13 LYME ST - BUILDING INSPECTION r CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicaut Information �f_� ��,t Please Print Leeibly
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Addrews: r
Cily/StateiZip: CJjP-Ni l 3G7S Phone N:
re on an employer? Check the appropriate box: fypo of project(required):
1. 1 am a employer with r 4. 111 am a general contractor and 1 r,,
. ❑ new onstrueuonetrgaloyccs(full AnWor part-tine).• have hired the sub-cumractors2.❑ I am a sole proprietor or partner- listed on the attached sheet : • cdel;ng
ship and have no employees These wb•eontraetors have 'S. ❑ Demolition
working for tnc in any cap=lty. workers'comp. insurance
f No workers'comp. insurance S. ❑ We are a corporation and its 9' ❑ Budding addition
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself(No workers'comp. c. 152.044).(4),and we have no 12.0 Roof repairs
insurance required.) t employees. (No workers' 13.❑ Other
comp. insurance required.]
•Any;,ppliuua and chocks box 01 muse also lilt as ate section twtow stwwias their wwkins'cumpanuaiun putiuy infurmtuiwy
't lutnwtwno"who submit this amdsvit indicating dwy a"doing as watt and Ike hie maride eoetraseo"mug submit a new amdavit indicating such.
Cott ml"rs the chuck this base mot aaachud m addiUa"d chest.hewing the nama of am avb•eontractm ntd their work*"'camp.policy infbrmanw.
1 u/n an employer that Is providing workers'compenraton huuranc i for cry employees. Below Is the polity and Job site
Insurance Company.Name: Z, P/ ok L
Policy M or Self-ins. Lic. I j j_&12_ pia ion Date: .. Z� Z �Gy
)ub Site Address:' 3 �-]/tn F CS-I-iP e� �^ cuyrslatu2;p: r/ 62102 .�{7
�
Attach a copy of the workers'compensation policy declarrtion page(showing the policy number and expiration date).
Failure w secure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
rTne up to S1,500.00 and/or one-year imprisonment,an well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against dm violator. Ile advised that a copy of this slatement may be furwarded io the Of ice of
Invc,ngauotu ul'thc DIA for insurance covcra , verification.
/do hereby certifyy er the pains stud if. ajperfury tkat flee iaformW/on provided above is true and correct
tiiga:uurc' //IJAA/,f / i�r NLa�t Date 212-747
tt••,
O f/rial use an/): Do wot tvrhe in fh/,area,to be comple/ed by e4 orTown ofjlt ia[
City or Town: _ Permit/License if
Issuing ,%uthurily (circle one): --
1. Ituard of llcalth 2. Building Department 3. Cityffown Clerk a. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ Phone q:
Information and Instructions '
Massachusetts General Laws chapter 152 requites all employers to provide workers' compensation for their employee&
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."
:tit employer is defined as"an individual,parmers6ip,association.corporation or other legal entity,or any two or mom
of the foregoing engaged in almint enterprise,and including the legal representatives of a deceused employer,or the
receiver or trustee of an individual,pomers6tp,association or otter legal entity.employing employees. However the
owner of a dwelling house having not more than three aparonants and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work oo such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
btGL chapter 152. g23C(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 W not produced acceptable evidence of compliance with the insurance coverage required."
Adtiitionatly.MGL chapter 152,$25C(7)stars"Neither the commonwealth nor any of its political subdivisions shalt
ic work until acceptable evidence of compliance with sloe insurance
enter into any contract for the performance of publ
requirements of this chapter have been presented to the contracting authority."
Applicaab
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation arid,if
necessary.supply sub-contractor(s)name(s),address(es)and phone number(s)along with their cerrificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partner,am not required to carry workers'compensation insurance. If au LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe 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 Deportment 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 Offlelals
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 rill out in the event the Office of Investigations has to.contact you regarding tte applicant.
Please be sure to till in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pernitilicense 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. when 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 bum leaves etc.)said person is NOT required to complete this affidavit.
Chu 0111.x of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du nut hesitate to give us a call.
The Department's address, relephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
091ee of[tvesliptlow
600 Washingtal Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-977-MASSAFE
Fax M 617-727-7749
Rcvi>cd 5-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Z11s:�a3••t9ss •fur 9i7sJ�69sN
Construcdoa Debris Dispossf A01dsvit
(required fat all lamed m aid renovation work)
In awAnkme with the six&edition otthe State Building Cods.7SO CNLR suction 111.3
Debris,am the provisions of M. GL a 40.S SIG
Building Permit 0 - _ is inua with the condition that the debris resulting 6aas
this wait shall be disposed of in a properly licensed wash disposal fbcility as defined by%iGL e
I It. 3110A
The debris will be transported by:
In"N of haul•)
the debris will be disposed of in :
(n:usss ur fxd�ty)
6.
�fllldlt4lGUKL&I L�
' :osrd of Building Regulstioas and Standards
�onstruation Supervisor License
License: CS 70882
�i.. Birthdate: 7/28/1956
Expiration: 7/28/2009 TAF 16025
Restriction: 00
RICHARDJ SMITH
PO BOX 1769
SALEM,NH 03079 Commissioner
fie f
a1neGrC� /'Bd of Building Regulatfons and Standards
One Ashburton Place - Room 1301
lug Boston, Massachusetts 02108
Construction Supervisor License
License CS: 70882
Restriction: 00
Birthdate: 7/28/1956 Tr# 16025
Expiration: 7/28/2009
RICHARD J SMITH
PO BOX 1769
SALEM, NH 03079
Update Address and return card.Mark reason for change
Address Renewal 0 Lost Card
DPS-CA1 0 50M-W08-PC8490
Bo r o uildmg egulatfons a�nod S�ards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement-Contractor Registration
._:. . .
Registration: 106603
Type: Private Corporation
Expiration: 7/24/2008
AJ WOOD CONSTRUCTION, 'NC. --- - - -
Richard Smith
5-7 DELAWARE DR
SALEM, NH 03079
Update Ad ress aad return card.Mark reason for change-
Address) ❑ Renewal j Employment - Lost Card
)PS-CAI is SOM-MOB-PC8490
.. - „/�¢ -(9ovlt))t¢9ztl/e�llt. O�✓`t�:AtluYtUQ✓,CQ
Board of Building Regulations and Standards License or registration valid for individul use only
before the expiration date. 11 found return to:
HOME IMPROVEMENT CONTRACTOR Board of Building Regulatio,is and Standards
Registration: 106603 One Ashburton Place Rat1301
Ov
1
Explratlon:r 7/24/2008 Boston,Me.02108
Type: Private Corporation
WOOD CONSTRUCTION,INC I -
Richard
-
Richard Smith
5-7 DELAWARE DR < - Not valid wit out signature
SALEM,NH 03079 Deputy Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Laura M.Marlin,Commis mw q�
Deleader-Contractor 11�
RICHARD S.SMITH
Eff. Date 07/10/07 � � w-�—+x►—;—�+�+
Exp.Date 07/10/0B
DC001721
Wmbucd C.O.N.E.S.T.
00010553 C E R T I� F I C A T E O F I N S U R A N C E Issue date: 5-16-07
Producer This certificate is- issued as a matter of information only and
CESI Agency of New England "confers no rights upon the certificate.holder. This
-
10 Chestnut Drive Unit E certificate does not amend, extend or alter.the coverage
Bedford . NH 03110 afforded by the policies below. .
COMPANIES AFFORDING COVERAGE
Company letter A Nautilus Insurance
Insured
A J WOOD CONSTRUCTION CORP Company letter S
P.O. BOX 1769
SALEM NH Company letter C
03079-1769
Company letter D
Company letter E
COVERAGES This is to certify that .policies of insurance'listed below have peen 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. '
Co PolicyE01icy
Lt Type of Insurance Policy number Effective Expire AIZ LIMITS IN.THOUSANDS
GENERAL LIABILITY General aggreg ate. .. . . .$ 2,000
A X Commercial General Liab. NC64417'4 5-16-07 -.5=16-05 Products-completed
Claims made - operations aggregate-$ 1,000
X Occurence Personal- &
- advertising injury. .. .$ 1,000
Owner's & contractors
protective Each occurrence..... . . .$ 1,000
Fire damage (any
one fire) . .. . ... . . ....$ 50
- Medical expense '(any
. , -.: one person) . . .. . . . .. ...$ 5
AUTOMOBILE LIABILITY CSL $
An .auto
"- All owned autos Bodily Injury
- Scheduled autos (per person) $
- Hired autos -
Non-owned autos Bodily Injury
_- Garage liability - (per accident) $
Property damage $
EXCESS LIABILITY Each occurrence Aggregate
Umbrella form
-_ Other than umbrella form $ $.
WORKERS' COMPENSATION Statutory_
AND $ (each accident)
$ (disease-policy limit)
EMPLOYERS' LIABILITY $ - (disease-each empl.)
OTHER -
Description of operations/locations/vehicles/special items -
CONTRACTOR-WORK PERFORMED BY EMPLOYEES IS .
CARPENTRY & ROOFING. ALL OTHER WORK Is
PERFORMED BY SUBCONTRACTORS.
Certificate holder CANCELLATION Should any of the above described policies be
cancelled before the expiration date thereof,
the issuing compan will endeavor to marl 1 0* days written
notice to the certiy ficate holder named to the left, but failure
. to mail such n ice shall impose no obligation or liability of
any kind upon v 00 any,
it>vagery`ts or representatives.
Authorized re es
(OMNI7 CERTGA-0304OW0705161358)
A=R—De. CERTIFICATE OF LIABILOTY INSURANCE 03/i 9/2007
TM CERTIFICATE 18 WOUED A3"A MATUM or HUROM"TON
MBtthews Insurance Agency OMY AND CONFEM NO R GHM UPON no CERTIFICATE
M Parker Street AUER IM COVERAGE AFFORW BY THE FM AM
Lawrence, M 01843
978-681-1212 DISURMIS AFFCRMONG COVE OU NAMP
MEMEW W Wood Constructlon, Xac iN6wwkB - r p Mutua3 ns
BMPJFMR a
P.O.Eox 1769 ocela
Salem, 199 0307.9 HRIAe�a
1-603-235-7624
GOES
THE POLICES OF INSURANCE UBTED BeLOW.NAVE OMEN so=TOTHE INSURED NAM®ABOVE FOR THE POLICY PERIOD WDWATED.NOTWnMTM N G
ANY REOUIREUF.NT.TERM OR CAN OF ANY CONTRACT OR OTHER DOCUMUff VOM RESPECT TO VVH=H TM CERT54C ATE MAY BE!.SUED OR
MAY PERTAIK THE NSURANCE AFFORDED BY THE POUCM8 DBSCFM D HEREIN A SUBJECT TO ALL THE TERMS.EXCLUSIONS AND COMMOMS OF SUCH
POUCIE&ADDREBATEUUR8SHOWN UAY WAVE BEEN REOUCEDBYPAmCLADL4_
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PUBLIC PROPERTY
DEPARTMFI�IT
KMOr=&V ORQCOLL
WVOt 130 WARd"=w 5tRW•SAI,rK.yAiaApK;srYfs 01970
1%L-M7 0 FAZ 97a.7469W
APPLWATION FOR THE REPAIR. RENOYATieN_ C0rq9MUcnQM
D&MOLIT HANGE OF USE OR OCCUPANCY_ FOR ANY EXISTirTG
STRUCTURE OR BUILDING
1.110 SITE INFORMATION
Location Name: p Building:
Property Is located in a;Cwae iMm Are@ YM HWA to Ol Ula YM
2.0 OWNERSHIP INFORMATION
9.1 Owner of Land
Name: j
_ e
3.0 COMPLETE THIS SECTION FOR WORK IN E7118II M 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
r0foxis"ting building New
scription of Proposed Work: irNs*a ll ILAD�wg 2l'if er (Or� S S��� P � ncl rH �oa
�lec1- r«� ^J PluA.bI ^,) f QPx�r's
--- - ---Mail Permit to: -�i �
What is tM aurw t use of tM Building?
Material of Building? If dwelling,how many units?
WM iM&Adkq Cordbrm to Law? Aebeftm?
Archk&Xs Name
Address and Phon l 1
MechaWs Name V
a 3 0-7 5
Address and Piton. a F
Conet udion Supervisors Lianas HIC--�.___—
Esth+ated Cw��`. b P FN_ala+lallon
pwmit Fee=J Estimated Coat X$7/$1000 Residential
Es*nated Cost X$41/1111000 Commadal
An Additional$5.00 is added so an
Administrable dvrgs.
Make sun that ail fields an properly, and legibly written to avoid delays in processing.
TM undersigned does hereby apply for a Building Permit build to tpM� abet! 9 ,fated
spwAcatbns. Signed under penally of perjury "`�'
Date _
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