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18 LINDEN ST - BUILDING INSPECTION (2) °7 S- 7 7 i\ *-So �a � IOU . The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF �j Massachusetts State Building Code, 730 CMR SALE1d Rdvised Uar Z01 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling '[his Section FbrOfficial Usti Only, Building Permit Number: Date:Applid Building Official(Print Name)fu date— SECTION 1:SITE INFORMATION I.1 Property A dress: LZ Assessors Map.4 Parcel Numbers 1.t a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoninglnrormation: 1.4 Properly Dl enilodtd'" A r..tzT.'tSt. A (n Zoning District Proposed Use ILotAres(slift) " Frodiiie(ft)1:'r 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(MG.L c.40,§54) 1.1 Flood Zone Information: 1.3 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal system lel el O On site disposal s s Q Cheek If es0 p P Y SECTION A'' PROPERT1d'OW(4E1 Us 1.1 Ow>tettt of Record 1Q z 1 �mmen S s!� i Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 1 DESCRIPTION OF PROPOSED WORKa'(c'0, eck alI that apply} New Construction❑ Existing Building❑ Owner-Occupied Q airs(as) Q Alteration(j) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ NumberofUnits Other ❑ Specify: Brief Description of Proposed 1Yorka: Slow ex acel a Lj a 5 Cam( 4 D� — — a� �SECTIOt`F4: ESTENIAf Ell CONSTRUCTION CSTS- item Estimate sts: Ofilclal Use Only. . LabMdCt)e I. Building S1. Building Permit Fee:3 indicate haw fee is determined: 2. rkctric:d ❑Stvtdaid.Cityfrown,ApplicationFee. ❑'Cunt Project Cost(Item.6)x multiplier x 1. Plumhing i �- OtherFies .S t. ,Mcchanival (liv.kc) iList:_ i. \I�chanic.tl Witc l'ot'll All Ices:5 I' tal I'rnjeet ( ' st S /DO(J -�� ac.l' No. _--Checc luwnut: _---(',ish :\maune ----- (] P lid in I_nll. _ . _,❑lhd;t:wJin;;,_Ilal:uica I)na: _ SEcrioty 5: cw4s rRUcrION SERVicPS 5.1 Construction Supervisor License(CSL) ? 7 _ 1 �`� License Number Gspir;uiuu-5 Date ,Jame of CSL I hider List CSL type(see beluw) 3 Hilton Street r e Dascriptiun No. and Street 3RCrtuot-m restricted Duildin s u to 35,000 cu. tt. rtricted IA2 ran,il Dwcuht nt Cit- rown,State, ZIP Cuvcrinindow❑nd Sidinlid Fuel Burning Appliancesq� �yy_Lyjulation'cle hungEmail addressmolitiun 5.2 Registered Home Improvement Contractor(111C) Y20 8� 3�rL y s �l,.�T -� HIC Registration Number Expiration Date I IIC Company N�t�er�f c utAe rno (M o I CG ye Email address No.and Street 4T —�I y7 Ci /Town Stnte 'LIP Tale hone SECTION 6: WORKERS, COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL 125C(6)) completed and submitted with this application. Failure to provide Workers Compensation Insurance affidavit must be this affidavit will result in the denial of the Issuance of this.building permit Signed Affidavit Attached? Yes .......... No.......... 13 SECTION 70:OWNER AUTHORIZATION TO DE COMBLETED WHEN OWNER'S AGENT OR CONTILICTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property,hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. 1u. Fm�� 5 25 Data Print Uwner's Nnmt(Electronw Signaluro� SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my natne below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Date rrint Owner;or Autiwrimd:\Sentb 11....(C•leetrrnw�ignatur�) ------------- NOTES: I. -kn Owner who ubtains a building permit to do higher own work,or an owner who hires an unregistered contractor (nut registered in the Houle Improvement Contractor(HIC) Program),will no have access to the arbitration pro,: ur guarmtty tired under�Lt).L.c. I�?.\. Other important infonntrtion on the HIC Program can be fuund at www nnu:.uov%ace httbnnation on the Construction Supervisor License can be fuund at tr tvw,mass.�v�ILt When sub;tontinl work is planned,pruvi.lu the info mtion belorr i a tini;hed basuuunVattics,dec.ls or porch) Total tloor mca(;+1. 1t.) _----- —(including 5' ` g f hbitablo room count _ iro;: living arr.t(" Number of bcth•ouuts `Inmbcr of firapl.iecs _-- - -------- Nuutherofh,tltb.uhs Vumhcr of bmuhnatni; --- ?inwberotAcel ' I•orchea _ .--- - _-- (•.lie , th..uiw; ;/:Idle -- - i'ndo..ad { `I-.oil I'n q.• .t � pi ua I d.r;c' IILty ie mh,ntot:d 11.1 I.,ril I'rpr.t l od- � f Massachusetts Home Improvement Sample Contract ii This tone satisfies ell besictequvemeuts of the slate's Home improvement Contractor Law(MGL chapter 142A),but does act led. calandaN ' hmgaegetopmteethomeowuurs Seelclegaludviceifneeessary.Any personplmnmg home im!¢ovameam should fast oUlnine doit,mda Massarhusgm Cotmumv(Sride t�Ime Improvement°before agreeing ro my Work on your residence:you tnay obtain s See in- by yelling the Office ofConsima.Affairs and Buenas Reguletton's Co¢sumerInformationHotline m 617 973-8787 or 1-888 283 3757 or onov_w_e_ r !rsit,. '• Homeowner Iit "In on Contractor Information, tfvmeT I M Company Name as..:nd� 41 UC t �s a to. C7,am aSox add Contracmu Salespen e / .L Err ?;! 611:Je xeA��sao Ciry/fovm Sto[e '+ tip Code Beninese Address(mrst include uw[m S Si;tcYYa`�f�01970 - Daytime Phone bYko' phoa C(tylfoua Smm 2(p Cade -- �k - �vyS- Mailin¢Address(It diffvent)tom abo{e) timmoce Phoro FMeed FmPloyaIDor S.a.Nm�a -i - Iimeam^��Camnm,aa MmWr e*miaa ' r.r,,.wvo ismm,zsa. rma mwam amha �_ 2/� The Conhuctoragreesmdomofa lowingworkhrtheHomeowner: - (DescnbeivderailWewosktocomp) speo(tying the �oW.brand,and Some of mmvvpleWbe used use edd'm'•nel.bsnif �) }�(E4i'1 Q0,A 5i K_1 .J /- _ as. -.3`.•.a... ..._ -.....T ... + _ w Required Permits-The followv�liwldingpmmim aro�uu�` Proposed Smrt noel Completion Schedule-The following sd.Mulewill and will be seared by the nouns as the home C be adhered to unless cimumstacm beyond the conimetots coned seise (OWners who secure their owe permits will be excluded from the Guaranty Fund provisions of I O Dam when ombactor will begin contacted wore. M(GjL chapter 1424142 A.) Ddewhm contacted woricwiU be substantially completed. TetalCmtrvct Priceend Payment schedule The Contactor agrees to perform the work,furnish the material and labor specified above for the total Sam of. Pbemade according tophe followingsthheduie: __w'.. upmt�gm-tg cm-"�aectTdut fo ekM 1'3'6fthef oaet5on-taa-Tpnce—iff coil bTgPcdiid order ii niW wFdenevv-,a- by 1 /_i.m'Wwn o^opled.of s �uAl. by_�/y! or upon Weelded.of (3. uponampledonofthecontact (Lawforbidsdemandingfullpaymentuntila tract roan Ietedto both .� P PsrtY�s satisfaction) rnetbltOwivgmNeelel/p(uipm must be special 's mbepaidoer - mderWbetbretheemumed begimiamda temeathewmpiederschedul6. •) s robe paid fen NOTES:(-)b d.ding ell tineace chdg'es(••)I awrequues that may deposit or down-paym m,copied by are contractor before vgdc y begins may not ase ed the greater af&ono-thinf othh toll wmampdm or(b)the w o l wet otary special equipmem mmmrksuem made mart' which vmatee specialad la edvanceto meet the completion sehedvla oea Ire IizprmWaruanw.la nn aoress waTia lv bU WtlM haft ten tort ❑N ❑Y ate f[h ter b tbU tit ll b Subcontractors-The contactor egrees to be solelyresponsgrle fv mmpletmn ofibe vm&(Iwmbed mgardless ofthe actions of my ttird party:/mbcontacterub7ved by We dded amor.The contactor further agrees to be solelyresponmble for ml paymmm a all subcontactpm for material,and labor uudsthis U=61 t - ContractAccepmutt•Upon sigmhg,this dommentbemmes abmdmg conersoa mderlmv. Untm otherwise noted writinn this document the contract stall tot imply that any lick br other secuity interest has been placed on the residence. Reviewthe following thin tcautions and notices caefully before signing this comma] • .. - o Dual be pressured into sigoiu9. a contract Take time to read and fullymderstmd it.Ask questions if something is uncles: MabLng;themmImMrhasW3VIdjjQ,,bR act Contractorgn-'--- The lawmquires mosthomeimprovemmt contracmm and subcontractors robe reguitered'la�rth the Director ofldome Improvement Con¢smorRegistation. You may inquire about contractor registration b)w ting to the W*mor at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973.8797 or 988-283-3757. •. Does the wnoaetorhave insmedce7 Ask the Contactor for his insurance company Warmation so that you cm confirm coverage,or ask to saawpyofa"proofofiusurddw"document - _ • Knowyourrighmmdresponsiboties. Read the hnportmtlnformation onthe reverse side of this form and getawpy otter Coarnmer Ouide to the Home SmpmJeme6}ConirecterLaw. You mnY cancel this agreement if it has been signed s a place other than the contactors normal place of business;provided you notify the mntracty in writing athis/hermafnjdtBce vbrmch o&a by ordinary mail posted,by telegram sort or by delivery,not later than midnight of the third braaness day fallowing the sigdibg of this agreement Sea the attached notice ofcmwBation form for an explanation of this right DO NOT SIC I THLS CONTRACT IF THERE ARE ANY BLANK SPACES[!I ����yy��Twiaraivlaydoale mwet»roa,pr•aa®adgyca oaewpy,nowdaoromemaxo.mar.nee,e �� aombb-- iramo� y xners srgaetse Dal it Contractor Arbitration , The Home Lnp'rovemem Contractor Law provides homeowners with the right to initiate aharbitrationaction(as an alternative to court action)if they have a dispute with a contractor. The right is LiQt aj>�omaticall contractor,however, The contractor would have to resolve an both parties agree to the o do 1 clauseY afforded to a P °$ provided below. This cuse dispute he/she a has with a ho eowner in court unless arbltrahon as is afforded to the homeowner by the Home Ito rove. give the coati t i or the same right to - The contractor and the homeowner hereby mutual! P OR Contractor Law. y agree in advance that in the event the Gpntractor the Serajtlg this.con -tye,eontrsc, maysubmit the dispels to a privam azbitration firm! a dispute eciet`ar`y of dieEiZecutive 0.ffice o Consumer Affairs and Business Regulation and the meh been approved to submit to such,mditttw6n'es rounded In PP ved by P Massachusetts General Laws,c ns°mer shall be required chapter 142A. Owner's Signature NOTICE;The signattirey of the patties above 1 Contractor's Sty------- resolution initiated b aPP Y only to the agreement of the parties t9 alternative dispute y the contractor. The homeowner may initiate alternative dis ute s t section is not separately signed by the allies. _ P Nfition even where this Hohteowner's,Rights A homeowner's rights under the Home Im rove Protection laws(i.e.MOL chapter 93q)�y not ye YwContractor� Law(MOL chapter 142A)and other consumer may be excluded from certain rights if the con Y way,even by agreemea.I However,homeowners Homeowners who secure their own tiuil ' contractor they choose is not properly registers as Permits are automaticallyallI prescribed by law. the Home Improvement Contractor Law. The contractor is responsible excluded the iv�'ork as described,in a_ __ timely and workmanlike manner. Homeowners m uazamY Ftmd provisions of guarantees ar provides ea express wairmn maybe entitled to other specific legal righ)S if the contractor rounded goods sot in oMassac}tnsc or materiels, In addition to puazantees or warranties P by the contractor,all a particulaz purpose: An eau. mTY an implied warranty of merohamability and fitness for added to the eration of other matters on which the homeowner and con4pctor lawfully agree may be terms-of tke contract es:long as they do not restrict a homeowner's basic coasirmer rights. If you have 9uestions'aboirt yo�s'consumer/homeowmer rights,contact the Consumer mformatioa Hotlnne(listed be]ow). Eiecation of Coafract The contract must be executed in du I'ca and should not be signed until a copy of all exl�bits and referenced tlocumems have been attached, parties are also advised not to sign the document until a!]blank sections have been filled is m marked as void,deleted,or not applicable. One original signed copy of the cot}tiam with attachments n to beg van to the owner and the other -end agreed.to by boUrparties:Coatcectetl�v7mdrk-may nbtbegin iiiitil bdotG•—a[t es the origins)coniract.musYb�in.Meting __ _the contract,and the tlaee day resrSssiosperiod has expued. P have recein?ed a fu11y'e5tecmed copy of Accelerated Payments ... A contractor may demmnd payments in advance of the dates specified oa the a ! homeowner de - erseL:to be financiall ins p Y.ent Schedule in cases where the to be fiaanc]ell .sec Y ecnue. However,in instances where a contractor deems him/herself y it e;the contractor contra require that the balance offunds not yet duel be placed in ajoint escrow account as a prerequisite to continuing the contracted work Withdrawal of funds from sai��accouht would require the signatures of bout parties. Additional Information If you have general questions or need additional information about the Home Tmprovemeritj Conttactor-I,aw or other consumer rights,or ifyou wish to obtain a free copy of "A Massachusetts Consumer Guide to Homo Improvement,, contact: _ I Consumer Information Hotline 'Office of Consumer Affairs and Business Regulation !j 10 Park Plaza,Room 5170,Boston,MA 02116 ` 617-973-8787,888-283-3757 of visit the OCABRwebsite at ht�•//www rilass i°cabr/If you want to verify the registration of a contractor or if you have questions or need additional.information specifically about the contractor regishation component of the Home Improvement Contractor Law,ob}rtact: - DirectcrafHome Improvement Contractor Registration '! Office of ConsimiOr Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at •/www Mfts''Aovlocabd Go online to view the status of a Home Improvement Contractor's Registration ! --b t , u o 'm ov 'ce s e i i For assistance with :!informal mediation of disputes or to register format complaints againy�a business,call: Consumer Complaint Section j Office of the Attorney General 617-727-8400 .jl. "" .. AND/OR Better Business Bureau I - 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-I M12,7olo lk.R CERTIFICATE OF LIABILITY INSURANCE DATE(MM001YYYY) `� 3/11/2013 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 endorsement(s). PRODUCER CNA MTeCl_C_OnS traction Eastern Insurance Group LLC PHONE . (508)651-7700 Fax 233 West Central Street X- L SS- INSURERS AFFORDING COVERAGE NAIC 4 Natick MA 01760 INSURER A Arbella Protection Ins. Co. 41360 INSURED INSURERBArbella Indemnit Ins Co. 10017 Atlantic Weatherization INSURER c Nautilus Insurance Co 61 Rear Jefferson Avenue INSURER D: INSURER E: Salem MA 01970 1 INSURER F: COVERAGES CERTIFICATE NUMBERMSTER 2013 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, INTRR AWL WISH TYPE OF INSURANCE POLICY NUMBER POLICY DEFF MMIWD Upt-COMNOP LIMITS GENERAL LIABILITY RENCE E 1,000,000 X COMMERCIAL GENERAL LIABILITY o unan E 50,000 A CLAIMS-MADE �OCCUR 500042816 /20/2013 /20/2014 one arson) S 5,000 ADV INJURY S 1,000,000 REGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: OMNOP AGG b 2,000,000 POLICY LE PRO- LOC E AUTOMOBILE LIABILITY COMBINED I SINGLELIMIT Me INE 11000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 020015871 /20/2013 /20/201d AUTOS AUTOS BODILY INJURY(Per ecaidem) S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Parac art E X UMBRELLA LIAR ]{ PIP-Basic $ OCCUR EACH OCCURRENCE E 1,000,000 A EXCESS LL49 CLAIMS-MADE AGGREGATE S 1,000,000 DED I I RETENTION 600047820 /20/2013 /20/2014 E WORKERS COMPENSATION W'C STA U- OTH- ANDEMPLOYERS'LIABILITY YIN ER ANY.PROPRIETOR,PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT E (Mandatory In NH) E.L.DISEASE-EA EMPLOYE E if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I $ C POLLUTION LIABILITY PL2003786001 0/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addmonal Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF RAT M ACCORDANCE WITH THE POLICY PROVISIONS. 93 WASHINGTON STREET SALEM, MA 01970 AUTHORIZEDRFPRESENTATI IS Rosemary Fulham/PMA G�.-+T•a 'V ACORD 25(2010105) 01988-2010 ACORD CORPORATION. All rights reserved. IN5025 rm,m5,M Th.&r-nPrT nvmn anA Inns n.n.nnialn.url ma.kc of A(:rlpfl IL Right£ax C3-2 3/11/2013 4 : 45 : 54 AM PAGE 2/'002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) T TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE O S 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 233 WEST CENTRAL ST (A/C,No,Ext): IA/C,No): E-MAIL NATICK,MA 01760 ADDRESS: 22MLW INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: AMERICAN ZURICH INSURANCE COMPANY ATLANTIC WEATHERIZATION LLC INSURER B: INSURER C: INSURER D: 61 REAR JEFFERSON AVE INSURER E: SALEM,MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: HIS IS TO CERTIFY O LISTED BELOWHAVEBEEN 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 SUSJ ECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITSSHOWNMAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MmomyYYY) (MATDDIYYYY) UNITS GENERAL LIABILITY =ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. DAMAGE TO RENTED $ EMISES(Ea occurrence) MED EXP(Arty one person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY =PROJECT =LOC RODUCTS-COMP/OPAGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALLOWNEDAUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE s EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ S A WORKER'S COMPENSATION AND X we STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-5B270121-13 03202013 03202014 uMITS ANYPROPERITCR/PARTNERIEXECVTVE N N/A E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED'+ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE I s 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLArES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED 93 WASHINTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR 7 TA'(}VE Ant— SALEM, MA 01970 r- ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. +t xr• CITY OF Smy'.M, 1tL-kSS-1CHUSETTS BULDLNIG DEPARTMENT • , 130 WASHINGTON STREET, 3i°FLOOR TE.L (97$)745-9595. FAx(978) 7 i0-98at6 KI\fgFRi F.Y DRISCOLL 'THo&WSi.P►ERRI3 MAYOR . DtRECTOR OF PL BLIC PROPERTY/HUMMING COMMISSIONER' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers A fljjcant infiirtnation Please Print Geaibly Name(BusinessiorgtnizatioNlndividual): y M on, Erc Address: 61 R Jefferson AvLenue ; Salem 41 70 r City/State/Zip. 7fione �? �4N �/ y 3 Are y an employer?Check th�propriate box: Type of project(required): 1. _ 1 am a employer with -�- 4. (] 1 am a general contractor and I 6. ❑New construction , employees full and/or part-time):' have hirer!the sub-contractors.. _( 7. [:],Remodeling 2.0 1 am a sole proprietor or partner listed on the attached sheet t These subcontractors have N. ❑ Demolition ship and have no employees working for me inanY capacity. workers'comp.insurance. 9• Building addition [No workers;comp.insurance S. (] We are acorporation and its !0.(]Electrical repai[s'oradditions required.] officers have exercised their, r right of exetn ion r MGL l l.0 Plumbing repairs or additions. r 3.❑ 1 am homeowner doing all work b Pt Pe , - . - myself.[No workers'comp. c. 152, 1(4);and we Have no 12,0 Roof repairs, ` t employees. No workers : insurancerequired.jy ees. ' ['. P Y 13.00llier camp.insurance required.) S ' ust also fill out the section below showing then workni'cempeoutian in policy formation •nny applicam that cheeks bot[i/l m - r I dmwuwnets who submit this affidavit indicating they are doing all work and than hiro outside contractor,must whmita new affidavit indicating=h. Contmium that check this box mtatt attoched an additional sheet showing the name of the'ub.tont"re and their workers'comp.policy inIbUnadon, lam art employer that is providing workers'rompensadon htsuranco jor my employees Below is the policy andfab sits hrfonnutioa , ' Insurance Company Name: Policy 4 or Self-ins.Lice tt: C� Expiration Date: � y j Job Site Address�� C.it .J.'� - City/Stawizip: S� Anach'a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to sccurc coverage as required undec$cction 25A of MOIL c. 152 cap lead.to the imposition of criminal penalties of a tine up to S 1,500A 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. Be advised that a copy of this statement may be forwarded to the Office of. I nvestigutionsvl'ilia DiA for insurance coverage veriliealion. - f do hereby certify carder the painst and penald if rrjuty that Ohio h1farmuflon provider!ubov is tr/of and correct ii n nurc• �/ V ,Lsy Date! Phone 4, OJfrchd use only. Do :at write in this area,to be completed by city or town offfclal City or Town: PcrmiU1Jccnse# issuing Aulhority(circle one): 1. Board of health 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other, Contact Person: ____._ __ Phone tf: I /}wr CITY OF S,U.&tif, M-kSSxkCHUSETTS ©UtLOLYG DEP.IltT..%oNT 120 C(/,iSHLYGTON STREET, 3AO FLOOR sy TEL (978) 743-9595 '<11tBE.4LEY D(ifSCO[l. Fuc(978) 7-W.9344 ,bL�YO.'i TF1O14\3ST.P1£FUtB DIRECTOR OF PLOUC PROP ERTY/8LMnLNG CCILNUSSIO.NER Construction Debris Disposal Aftldavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Coda, 730 C&fR section 111.5 Debris, and the provisions of b(GL c 40, S 54; Building Permit hi 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,bfGL c l 11. S 150A. The debris will be transported by: (aini ut'haukr) The debris will be disposed of in :: / (nama of facility)- of L_ 5fi A) (address of Yaaili(y) �z2— sigualnre ulpermit applicant Tile Unrestricted-Buildings of any use group which z CS o67s77 contain less that[35,000 cubic feet(991 u?)of enclosed space. ERIC W PAU& ' 3IiII.TONS'F _,",, ', SALEM PAA-01970 j ` Failure to possess a current edition of the Massachusetts `='3mm"c:;a 0412312014. - state Building Code is cause for revocation of this license. ..- _ For DPS Licensing information visit %vmv.Mass.Gov/DP5 ✓1 . 4c ct:. J y-� Office ofleoosumer:�#ain BUSmesa`llegoTattoa C A�-HOME IMPROVEMENT CONTRACTOR _ - License or registration valid for individul use only %ReOlstration: 142089 Type: Expiration: 3lf212014 eta tiablitpCarpoe before the expiration date. Iffouod"-return to: -e Office otConsumer Affairs and Business Regulation ATL`'frrlilC WEATHER2ATIO14L,L.C. to Park Plaza-Suite 5170 - Boston,riL4,02316 i ERIC PALM 61R JEFFERSON AVE, SALEM,MA 0197D Undersecretary Nat.vaallid-without signature `e.