2-4 LORING AVE - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
A DEPARTMENT
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CF.1:918.7ii-9i95 * F.Vc.978.74G9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 Ch1R section t 11.5
Debris, and the provisions of v1GL 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 v1GL c
l 11. S 150A.
The debris will be transported by:
flame of hauler)
The debris will be disposed of in
InunruFfacility)
— ladil[c�. oI'faciLly)
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CITY OF SALEM
PUBLIC PROPRERTY
' DEPARTMENT
61111P:RLISY t)RL1tIULL
MAYOR 120 WASHINCfON SfAEL•T •SALEM,MAssACI IUSE:its01970
Ttii:978-745-9595 ♦Pax:978-740.9340
Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers
nDlicant Information Please Print Leeibly
Name (Business/Organization/Individual): l l�l� C
Address: 1` c. -
Citylstacc/Zip: �Zpj/P fio /rL 4 rPilS�Phone
Are -ou an employer'.' Check the appropriate box: 'Type of project(required):
1.91 am a employer with_1 4. ❑ 1 am it general contractor and 1 6. ❑ New construction
n Flo •cex full and/or art-tine).* have hired the sub-contractors
^ t y ( P" ❑
am a sole pproprietor7. Remodeling
or partner- listed on the attached sheet. t
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
No workers'can insurance 5. ❑ We are a corporation and its
I. P• 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions
myself. (No workers' comp. c. 152, y 1(4),and we have no 12 Roof repairs
insurance required.] t employees. [No workers' 3.01 Other
comp. insurance required.]
-Any applicant that cheeks box#1 must also till out the action Ixluw showing their workers cutupenwtion pulicy information.
r I lumenwncrs who submit this affidavit indicating they are doing all work and then hire outside contractors must utmtit a new affidavit indicating such.
�G,ntmcton that cheek this box must attache/an additional sheet showing the ,auto of the subcontractors and their workers'comp.policy information.
l run un employer that is providing workers'compensation insurauce for my employees. Below is the policy and job site
information. J_
Insurance Company Name: }, ' 0hrr-04,._.(. / �k 'ftX2�r�/r'• ,
Policy!<ur Self-ins. Lic.#: w �tl �•`r _ Expiration Date: 'S / �l /t9
/�
JubSim :1ddress: a City/State/Zip: Sti �Pa� % (ti- (9/%�
Attach it 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
tine up to 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 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ul'the DIA for insurance coverage verification.
l do her, certify under fir pains and penalties of perjury that the information provided above is true and correct.
Sienuutr.1 - Date: d
Plun:c is /('
Official use only. Do not write in this area,to be completed by city or town official.
City or'Tonvn: _.__._.___._.._..-- Permit/License# ---____-- -- .. -- _ .. _-----__—
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other _
Contact Person: ---,---._-----_---- Phone#:
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 individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not snore 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 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, b1GL 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 rill 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 nmtnber(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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the pernk/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/licetse 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. it dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
The Office of Itrvestigations 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 021 It
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/tile
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From:Krishna Gove At F.J.LaRovere Insurance Agency;hC FaXID: TO:MICHAEL'_ONGO Date:5/21G007 09:53 APB Page:2 of 2
ACORD CERTIFICATE OF LIABILITY INSURANCE GPID DATE II IDD YY)
MIRA-R2 06/21/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
F.J. LAROVERE INSURANCE AGENCY HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
492 BROADWAY ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. _
EVERETT MA 02149-3617
PhGne: 617-387-9700 FaX:617-387-9702 INSURERS AFFORDING COVERAGE NAICH
INSURED INSURER a.. CONNECTICUT UNDERWRITERS,
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DBA RVDY'S ROOFING 6 CARPENTRY
REVERE MA 02151 iNsuRER D'
INSLREF E'
COVERAGES
THE PCLICIii INoUI.L'STEDBELOW/HAVEBEENISSUED 107HE INSURED wWEDABOVE FOPTIE POLICY PERIOD INDe ED.NOTWIPTSTF4vDING
AT,REQUIREMENT TERM OR CQrI I110N GF NNv CDN DRII OR OTHER DGLUMENT WITH RESPECT TO WHIC3i THIS CERIIFICATI MAY BE!.wUED OR
MAY PERTAIN THE IN(AIFMCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TIF TENS,EXCLUS'OINS SND COFLIIT)NB OF SJCM
FOLICIES AOCREOATE LIMIT'S SiK+W IN 1M,,y HAVE EFEN REDUCED BY PAID CVJMS.
LTR NISR TYPE OF INSURANCE POLICY NUMBER DPTE(MMIECEF IDDi ICIDATELCY(MM DDAIIUN I LIMITS
GENERAL LIABILITY EACH OCCURRENOE $500000
A X coNMCRCIAL CEreRAL LIAAI>Iry 14PP1111262 05/14/01 05/14/08 'APR—=_M—lss(E.occuranra) $
B ❑.AIISMADE F-11 DWUR. NtED EXF jAny F"parmn) $
FERWNIC&aov IN.ILW\' $500000
GENERAL AGGPECATE $500000
GENT AGBRESATE L IMN APPLES PER: �PRooucs-1OMPX)PAcc $500000
POLICY I �1CT LOC
AUTOMOEYLE UABILITY
''LJMEINED SINOLE'JMU $
.NPY AUTO �S,,acoiryJnp
ALL OWNED AUTOS SOD i INJI;P'(
bY,HFDI A F D Al TO'
HIRED VJTOS
BOCIU'INJURY $
NON LOPNEDAUT�� I (Per acc.if.
DFF PTV DAM A E
iCer acaltlerM1l $
ARAGE LIABILITY .AUTO 011Y-EA ACCIDENT $
NNl'AUiO Or TN'F 1YWN EAACr F
AGO $
EXCESSI BRELLA LIAOILT' ACM>r•L_iRREN'E_ $
rx]Q1R CLAIMS MADE ACUPEGATE ___�.�
$
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DEDI'CTIBLE � $
RE
T NTION 9 $
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190RHLR3 COMPENSATION AND F 1
M _MS ER _
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d TIERS LI bILNY
8 Aar - PRE SX;I- .E EcurnE NEW 05/14/07 Q5/14/08 �-A Y;r eioENT
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SFRI-IAL FROb..]INhnxlrn EL.DISEAf.E POI_C.LIMIT�6
OTHS
DESCPoPTIOL OF OPERATpI431 LOCATPNS I VEHICLES:EXCLUSIONS ADDED BY ENDORSEMENT i SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOD D ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL
SCOTT NUGYEN IMPOSE NO OBLIGATION OR L IABILI'T1 OF ANY KIND UPON THE INSURER,ITS AGENTS OR
4 LORING AVE
SALEM MA 01970 REPRESENTATIVES.
AUTIMRILED REPRESENTATIVE
TIMOTHY LAROVERE, CPCU LIA
ACORD 251200U08) LbACORD CORPORATION 1988 '
Eny-Op --
PUBLIC PROPERTY
DEPARTMENT
KI\aScnZrD WA"
%IAVM 130 WA2GNGww h'nww•SAuir.Yws&mxLSh7R 01970
14l-M74&9"5•PAZ 97$.740.96N
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY VUSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
--- - Property Address:- ---------------- - — --
u . e--
Property is located in a;Conservation Area Y/N Historic Dbhict YIN
2.0 OWNERSHIP INFORMATION
2.1 owner of Land
Name:
Address. p
Telephone: O
3.0 COMPLETE THIS SECTION FOR WORK IN EX TING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Sdd Description of Proposed Work: 51-yj/-:>
5A;;,l3`S
--- - - ---Mail Permit to: --
What is the current use of the Building?
Material of Building? /G p If dwelling.how many units?
Will the Building Conform to Law? CPS Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name rj
l e r2 0�1 S I
Address and Phone
Conatnution Supervisors license# HIC Registration#
Estimated Cost of Projed Permit Fee Calculation
Permit Fee$ � 'od Estimated Cost X$71$1000 Residential
____ Estimated COSI$11/51000Cammerciat— - __—
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields are property 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 perjury /�
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Date
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