEABODY MA 01960 INSURERS AFFORDING COVERAGE NAIC# INSURED MACFARLAND ED INSURER A:AMERICAN ZURICH INSURANCE COMPANY INSURER B: 36 WASHINGTON ST INSURER C: PEABODY MA 01960 INSURER D'. INSURER E. COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(EFFECT ) POLICY EXPIRATION GATE(MMFECTIV DATE(EXPIRAIO LIMITS GENERAL LIABILITY EMED�P(Anyane�mn) ENCE $ 'ONCOMMERCIAL GENERAL LIABILITY Itu occurence) $ Cl-AIMS MADE a OCCUR anepemon) $ DV INJURY $ REGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: OMPIOPAGG $pPOLICY RO- CT LOC E AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIREDAUTOS BODILY INJURY S NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE E (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: ADD S EXCESSIUMBRELI-A LIABILITY EACH OCCURRENCE $ OCCUR ❑CIAIMS MADE AGGREGATE $ $ DEDUCTIBLE S RETENTION E A WORKERS COMPENSATION AND (6ZZUB-066OL91-6-07 06/21/07 06/21/08 TORYLA'TS ER EMPLOYERS'LIABILITY IN, ANY PROPRIETOR/ ARTNERIEXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICERIMEMBER EXCLUDEDi E.L.DISEASE-EAEMPLOYEE ESOOnder I DDD ❑yes,ALPRO PROVISIONS SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT E lOO,DDD OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION RAY PELLETIER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 303 R LAFAYETTE STREET DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN SALEM MA 01970 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR EPRESENTATIVES. AU N IZED REPRESENTA ACORD 25(2001108) ©ACORD CORPORATION 198