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120 LEACH ST - BUILDING INSPECTION CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT wh]1nr Rtflf DIRAIWOLL V1sY(M 12C VpnstCNGTON SrRrEr 0 SALEM,MASNACl n.It:Tn Ot97., Tel 978-743.9595 4 FAX:97x-74C'9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anniicant Inibrmation /�{ Please Print Leeibly Natile tOuaincsslOtMnizatiarVlndiv,dwi): („� e'-.n+e+t F KP✓t-/C it /�/��C.�,.tE'Sa-., Co.,,r5 Address: CitylStateizip: 40(_1 4 at .,t�tlt , o 195# Phone li: q 39 tl6fr29 S9 Are you an employer?Check the appropriate box: 'type of project(required): 1.0 1 am a empktycr with 4. 0 I am a general contractor and 1 6. 0 New construction employees(full and/or part-time).• have hired the sub-contractors 2. 1 am a sole proprietor or partner. listed on the attached sheet. : 7• Remodeling ship and have no employt as These subcontractors have S. 0 Demolition workingfor me in an ca acid . workers'comp. insurance. Y a Y 9. Building addition req workers'comp. insurance 5. ❑ We are a corporation exercised and its 10.0 Electrical repairs or additions rcquircdL) officers have cxcrcistxl their 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,§1(4),and we have no 12.0 Roof repairs insurance required.) t employees. [No workers' 13.❑ Other comp. insurance required.] -Ally applicwa tiw clucks box nl must also till oW Ute scctiuo below showing llicir workma'cumpenatttkm pulicy infurm;uiun ' llumut,wron who submit this affidavit indicating they art doing all work and then hits wtside eantracton muss submit a new affdavil indicating uuh. C"—-ststars that chmic this bee meat anachad an additional.heel%bowing the name of she sub-comractors and their wurken'entrap.policy infwmarion. l am (in eaployer that tv providing workers'compensation lasaranee for my employees. Below is the pis/icy and job site iafunnatialt. ! Insurance Company Name: Policy it or Self-ins. Lie. #: _ .. .. .-__._ 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 uf:VIGL c. 152 can lead to the imposition of criminal penalties of a tine up to SI.500.00 and/or one-year:mprisonment, Al well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to S250.00 a day against [lie violator. lie advised that a copy of this slawment may be forwarded to the Office of Investigations of the DIA for insurance covera.,u verification. I do hereby certify under the pains and penuhies ufperjary that the infortarallon provided above is true and correct. tiie:rtturet Cer.. Datc• t5—/`� —O 7 Phtn:e a: OfTic hd use only. Do not ivrite is this area,to be ruarplered by city or town officiaL City or Town: _-_ PcrmitiLicense# Issuing Authority(circle one): 1. Iluard of Health 2. Building Department 3.Citytfoivn Clerk a. Electrical Inspector 5. Plumbing Inspector 6. Other Cashel Person: -" _ __ Phonc #: Information and Instructions titassachu;etts 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, eapress or implied,oral or written." An eorployer 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 shag withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any appiicant 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-eonuwtor(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 Offlclab 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 till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit 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 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. 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. I'hc of Investi'�.-ations 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 OtIIee of Investiptleas 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised i-26-05 www.maw.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTv1ENT \t u K 12C W.%stau •>u:t.WA-M ::u Tit:9M7+f•)M &F. 978•74G9844 Construction Debris Disposal Affidavit (required for all demolition mul renovation work) in accordance with the sixth edition of the State Building Code, 790 Cb1R section 111.5 Debris,usd the provisions of MGL c 40, S 54. Building Permit N _ . _ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defused by MGL c 111. S 150A. The debris will be transported by: — — (name of hauler) me debris will be disposed of in mane of fa�;illty) ..d.:rez� 07 f�iiLly ♦ _d:It.i d.lI ,:�:R'd[.l:�LIC JAI I , p. i "yBOARD OF BUILDING IIEGULA'190NS RVIS ir`snse; CONSTRUCTION SUPEOR Num 6.s, BiRhd $7N�8 12470' �R1 �1�17�O,Q7"�" Tr.no a . .. Restnct�ed'f0U ,' P- ^' • ,• e': k CARMON.E HERRIC y �' k i 113PLEASANTST }`; .'. ' } WENHA4h„M� 01984 „� �.w p}Oomml %'��, I f i� ii EI'I'Y-OF - PUBLIC P'a ROPERTY DEPARTMENT VJ..QIEMLLV o.�_ •L w eYaa I30wwvuriUrM SMERr• &nt,lK NwSSACJ11:3h11501970 14i 97s-743-9S"•FNe 97s.740.96K APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION DEMOLITION,OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION . Location Name: S C1 M, P;LL es 'e- Building: Waage ---- - sw - — -- _ Property Is located in a.Conservation Area Y/N— Y—Historic District YIN_t� 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: 1 vD L E�4C�j may/` rf� Telephone: 00 9- 7Y —$`)V 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation ✓ Number of Stories Renovated Change in Use �� New Demolition Existing L re/ re o Approximate year of Fq7� Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: feq- I-a c & a G t w t C'P�av S oW5 d ! pS- Rer(00P dQ f r -- -Mail Permit to: /Z o ,•IZ PS -_ What is the current use of the Building? � Material of Building? 4420 o cY if dwelling,how many units? Wit the Building Conform to Law?T f — Asbestos? �d Architedb Name �a Address and Phone Yl 7 l Mechanids Name w G Pvr�c n ,ion . Address and Phone 3 Construction Supervisors License# o 0777D HIC Registration# t!L!S 3 Cost of Project ty �0 Permit Fee Calculation Estima ted —t-- r a Permit Fee Estimated Cost X$7/$1000 Residential - - i���° - - . Estimated Cost XS11/51000 -- - An Additional$5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perlury Date of o N O buy O �� � • Gies N -- V 12/11/2006 09: 54 9999999999 PAGE 02A2 ACM—P. CERTIFICATE OF LIABILITY INSURANCE OPID OATS(MM,DDJYY") - PRODUCER 12 11 06�y THIS CERTIFICATE I5 ISSUED AS A MA-€TER OF INFORMATION ONLY AND Soderbarg insuratice BerVicea ' !/� HOLDFICATE ER.THIS CPERTIFICATTE DOES NOERS NO RJGHTS I'd AMEND,E I THE XTEND 200 BroiLdway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Lyanfield MA 01940 Phons: 781-593-9393 Fax:701-599-7338 INSURERS AFFORDING COVERAGE NAIC0 INSURED — INSURERA PHtrOA9 Mutual Ine C�Bt an 14923 INSURER B. orneratope RE DaTrelopaxs, LLC - 101aMain Shextytraot INgUReR C. Saugus MA 01906 INSURER 0', ' INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY RFOLAREMENT,,TRAM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WNICH THIS CERTIFICATE MAY 8E MUED i]R MAY PERTAIN,THE INSURANCE AFFORDED SY THE POLICIES DESCRIBED HRRIMN S SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF BUD" POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS, ox— NSR TYPE OF INSURANCE PDMCY NUMBER TB NM MIO LIMITS CGN®RAL LIABILITY EACH OCCURI PENCE 81,000 000 3L Ix CdAMERCIAL GENERAL LIABLITY CTR0000565 09/06/06 139/06/07 PREMISE :occuenee $50 000 CLAIMS MADE DX OCcuR MED EXP(My e.n pxeon) S.T1,000 _ PERSONALAAOVINJLF" a 1 000 000 GENERAL AGGREGATE 52,000 000 GEML AGGREGATE UNIT APPLIES PER: PRODUCTS-('OMP/Dp AGO a2 000,000 POLICY PEC LOC AUTOMOBILCLU BIUTY COMBINED BUGLE LIMIT a ANY AUTO (EllACtitlmA) ALLOWNEDAUTCS GODLY IN.XIR'+ F i I SCHEDULED AUTOS (Pm wwA) HIRED AUTOS BODILY IN.I F NOFFOWN6D AUT06 (Pat AmNPS) — (PPROPICER OAIMUE a Pr dwTY M) GARAGE UABILITY AUTO ONLY•EAACCIDENT S ANY AUTO AUTO ONLY, 6A ACC S AUTO ONLY; AM S EXCIIMUMBREL LUIBLITY EACH OCCURRENCE a OCCUR 17 CLAIMS MADE AGGREGATE $ g II DEDUCTIBLE S RETENTION S 1 a WORKERS COMPENBATION AND TORY TATI UNITS ER EMPLEFYER9'UASILRY ANY PROPPIETORXARTNERMXECUTIVE E.L.EACH ALCII]HJT S OPPIDER/M6MUER OCCLUDED? E.L.DISEASE-HA EMPLOYEE $ Ifyn bealtA uneYx SPECIAL PROVISIONS DeIPr G,L.DISEASE-PAL ICY UNIT S OTHEt DESCRIPTION OF OPERATIONSILOCATIONS I VEHICLES I EXCLUSIONS ALTO ENDORJUSNT I SPECIAL PROVISIONS f �(�ES�lLU64•fldn� (-�ovscrv� ���,�uv��.s� ,l;�C.. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THRRXNRATION DATE THEREOF,THE aSWNG INSURER WILL EAGEAVTW TO MML 220 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FMLURE TO DO DO SIwLL !`-(��/-'/^ NO OBLIGATION OR LIABILITY OF MY KIND UPON THE INSURER,ITS AGENTS OR �©l/! REPRESENTATIVES, lT U�(L�Y Q 990 AUTHORIZED REPILESSNTATIYE Z . Don las G. BOfl ACORD 26(200110 ) f PORATION 1966 CITY OF SALEM PUBLIC PROPRERTY �. DEPARTMENT door at Fr uatsd:uu MAYOR I=WAuu.NG rot.STRbtT•SALEM.MASSACI 111.1Vrn 01979 Thu 978-743-9595 4 FAX:978-744.9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AnWicant Information Please Print Le ibl '4-,ime jauaiitWOrganizatioNlndividuul): Address: CityiStarcizip: 61/9� Phone Et: /d I— ?6� Are you an employer? Check the appropriate box• 'type of project(required): 1.❑ nt 1 a a employer with 4. . am a general coauactor and 1 6. ❑ New construction employees(full and/or part-tine).• have hired the sub-contractors ?❑ 1 am a sole proprietor or partner- listed on the attached sheet. ; 7. [3 Remodeling ship and have no empioycwx These sub-contractors have S. ❑ Demolition working for me in any capacity. workers'comp, insurance. g, ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.[1 Electrical repairs or additions required,] officers have cxcrcL%W their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LED-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.[3 Other comp. insurance required.] 'Ally applicwa dud chucks boa el must also lilt con the section below dwwiag ib6ir wwkas'cumpemWiwt pulicy in6nrtuilort 'I lotmomners who submit this Affidavit indicating they are Joins all work and than him outside cantraQon moat.ubmit a new amJavil inJieding sncA. Cunurxlnra that chuck this box must anached an additional great showing the name of nto subeomractors and their workers'comp.policy information. fain an employer that Lr providing workers'compensation insuraaaee for any e/opluyees. Below is the policy and Job site infarmaraan. Insurance Company Name: Policy is or Sclf-ins. Lic.#: _.-. Expiration Date: Job Site Address: Cityistate/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 ro 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 it Jay against the violator. Ile advised that a copy of this statement may be forwarded io the Office of ht�e,ngauuns of the DIA for in ranee coverage verification. I du hereby certify under t p 'us and pa Nesuf erlarl that the Information provided above is true and correct Sieaanve: pat c: 9— </,cO 7 Phone#: Official use only. Do not write in rhir area.to be completed by city or town oalciaL City or'rown: Permit/License l! Issuing Authority(circle one): I. Iinard of ueaith 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Cualuel Person: Phone p: It 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 indvidual,partnership,association or other legal entity,employing employees. However the owner of a dwelling have 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 shag 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, bIGL 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(&),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 _ .elf-insurance license number on the appropriate line. City or Town Officials Please he 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. i'Icase be sure to till in the permit/license number which will be used as a reference number. in addition,an applicant that most 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 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.e. a dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. fhc Otiix of Investigations would like to thank you in advance for your cooperation and should you have any questions, please du not hesitate to give us a call. The Departmcnt's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents O@les of investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-49M ext 406 or 1-877-M4kSSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY ,as DEPARTMENT �t�utt 12c w.%ituu::aNs.-RErr•SA a.MA%W:u *i a 7:9IC T¢t:97s•74545" •F.ar:9M74(19M Construction Debris Disposal .Affidavit (required for all demolition atxl renovation work) in accordance with the sixth edition of the State Building Code, 730 CNIR section 111.5 Debris, and the provisions of vtGL a 40, S 54; Building Permit M - . ._ 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 vIGL c 111.S 1.50A. //The debris will be transported by: t,cQ�Cnl���ai✓�E l�Ur�LoP�ir-r (toms of fouler) file debris will be disposed of in : 1( � —.. . - n�lmt:�t'1a•i6t Y) ..1C. I P P ROPERTY FARTMF.,�1T 1:lwres.av Diusuxl Nwvoa 13o wws�uH[.-Rw 5nesi•Y%U1K wUACHL$e„s 019to T13-M745-959S•FNo 97L740.9W APPLICATION FOR THE REPAIR. RENOYATi N CONSTRUCTION DEMOLITION.OR CHANGE OF USE OR OCCUP NCY FOR ANY EXISTING STRUCTURZ OR BUILDING_ -' 1.0 SITE INFORMATION Location Name: Sgcm A4 S. BuikUr>g: `')I -- - property Address,-- - - -- -- - - -- - -- -- -- Property Is located in a:Conservadon Ares Y&L_Historic Dlstrlot 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land "v�ESEst r/ an1 ��OC` Name: d oN C) Address: ,/fop,, 3A COMPLETE THIS SECTION FOR WORK IN EXISLNip 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 Met Description of Proposed Work: I7n(J C*P S��iow.:it S (�O 1C 36P • cfssi6ls; ----- ---Mail Permit to: ---. - - What is the current use of the Building? Material of Building? �a �' if dwelang.how many unitsI Wit!the Building Conform to Law? 9AI — Asbestos? �6 - prchiteasName Q ���_ ' � Address and Phone l SV- ( `Y Mechanies Name G'oic•^�i£" �i`oN r Z1 d�Co�,�.cr Address and Phone 7-"— Construction Supervisors license 0 O�o�/� d HIC Registration g-4�a���6 Estimated Cost of Proied S Permit Fee Calculation . Permit Fee: � Estimated Cost X$7/111000 Residential Estimated Cost X$11/411006 Cormmwclal----- - - An Additional $5.00 Is added as an Administrative dUwI Make sure that 1.ali"ilelds are properly and legibly written to avoid delays in processing. 09 The undersigned does;hereby apply for a Building Permit to b to the a to specftations. Signed under penalty of Perjury Date 3 ilk 3 e Y t! Y - 4 -