452 LORING AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigations
y,
600 Wd.t'hington Street
Boston, MA 01111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
.Address ) QQ R
Citv''State/Zip: Q Phone: cj7�-q )�-3it51
Are a an employer'. Check th appropriate box: Business Type (required):
1. 1 am a employer with_y employees(full and/ 5. ❑ Retail
_ or pan-tune). 6. ❑ Restaurant/Bar/Eating Establishmem
=.LI 1 am a sole proprietor or partnership and have no
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capaclrv.
[No workers' comp. insurance required] S. ❑ Non-profit
3.❑ we are a corporation and its officers have exercised 9. ❑ Entertainment
then right of exemption per c. 152. §1(4), and we have 10.❑ Manufacmrine
no emplovees. [No workers' comp. insurance required]* 11 ❑ Health Care
3.I_I \eve are a non-profit organization, staffed by volunteers,
ttiih no employees. [No workers' comp. insurancereq.]
'An•:applicant ilia;checks box el must also fill out the section below,showine theirworken compensation policvinformatiou.
"!i tine aorpo,aV ot`i Uits have exempted themsel.cs.but the corporation has other emplovees,a workers'compensation policy is required and such an
o,sece,uou should check box.'1.
I mn air emplo.per that is providing workers'compensation insurance for my employees. Below is the police informatiorn
LnsurunceCom anyName- t
P
Insurers Address'. ��y; . )'�t �-GhCi_(1'u'�r1�1- yc_
Cirv'Stale,-Zip. oi:—
r
Pofcv - or Self-ins. Lic. 0U h ..5 60-7 Q 6D -3 - 0 r Expiration Date: ! t7-J I-Cl-1
Attach a cope of the workers' compensation polev 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
frie up to S 1.500M and%or one-year imprisomneri as well as civil penalties in the form of a STOP WORK ORDER and a fine
cf up to S_'50-00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage�erificatiou.
I do hereby cerrifr, under 11,he pains and pen Vies of perjury that the information per. 'ded above tru/e/l and correct
JICRlatilTe \\//V�`� � �— -{ ]date t 07
Phone =: 978-9-) f
Official use only. Do not write in this area. to be completed by city or town official.
Cin or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone;<:
ww•w.mass.eo vidia
02/02/2007 FRI 14:05 FAX 781 581 7200 BENEVENTO INS AGENCY - 001/001
ORD cAsirRr-1 oz o3 CERTIFICATE OF LIABILITY INSURANCE DATE 7
7
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE
Benevento Ina. Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR
497 Humphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Swampscott, MA 01907-
Phone: 781-599-3411 Fax:701-581-7200 INSURERS AFFORDING COVERAGE _ NAIC#
INSURED INSURER A: PREMIER INSURANCE AIC
w9uRER a HARTFORD INS. GROUP
Cabinetry Unlimited En}}�� rise INSURER C:Peeter BRgMglla Presideant
122 Rear-Maa.n S� INSURER D:
Peabody MA 01960
- 3a-6�Y6 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE USTED 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 8UCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS,
FF
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DA MHO DATE MMm LIMITS GENERAL LIABILITY EACH OCCURRENCE $1 000 000
A X COMMERCIAL GENERAL LIABILITY i-680--4753B409-TCT 10/21/06 10/21/07 PREMISES KLNItance $300 000
CLAIMS MADE X�OCCUR MED EXP(Any wN owwn) $5,000
PERSONAL b ADV INJURY b1,000 OOQ
GENERAL AGGREGATE 12 000,,000
GENL AGGREGATE LIMITAPPUES PER: PRODUCTS-COMPIOP AGG 9 2,O00 ,000
POLICY JEC
PRO- LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (E.accident) b
ALL OWNED AUTOS
BODILY INJURY S
SCHEDULED AUTO$ (Pa(PBABen)
HIRED AUTOS
BODILY INJURY S
NON-OWNED AUTOS (Pwa=1dwt)
PROPERTY DAMAGE $
(Pal ac .l )
GARAGE LUIBILT' AUTO ONLY-
ANYAUTO EA ACCIDENT S
OTHERTHAN EAACC S
AUTO ONLY: AGO $
IXCE09MMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR 71 CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE
S
RETENTION b b
WORKERS COMPENSATION AND X TWC UTAITS Eft
e AENMYP LPORYOEPRR.IETO]UPuXrr E%ECUTNE 686ouB-5807080-3-0 10/27/06 10/27 07 E.L EACH ACCIDENT _s10 00O0
OFFlCERINEMBER EXCLUDED?
E.LDISEASE-EAEMPLO $ 100000 tt yyeeee meanie uWn -,..�
SPE62PROVISIONS below E.L.DISEASE-POLICY LIMB SSO0000
OTHER
DE6CRIPQON OFOPERATIONSILOCATIONSIVEHICLESIEXCLUSIONSADDEDBYENDORSEMENTISPEC PROVASIONS
Kitchen Remodel
CERTIFICATE HOLDER CANCELLATION
CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TIE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAKED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
City O£ Salem 1 New Liberty St IMPOSE NO OBLIGATION OR LABILITY OF IUND UPON THE INSURER,ITS AGENTS OR
e Salm MA 01970 REP TIVEs
OZWRnp7 T
HONY BENS
ACORD 25(2001/08) (DACORD CORPORATION 1986
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON arraasT, 'ao Fwom
BALaM,MA Ot Y7O
ESL.(276)74"595 EXT.360
FAX (E78) 74O-9"6
sTAwLEv J. usowcz, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In acoordamce with the provisions of MGL c 40,S34,I aclmowledge that as a condit,(w
of BmldinS Permit .all debris resulting from the cousbuction acdvhy
govemed by this Building Pemrit aba8 be disposed of is a pz opedy licensed Solid-waste
disposal may,as defined by MUL c IlL S130A.
The debdo wM be disposed of at /
Locatim of Facility
FULY
�_ignanue of PamrtApplicaot%.
•'�Date.
MY-An PRW CLEARLY) mfo�ation
Name ofPesmit licard
Firm Name,II any -
�a
— P o
Address,City dr State
The above statute require that debris b m the demolition,movation,rehab or other
alteration of bufl&*or sbuctun be
disposed in a PnopalY-licensed solid-waste to
fidlity as defined by MGL cM S 150A, and the building permits or liceosea an to
�
indicate the location of the 6cility,
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CITY OF SALEM
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PIRA=ILL OUT LAOKY A 001111PIXTSILY TO AV=DrAAYr M PrIOCr
TO THE INSPECTOR OF rIAU)Wa :
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