38-48 LIONS LN - BUILDING INSPECTION The Commonwealth of Massachusetts
CITY OF
Board of Building Regulations and §Tllodards
EM
Massachusetts State BuildinRcair,
780 MR Sd Mar
Revised Mar 2011
Building Permit Application To Construct, Ren vale Or Demolish a
One-or Two-Familyg
This Section For Okficial Us
y Building Permit Number: I D to App
Building Official(Print Name) i atum Date
SECTION 1:SITE FORMATION
1.1 Pro pe Atiydr�s: 1.2 Assessors Map& Parcel��bgfC
((-�/ l � N
l.la Is this an accepted street?yes_ no ✓ Map Number Parcel Number U�
1.3 Zmu In rmatmn: 1.4 Propert Dimensions:
Zo rig District Proposed Use - Lot Area sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Prqvided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brie Description of Proposed Work':(1�� 7
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ �.--.ct r,s ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ rv-- 2. Other Fees: $ n�
4.Mechanical (HVAC) $ �p� List: V
5.Mechanical (Fire
Suppression) $ _G-- Total All Fees: $
$ Check No. Check Amount: Cash Amount:
..CJ�D
6.Total Project Cost: , 11Paid in Full [I Outstanding Balance Due:
1� �1
SECTION 5: CONSTRUCTION SERVICES
5.1 structi n Supervis r icense(CSL) �3 7 /
License Number 7 Expiration Date
NAinj of CSL Holder
29
/n ���� 9 / List CSL Type(see below)
r No.and Street (J �/ Description
/� U Unrestrictedl Family
(Buildings u el ing cu.ft.
/--1 t Restricted 1&2 Famil Dwelling
City/Town,State,ZIP /// /l M Masonry
(/, G RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
-. 5.2,AVsterel Home Impro4 n ent Contractor(HIC)
HIC Registrati n Number Expiration Date
C npany Nam pr Registra m 7�
No. Email address
Ci / own, State,ZIP Telephone v
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRAC R APPLIES FO UILDING P RMIT
I,as er of the subject pro ,her by authorize
to a on ehalf,in all tters relat a to work authorized by this building permit application.
Print
n wn 's N ame(Electron c a[ure) /! /� � Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
coot ' ed in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HTC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass. og v/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supen isor
License:CS-091942 d� -
MICHAEL L MERCURIO x ''
127 OAK ST
WAKBFIELDMA 01880' Rxf 4
Expiration
Commissioner 01/04/2015
OfOee�one'r'� ai-ie& a3ioes'� atTou"" ! License or registration valid for Individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Reglstretion:, 149839 Type: Office of Consumer Affairs and Business Regulation
Expiration N732,014 OBA ( 10 Park Plaza•Suite 5170
I _r I Boston,MA 02116
M - URIO CONSTO'U 'TION r'ri
pi
4 ,
MICHAEL MERCQRIO !,�i' ai iJ I .01
�f
1270AKSTREET , i'. y
--�
WAKEPIELD,MA O1880„ , Undersecretary t Not valid without signature ,
ri
CITY OF S.U.EEM, iNass.kCHUSETrs
BiB.DvqG DEPARTRI-*T
. + 120 WASHINGTON S REEli,3-FLOOR
p, TEL (978)7.85-9595
PAx(978)7 9,8 6,
K1iIBFRqIY�� y DRISCOII "I'
b %YOR - 3tORtidsST.FYf..Ait6
tlL .
DIRECTOR OF PLHLIC PROPERTY/BL'ILDL,G_CO:uLMISSIONER.
Workers' Compensation Insurance Affidavit:BuilderslCgntractorafE]ectric]mns/Plumbers
Jaltlicam4-]nforma4iifn Please Print Le i'bl, :
V mna (BusineswOryaniza+ioNlndinduul): f / I f elf f''/-f/}
Address:
City/State%ip: / LAC t rt Ph / �)z z T1�1
Are you anern ployerla Check the apgiroiniate Lox: Type of project(required'):;
1.❑ I am a employer with #• I am a general contractor and 1 b: ❑New construction
employees(foil and/orpart-time):'°. .have hired the sub-contractors
2.:[� 1 am asole proprietor or partner listed on the attached sheet,> 7: Remodeling
ship and have no employees These sub-contractors have H. Demolition
working.for me in any capacity. workeW comp, insurance. 9. Building addition
[No workers'comp..insurance 5. ❑ We are a corporation and its
officers have exercised their 19�£lectrical-repairs or additions
required.]
3. 1 am a homeowner doing all work- 'right of exemption per MOL- I I.E1 Plumbing repairs or additions
myself.(Na workers`comp.. c. 152,91(4),mid we have no 12,El Roof repairs
:insurance required.) employees. [No.workers' Other 1J'�� rJ
Comp.insurance required,] f r�
-Any applicant that checks box 01 muei 41w till out the section below showing olicy information.
t.I F'.owniss whosuhani this affidavit indicating They ors doing all work aW then him owcidc comntttorx most suhmit anew affidavit indicating such.
-C....i n.inn ihni ehet¢.thi.box must anaeW an a+a Woral sheai showing the cssme of the rub-comraetmx and Ihair workere'cornnp.policy in!unnwion.
d um an employer that&providing workers'camperlsadlon immiromce for my eniplpyees. Below is the policy and Job side
balornaation. //aa
Insurance company Name: Ar E;-, f�„ ,��
Policy#w Self-ins.LiC.q:_ Expiration Date: 2zz-/
Job Site Address: tYr1Yal7l ' -+t .(i f .. c) (. i '✓r°1% city/slaw/zip: ��if�IJz`f�f
Attach a.copy of theworkers'eompenscillu polley dec Location page(5110VA09 tha policy number and expiration date).
Failure to secure coverage is required under Section 25A of MGL p..152 can.:lead'to the imposition of criminal penalties of a
• tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of ii STOP WORK ORDER and a fine
of up to S250.00 a day against the violator.. Be advised,that a tmpy of this statement may be.forwarded to the Office of
lovestigaliuos ot'the DIA'for insurance-coveragu v_elzificanoa.
F.do hereby c r#11 r )dhe� r�s and ' ulliees perjury that
ha+t the afonnaliver provided above)lt Irmo and correct
Sin;i re. C��'k" �/t.- . �/_ .!��/sK..��/1/(.-./ 'Out• S�l�! ��.
phone#:
Official use only. na nor write its ibis arru,.to,he completed by,cilyortown.anfficiall
City or'pown: -_-.:— - Permlt/l.lcenvefi -
Issuing Authority(circle one):.
1.Board.of Health 2.Building Department 3.City(fown Clerk d.Electrical Inspector 5. Plumbing Inspector
Contact person.-___ _� Phone.Jd _. "
• - 07 tt-'3:Co 09PM.;.S'L_S ov Y°+R1ewa k073/4.S0084. 1.80.35,�C2.01 J./
kbT'10E OF ASSIGNMENT
EMPLOYER:. COMBO W. 5TATUS OF EMPLOYER
MICHAEL .MERCURIO DBA G k. M"ENTERPRISE 000694051r Individual
PO SOX :438.
WAKEFIEDD, MA 01680 COVERAGEGROUP _
0718059
~ - Coverage under this assignment
The Waiver of Our Right to applies to Massachusetts
Recover from Others- Endorsement -operations only. For coverage
is available on Pool policies, outside of Massachusetts, contact.
Contact your agent for details. the appropriate Pool or Plan. for
that state:..
4 �
A. - -.: K INSURANCE COMPANY:
AGENT 'TL SOUTHMAYD INSURANCE AGENCY.LLC ``'"- ACE AMERICAN INSURANCE CO
OR '�"LOUISE SOUTHMAYD "a: ,,. - Jonathan Scharnberg'
PRODUCER: .668 MAIN STREET P O BOX 3556
WILIMINGTON, MA- 01887 ORLANDO, FL 32802-3556
(.806). 453-9843.
AGENCY FEIN::202671711 i.
CLASSIFICATION OF OPERATION CLASS ESTIMATED ':RATE ESTIMATED
CODE: TOTAL ANNUAL PREMIUM
REMUNERATION
CARPENTRY NOC 5403. $D 9_.61. $0
CARPENTRY-DETACHED ONE OR TWO FAMILY DWELLINGS 564E $0 8.68. $0
CARPENTRY-DWELLINGS - THREE STORIESOR LESS 5651 $0 8_68 $0
EMPLOYERS LIABILITY 100./100/500 9845
STANDARD PREMIUM :.. $0.
LOSS CONSTANT 0032 $50'
EXPENSE CONSTANT 090.0 - $159
TERRORISM CHARGE 9740, $0
RISK MINIMUM PREMIUM 09904 -. _ $800-
TOTAL POLICY MINIMUM PREMIUM. Eu. _ - $500
TOTAL ESTIMATED PREMIUM $500
DIA.ASSESS:. 3..4 ,. $0
------------
TOTAL EST. PREMIUM.PLUS ASSESSMENT $500
INSTALLMENT BASIS: Annual DE0051T:PREMIUNt:. $500
THIS IS NOT A BILL
COMMENTS .
Coverage effective. 12:01 AM on 07/11/13
DATE OF NOTICE: 07/11/13 PREPARED BY; Paulette Hoffman
EXT-`5i4
* * VOLUNTARY DIRECT ASSIGNMENT * '
LETTERID: 3994416
s
7
`i4,. =� The Workers'Comperisation Rating andInspect on Bureau of'.Massachusetts`
}: 101 Arch Street-Bo
s@oaay MA 02110
' (617)439-9030 FAX(617)439.6055-www.wcribrna org
ClT- y OF �. �dS.;V�1SL89Ldb�SYL SJ
BUiLDNG DEPARTiiENT
Ia 120 WASHNGTON STREEt,3" FLooR
TE1.. (979) 745-9595
FAx(97s) 7443-98
ictaIBERLEY DWSCOLL
v$AY€J Ito sA as S:.
DMEC-rOR OF-PUBLIC PR0PERTY/BUUMrNG CO.%LNIISSIONER
Cotistrue.titan Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance With the sixth edition of the State Building Cane; 780 CMR section 111:5
Debris; and the provisions of MGL c 40, S 54;
Building Permit# 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
111, S 150A.
The debris will be transporkd by: Ft' �i ��C' �f J/1'✓1G y � ;1 t `t
DYNAMIC. :DISP03AL. P.O. 'BOX ESSF,X, MASS. f
('name of hauler)
The debris will be disposed of in'.
(name of facility).'
(address of facility)
�Jt c
j signatur %,Epermit applicant
date-
. . 31:.LY.DLVG P�EP.LRTB{F'.atix
' - 120WASHINGTONsiREE.r,3`a'FLooR.
1 1_ (978)745-9595
P.u<(978) 740-9846
iBERLF-Y D91SCOLL "TtioNw Sx.Pmans
,,MAYOR
DSRECTOR OF PI:BLtC PROPERTYItUII:DLlG.COSL4tISStOtiEtt
Wlterkers'Comapensation'l nsurance rkfridmvit:BuilderitContractmrs/Electricians/P'titctihera
A) licant Information n P'P ass Print Le ilil
f i
Naine(BusitxSwOrga izaitoNlndividiial);
Address �j. f � Z/6
City/State!.Zip: j �� _J Ll � Phone#:
Are yme an employer?Chetlr the appropriate bor_. 'Type of project(required):
1:[J 1 am a em 10 er with e- I=a general contractor and 1
P Y '' b: New construction
employees(foil an part-time).* have hired the sub-cantiactors
2 ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling.
ship and have no employees These sub-conbe ewrs,have 8. ❑Demolition
working for me in any capacity.. workers'comp.insurance, 9,. [] Building addition
[No workers'comp.:insurance 5. ❑ We are a corporation and its`
required:].
officers have exercised their 10.❑Elactxical'.repairs oradditioas
3.0 1 am a homeowner doing all work- right of exemption:per MGL. I.f f]Plumbing repairs or additions
myself.j\o workers'comp., c.152,§1(4),and wehave,no 121.El Roof repairs'
insurance required.)f dmplayecs.(NO workers' !e f7' 1, /7> 7
13, Other a .t'`
comp.insurance required.) 1'4' f-Jt�T
-Any apple N,Iatchoeltchox 01 mussalsofill eet the section WOWirwwing their workers'wmpensaiion policy information.
T l lomcownen whosubmit they affidavit indimling'they ere doing all work and then hire oafsidecoigntttom must=hmlt anew aflida0 iodicnd g seah.
-C.mtnct..that cheek this hoe mun7 all.di d on.Wditiwo l.hart showing the rum,otthosubiontroxont end their w4+k.'wrap.policy in!ormatiow
am as employer than is providing workers'compensation insurance for myetaplayees. Below is the policy and job rite
inforrnmion.
Insurance Company Name:.--� '`(�'Policy 4 or Scl£-iris.hie.#: ; _ _ -. - Expiration.Date: �/7
"1i'"';L4
411
Job Sire Address: 'rY�!/P', Pl,{J / 121 ti:. . rU1---111Ciry/Slatrt2ip.- Z/tl�f
Attack a copy ortua workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure:covetage as required under Section25A of MGL t. 152 can lead to the imposition of criminal penalties of a
fine up to S 1y500.o0 and/orone-year imprisonment,as well as ctvii 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
Investigations of the DIA for insurance coverage vcnfication.
f do hereby r r the ' s uud p allies perjury that the infonnalion provided above is trine and correc_4
Phnnr#:
OjTicial use only. Do not write in this:arru,to be ruinpleled by city or to an 0000-cial
Cityoe'i'uera:, ._. - Permlt/l.ieense#
Issuing A thority(circle onc):. '
ssuln Jorltcalth 2.13uildingDepurtmunt 3.Cityrrown0erk 4.Electrical Inspcctor 5:-Plumbing Inspector
:j
N,flw N_
7 8 7
11-1 05 C 4 5 0 0,8 4 1:' j ;,9736e70201 �e
07 oopm;I L So�f�WaTd
1 I .- I . 'k
J" 41-
A
a
N OTICE OFASSIGNMEMT,
--------------
EMPLOYER: ` 'COMBO LD. STATUS OF EMPLOYER
_
MICHAEL,MERCURIO'DBA'G &'W8NTERPRISE �0,00694051 Individc.al
PO BOX4* nm!�4-1!�N ', �!N
a,
WAKEFIELD, MA 01880 COVERAGE GROUP]
_N
0718059
�-g
4 -ij4l�ln4 N,
ZL
a. 10 _i�;Coverage�underithis assignmentf
"n
iDpl ies�-to'Massachusett
The Waiver of,.Oiilr�R k"xir O f. a
nl F Recovex.from:Others Endorsement" ''kl ,_I Ir J_,_overationso - or covexage_ A
A 'Y_
is available - outside,of.'Massachusetts, contact '. .
t
able =�Pool�,poli policies ,
Contact your j agent f or de the appropriate. Pool' or Plan,foxl t
-that estate..
F
x
-x-
;,y,
AGENT >,TL SOUTHMAYD INSURANCE AGENCY,LLC irde5'I__ ACE AMERI CAN INSURANCE CO
3.
OR J UTIOIXYD j;.. c
;�, - " 1 1-1 - -�; . 4,
LOUISE, So Jonathan
PRODUCER:,669 �MAIN STREETA4,,i-��. P 0 BOX 3556_11111`?
WILIMINOTON, FL ORLANDO; 3280
:g 3-S843,,-(600) 45
AGENCY FEIN:202671711`
mi
41
-------------
RA
TE ESTIKATED
CLASS'I ESTIMATED iA
CLASSTFiCATI6WOF,OPERATION
COD ANNUAL E: ATOTAL PREMIUM'
-REMUNERATION
H
--------- ----------------- ------ ----------- - -------------- ----------7 ----------
A,
CARPENTRY NOC
5403, $0. 9.61 $0
7
CARPENTRY-DETACHED✓ONE,OR-TWO'FAMILY DWELLINGS� 564-5 so 1 8 68 $o
CARPENTRY-DWELLINGS' - THREE,STORIES OR,LESS- 5651 0 "8 Ga' $0
EMPLOYERS LIABILITY 100/100/500 9845
STANDARD PREMIUM
LOSS CONSTANT
0032'
EXPENSE CONSTANT- -All �ov, A -
040'
TERRORISM CHARGE, -W I
4 'VI - -11, - $0
q , ::� 9 It F ,.,
$500
RISK MINIMUM PREMIUM
TOTAL POLICY'MINIMUM'PREMIUM i� ". i. On-
i� r� 4" 4 '.$Soo
i, '$500s5oo
V,
%TOTAL ESTIMATED PREMIUM "N' 41,
DIA ASSESS. 3 4% 'A" $0
I�R .....
OF 'A%ijik $500
TOTAL EST. PRE
Gr
INSTALLMENT BASIS: Annual $500
J:
mw
-.THIS IS NOTA-13ILL'
A�
re
T
41H
COMMENTS
Coverage effective i2:01'AM'on 07/11/13.
me,
DATEOPNOTICE: 07/11/13 Hoffman
p. m
-AS GNMENT O_VOLURTARY DIRECT�AS
jail!_1zz
LEiTERIM 3994416
%q
s Rating-and"' 1 0 assac u
The Workers'Compen Compensationse-1 �_
,4
101 Arch Street-Boston,-MA,021101E�_�l
r�(617)43P)030'•FAX(617)4*6056 wwwmcirib=nrg
00-A, 4
' lul
P,
--w
11 J
-W
ek�
el,
2. N,
-te,
IN—
e B'unDz; DEPART CEA;T
I� 130 WAS}tLNGT0N STREET, 3n°FLooR
Ta- (978) 745-9595
FAx(978) 740-9846
KItiiBERI EY 17RISGC)71
MAYOR "THObt�S ST,
I7IkECTOR Of PUBLIC PR0PEkkTY/B ILDt vG CCNL�USSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)'
z_ Tn accordance with the sixth edition of the State Building Code, 790 C'MR section 111.5
Debris, and the provisions ofMGL c 40,S 54;
Building Permit#' is issued with the condition that the debris resulting from
this work shall be disposed of in a properly Iicensed waste disposal facility as defined by MG1, c
111, S 150A.
The debris will be transported by;
DYNAMIC .DISPOSATd. P.O. BOX ESSEX, MASS. • Y .
(narne of hauler)
The debris will be disposed of in :
(�ame of fac�Lty}'
- • (address of facility) // }
f;
rtYd signatu r errnitapplicant
1
.. date .��
dcbrufi:ltx:
BUILDLNG DEP.4RT%ff-iT
120 WASHIINGTOtvt STREET 3-FLOOR
' TEI_ (979)7$5-9595
tFA-,(97 S)-740-9846
1CiilSERI-FY"DRISCOU THOMAS ST.PTERRE
.MAYOR
..DIRECTOR OF PUBLIC PSCOPERT1if 13L'tLDtvG GOSLtii1SSIONER
YorkeWCtinpentiation Insurartrz Affidavit. BuilderstContractorslGlectric[ans/Piumbers
A t licant Information __ / it/ _ .: Please Print LeL#ibIv
vaine lf3usinusx+Organiza+ionilndivtduaA): t 1 � J l� :�Y ,. 1 �� f�'::
Atidrese:-
City/State/Zip:
Are you an employer?Check the appropriate box: Type of project(required):
1.[) t am a employer with "` `, a.g 1 an a generalcontractor and
6: 0 New construction
employees(full and/or part times).* have hired the sub-contractors
2:.❑ 1 am a sole proprietor or partner- listed on the attached sheet, 7. ❑Remodeling
ship and have no ctnployees These sub-contractors.have & ❑Demolition
working for mein any capaciryc` workers'comp,insurance: 9. ❑Building addition
[No workers'comp,insurance S. El we are a corporation and its
rcquired]
of7icers.have exercised their I0.❑Electrical:repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I1.❑Plumbing repairsor additions
myself.f No workers'comp. - c. 152,§10),and we have no 12.0 Roof repairs
insurance required.) 'c+nployees,[NO workers, r ;' �,�) t
13. Other �f / , �l�'! I ) . J
comp.msurancerequirdo.f � � t�jr/.
•Anv,applicant that checks twat 01 mdN alw fill Out the section bclowshowing lhi:irwwkcrs'comDnrcsazion pnhcyiirfor madam.
t Itiimeuwnas whosubmit this afdavia indicating they ace doing.all wort slid than hho oetSide cpivractors Must submits�w atlidavit indicating such,
=",ua cion thatiheck this bat must auacfuatan:sldifl acd shoe,showing she tuune ofas;suh- ntrnotors and their works Droop:.yvalicy inrorr aiian.
l urn On anpluyer rhea Is providing tvorker3'conrperrsaa/un ie+surance jor my emiployees. Below Is the policy und}ob star
ir+formurion,
Insurance Company
Policy k or Seif;ins Lic. y/- Expiration Date
/7(/.�- ✓`��"/
Job Site Address: j+�f!'7fl
Attache acopy of,the workers'compensation policy declaration page(showing the policy number and,eapirarhon date).
Failure to secure coverage as required under Section.25A rif MGL c!,1 S2 can lead'm the imposition of criminal penalties of a
fine up to S 1,500.00 and/orone-year imprisonment,as welt us civil penalties is the form of aSTOP WORK ORDERand a fins
of upto S250.00 allay against the violator. Be advised that a.wpyyof this statement may bu:furwarded.to:the Office of
Invcstigativa>s of the DIA for insurance covcrageverification. _
do hereby c r anshe ' s and p sill/es perjury that doe'injormutlon provided abo/ve/s ime and correc4
Phone#:
official use Only. Do not write ix rhis,areo:to be compkied by city or town.p�elnl
City or,town: PermfilLicense
-.Issuing authority(circle(me):-
1.Board of health 2,Bu lding Depurtincnt, I CilyllownClerk 4.Electrical Inspector SaPlnnttiinganspeeeor
6,Other
Contact Person:. Phone t
07r,'I1-13.05 :OOPM,TL>$OtiChmaytl- '* `E:7.8%4G8fish F9Z985]0209, y{, gj :.2
NOTICE OF ASSIGNMENT
k
EMPLOYER:- sCOMBOLO. STATUS OF EMPLOYER
MICHAEL.MERCURIO DBA G & M: ENTERPRISE. 0006.94051 - Individual
-PO BOX., ��
-436 + - -
WAKEFIELD, MA 01880 " COVERAGE GROUP
07,18059
Coverage under this assignment
The Waiver of Our Right to. y `, applies to Massachusetts
Recover :from Others Endorsements operations only. For coverage
is available on Pool policies „ g°+ {di;,iouts:ide;of Massachusetts, contact
Contact your agent for details l'- the appropriate Poet or Plan for
" -- - that.state.
n
INSURANCE COMPANY.
AGENT IL-SOUTHMAYD INSURANCE AGENCY LBC '.ACE AMERICAN INSURANCE CO
OR LOUISE;SOUTRMAYD Jonathan Scharnherg
PRODUCER: 668 MAIN STREET: P O .BOX:355b
WILIMINGTON, MA oiav _ c ORLANDO, FL 32802-3556
i ., (800) 453-9843
AGENCYFEIM::2 0 26 71711
CLASSIFICATION OF OPERATION CLASS ESTIMATEDRATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
..REMUNERATION
CARPENTRYNOC 5403 $o 9.61 $0
CARPENTRY-DETACHED ONE OR TWO FAMILY DWELLINGS 5645 - $0 a.6$ $0
CARPENTRY-DWELLINGS - THREE -S'TORIESOR LESS 5651 $0. 8.68 $0
EMPLOYERS LIABILITY 100/100/500 9845
STANDARD PREMIUM .. $0
LOSS CONSTANT 0032 $50
EXPENSE CONSTANT. } 0900. $159
TERRORISM CHARGE - _ ` "x 9740. "'.' $0
RISK MINIMUM PREMIUM 0990 $500
TOTAL POLICY MINIMUM PREMIUM. $500
TOTAL.ESTIMATED PREMIUM - " $500`
DIA ASSESS. 3.4%'. $0
- - —
- -
TOTAL EST: ,PREMIUM PLUS ASSESSMENT $5o0
INSTALLMENT BASIS Annual * DEPOSIT PREMIUM:. :.$SOO
~ TNISI A017,A BILL
COMMENTS.
Coverage effective 12:01 AM on 07111/13.
DATEOF-NOTICE: 07/11/13 :PREPARED,BY:. Paulette 'kdffman
EXT`514
* +�. VOLUNTARY DIRECT,ASSIGNMENT' * *
LETTERID: 3994416
4 a
q.
r`
The Workers'Compensation Rating and inspection Bureau:of.Massachusetts,
101 Arch Street-Boston, NIA 02110
(697)439-9030-FAX(617)439.6055-www.wcnbma:org -»
CITY OF S. _ . Ni,, �'L-�SSiYCIISETTS
` Ba:u.nLtic,DE�A�a1I�.�T
120'4WASHNCTOIa STREET, 3"FLOOR
TEt, (978) 745-9595
FAx(978) 740-9846
KISi$ERLF-y DIUSCOLL
M14°a'O I71c���as Sx,
DIRECTOR OF PUBLIC PROPER-IV/BUILDING COWN ISSIONER
co',11or'udiba Debris D19ppsal Affidavit
(required for all demolition and renovation work)
In accordance'with the sixth edition of the State Building Come; 780 CMR section 111.5
Debris; and the provisions of MGL c 40, S 54;
Binding Permit it 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 Y1GI, c
111, S I50A.
The debris will be transported by:
DYNAMIC DISP03AL P.O. BOX ESSEX, MASS,
(name of hauler}'
The debris will be disposed of in
r� f
J '
(name of facility).,
)
i
(address of facility)
ff Sig natur�`i, ermit applicant
X
,. .IeBrisatt::lni