90 MARGIN ST - BUILDING PERMITS 'rhe Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
1 Massachusetts State Building Code, 780 CMR Ta
ised sLfar 1011
l� Building Permit Application To Construct, Repair, Renovate Or Demoli
r One-or Two-Family Dwelling
This Section For.OMci se only
Building Permit Number: Date pplied5
br
I -building OQicial(Print Name): Signature ' . . - Date
to SECTION I:SITE INFOR�MATIO14
1.1 Prpperty Add EUAssessors Map&Parcel Numbers
1.1 a Is this an acce ted street? es no Parcel Number
1.3 'Zoning Information: y Dimensions:
Zoning District Proposed Use ) Frontage(11) . .
1.3 Building Setbacks(it)
Front Yard - Side Yards Rear Yard .
Required Provided 'Required - Provided. Required Provided
1.6 Water Supply:(M.G.L c.40,§Sd) l.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone:Public❑ Pr _ Outside Flood Zone? Municipal Po O On site disposal system ❑
ivate❑. check if esO
SECTIONI: PROPERTYOWNERSRIP!
2,,qi nert of I cord:
J oM t (_ rv\T'ry C) SN�ewe 1 tin
�me(Print) - City,State,ZIP
�^n qo A r c.-v M c:1 9 7S-ya 3-Ssya
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) 0 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of�roposed Work':
(.00 � A CQC Kn S�LIA re.
SECTION.{:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: ODteial Use Only
Labor and Materials
I. Building g 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
I. Electrical S ❑Total Project Costs(item 6)x multiplier x
3. Plumbing S P Pther Fees: S
d.Xlechanical (HVAli-iEoo
List:
5. Mechanical (Firerotal All Fees:S
Su ression) cy. Check No. Check AmCashount: Ch Amount:
6.Total Project Ct ❑paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction SupervisorLicense(CSL) O� �j-� IG �G- 1
CTO4 " l'F}M�A-dJ S License Number Expiration Date
-
Name of CSL Holder List CSL'rype(see below) U
P,O `IOG S T Description
No. and Street
nn U Unrestricted BuilJin a to 35,000 cu. It.
J'(= (30 4 t M IA C/1 / Restricted 10 F:unit Dwellin
City?own,Slate,ZIP M Masonry
RC Roofing Covering
WS Window and Sidina
7^� ��c !Nq• SF Solid Fuel Burning Appliances
MI 720.5- �J kAc--41c-,�/IJ I Insulation
Telephone Email address DI Demolition
5.�(egistered/IlomelmprovementContractor(HIC) �Yl q r'� /
/)6rq7"i4 ✓} f HIC Registration Number Expiration Date
I[IC Comp:yy+ny Name.gqr HIC egistrunl Name
/ it c l/ c Jd�w nanT4�Ja� ��alrne�t'.e
No.mid Street Mail ail adarfss
nFQ3a' r+ �,quo 92k-'Y i-7aar—
Ci crown State ZIP Telephone
SECTION 6:WORKERS'COrvIPENSATION INSURANCE AFFIDAVIT(M.94 c.I5Z.i 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 Isivance of the building permit
Signed Affidavit Attached? Yes .......... JY
No...........
SECTION 7a:OWNER AUTHORIZATfON.TO BE COMPLETED.W HEN' - }'
OWNER'S AGENT Oft CONTRAC--TOI APPLIESFORRBBUILDING.PERMIT
I,as Owner of the subject property,hereby authorize lri Ivr / D>1 r e 1 A J91
t9 act on my behalf,in all matters rel�ative to work authorized by this building permlt application.
f
Print Owner's Name(Electronic Signor ) 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
contained in this application is true and acc ate to a best of my knowledge and understanding.
r4l Ar
Print Owner's or Authoriz d AgenPs nine(Electronic Signature) Date
NOTES:
1. 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 no have access to the arbitration
progtam or guaranty fund under M.G.L.c. 142A.Other important information o"n the H►CProgr3m can be tat'it�d3t
+vww mass.cov'oca Information on the Construction Supervisor License can be found at www.mnass.eov,'Jns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) N (including garage, finished basementlattics,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 ofcooling system Enclosed Open
3. "Total Project Square Footage"may be substituted 1'or"'fatal Project Cost"
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Writers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �V',-
Address: (F-G 0cl- �_Ad(n
City/State/Zip: VAA OilW Phone##: c/7g L/(11— 7;20J
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.XI am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole I LEJ Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5. I am a general contractor and I h hired sub-contractors re the su -contract lid the sheet ors listed on e attached❑ 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.=
&❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContracmrs that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify u der the p ' sand penalties ofperil ry that the information provided above is true and correct.
Sim Date: -.
Phone#: 7 — G
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.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 more 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,MGL 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 fill 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 number(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 pemvt 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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 filled 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.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Q-IY OF SALEA MASSAaR SEM
B[urDnaGDEPAR7ME7Jr
120 WAgmgGTcNSmmEr,3D FLom
TLL(978)745-9595.
FAX(978)740-9846
KIIvIBERLEYDRISOt�LL
MAYOR THCMAS ST.P EM
DmEcrea or PuBLTcrRorERTr/j;uiLD G ammmcmit
Construction Debris Disposal Affidavit
(required for all demolition and,.renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will
lbbe� transported by:
/ Y(,C �c
(name of hauler)
The debris will be disposed of in:
PEA aoo�z l e-A"5 Pe
(name of 7/c
ityo�rP s� 1 �
(address 6f facility)
Ignature of applicant
—� Date
3
4�4RQ;. DATE.pAMIDOJYYYYr
` ..� CERTIFICATE"4F LIABILITY INSURANCE< orrt,ario
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CERTIFICAMMOLDER. CANCELLATION
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Commonwealth of Massachusetts
i Citv of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
' Return card to Building Division for Certificate of Occupancy `—
Permit No. B-16-199 PERMIT TO BUILD
FEE PAID: $70.00
DATE ISSUED: 3/15/2016
This certifies that FEMINO JOHN ANTHONY
has permission to erect, alter, or demolish a building_ _ 90 MARGIN STREET Map/Lot: 250631-0
as follows: Roofing STRIP & REROOF
Contractor Name: JOHN PANTAPAS
1
DBA: �e
` I
Contractor License No: CS-087003
J
3/1 512 0 1 6
Building Official Date
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request.
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same.
i
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
HIC#: 141402 "Persons contracting with unregistered contractors do not have access to the guaranty fund-(as set forth in MGL c.142A).
Restrictions:
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
Commonwealth of Massachusetts
bt
Citv of Salem
9 i
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 `.:.
Return card to Building Division for Certificate of Occupancy
Structure CITY OF SALEM BUILDING PERMIT
ExcavationPERMIT TO BE POSTED IN THE WINDOW � 9
Footing INSPECTION RECORD
Foundation
Framing
Mechanical 1
Insulation INSPECTION: II BY DATE
Chimney/Smoke Chamber
Final
1
0j Plumbing/Gas
Rough:Plumbing I {
1
Rough:Gas
Final I _
Electrical ! Ii
Service I t
t I 1
Rough t
Final I
Fire Department i
Preliminary
Final
Health Department
Preliminary
Final
Commonwealth of Massachusetts
f
"
City of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 t \
Return card to Building Division for Certificate of Occupancy
Permit No. B-16-199 PERMITFEE PAID: $70.00 TO BUILD
DATE ISSUED: 3/1 512 0 1 6
This certifies that FEMINO JOHN ANTHONY
has permission to erect, alter, or demolish a building 90_MARGIN STREET . Map/Lot: 250631-0
as follows: Roofing STRIP & REROOF
Contractor Name: EDMUND F. FOGARTY
DBA: E.F. FOGARTY CONSTRUCTION C. \
Contractor License No: CS-062349
3/15/2016
t,
Building Official �i' Date
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request.
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
1
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same.
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
HIC#: 111772 "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A).
Restrictions:
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
Commonwealth of Massachusetts
y
° Citv of Salem
4
m 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy -
Structure CITY OF SALEM BUILDING PERMIT
Excavation PERMIT TO BE POSTED IN THE WINDOW
Footing INSPECTION RECORD
Foundation
Framing
Mechanical
Insulation INSPECTION: BY DATE
Chimney/Smoke Chamber
Final
Plumbing/Gas j I
Rough:Plumbing J
I `
Rough:Gas
Final
Electrical I
Service A
Rough I
i
Final
i
Fire Department =
Preliminary
Final
f( l Health Department
Preliminary
Final
The Commonwealth of Massa�C lgEjWED
Board of Building . an tan ONAL SERVICE" CITY OF
� SALEM
cr- 0 �
Massachusetts State Building Code, 780 CMR Revised
CT' Building Permit Application To Construct, Repair, ft'e� of �dr�et t�li:a2
One-or Tivo-Family Dlvelling
This Section For Official Use Only
Building Permit Number, Date Applied3
3�.9 A(10.
Building Otticial(Print Name). Signature Date
nn SECTION 1:SITE INFORttNIATION
I Property Address: Assessors binp&Parcel Numbers
Go V \G t S4—
I.la Is this an accepted street9 yes_ noft
Mop Number Parcel Number
13 'Zoning Information• Properly Dimensions:
Zoning District Proposed Usei\rea(sy R) Frontage Ili)
1.5 Building Setbacks(R)
-. Front Yard - - Side Yards Rear Yard .
Required Provided -Required - Provided. Required - Provided
1.6 Water Supply:(M.G.L c.40,§34) t.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private❑. Zone: _ Outside Flood Zone? Municipal O.On site disposal system- O
Check if esO
SECTION2: PROPERTYOWNERSRIP!`
2.1 TX Qhnert6,of0
J
me Print City,State,ZIP
<MUr tt� S q?C07-3f7 - .1 0 \CL Vv\"nc) le 1 51, ..
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction(3 Existing Building O Mowner-Occupiedirs(s) O Alterution(s) O Addition ODemolition O AccessoryBlJg.O ther Specify:brief Description of Proposed Work':
SECTION-1:ESTISIATED CONSTRUCTION COSTS
Item Estimated Costs: - Official Use Only
Labor and Materials -
I. Building S9,w I. Building Permit Fee:$�Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S O Total Project Cost'(item 6)x multiplier x
3. Plumbing S V 91herFees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S 'total All Fees:S
Suppression)
Check No. ' Check Amount: Cash Amount:
6.Total Project Cost: 7 W i ❑Paid in Full ❑Outstanding Balance Due:
rv\A t L-,En -ram C co N h r - 3 11 S
Mte 1"SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supe"viidd L1keiiie(CSL) LY i
7! f: �lJ40.f �,'' et C6 License Number Ecpirulio Uate _
N:uneofCSLlluldei" " t °�'" ` '
j� list CSL'fype(see below)
Zb CACS,l��Sv�l < C R
Typ Description .
No.:md Street
, l - p Q !C, U Unrestricted Buildin a toing cu. ft.)
: -Z R Restricted I&2 F:unil Dweliin
Cily/-rown,State,ZIP - -- M Masonry
RC Roofing Covering
WS Window and Siding
/��y� SF Solid Fuel Burning Appliances
I Insulation
Telephone
moil address t D Demolition
5.2 Registered Home Improvement 1Contrnctor(III I f f -77� a
m g1 A— c1O HIC • 'station Number spin ion Date
IIIC2C ipl�tl a HICK l\tj�NIC-u�'a
Q
No.mrd S Email:ddress ke-Ir
wt,�atCe(�. rn q78?77-?33'l.
Ci /Town State ZIP !-e Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.O,L.c.152.§25CMY}
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isivance f the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 70:OWNER AUTHORIZATION TO BE COMPLETED.WHEN�
OWNER'S AGENT OR CONTRACTOICAPPLIEs FOR BUILDING PERN11T
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
f
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,) 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.
tn4-v%. \ o y, u i b
Print Owner's or Authorized \ is Nnmc Electronic Signature) Dale
NOTES:
1. 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 no have access to the arbitration
— -- p...-- -- —
program or guaranty fund under M.G.L.c. IJ2A.Othcr tat onant information on the H1Cl'rogram can be foundn: ---
www etas, eav;'oca Information on the Construction Supervisor License can be found at AAA11 ass.••ov:!dns
2. When substantial work is planned,provide the information below:
total floor area(sq. R.) ,(including garage, finished basememo/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
"fypeofcoolingsystem Enclosed Open
3. -total Project Square Footage'miry be substituted t"or-rutal Project Cost"
Jj
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PER]VIITTING AUTHORITY.
Applicant Information _ Please Print Legdbly
Name (Business/Organization/Individual): r
Address: o, '3
City/State/Zip: A'CJd,(9,k A- Phone#: 7?'7
Are;you employer?Check the appropriate box: Type of project(required):
1. I am a employer with�employces(full and/or part-time)." 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doing all workm elf. 9. ❑Demolition
❑ g myself.[No workers'comp.insurance required.]t
10❑Building addition
4.❑I am a homeowner and will be hying contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insumncz.l 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their tight of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Contracmrs that check this box most attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the polity and jab site
information.
Insurance Company Name: Cc-.-, A.—^ '3 v Policy#or Self-ins.Li+c.#: G qWq r O_ Is Expiration
��Jxpiration Date: /
Job Site Address: ` O WVA f`�1^ Si-Sfi City/State/Zip: C,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi title the pains and penalties ofperjury that the information provided above is true and correct
Si a[ure:
//�� —7 Date:
Phone#: `�'l — 2_ / 57 3 2.
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r ..
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 more 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,MGL 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 fill 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 number(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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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 filled 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.a dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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I Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Cnnstruc.`16n Sunemisor ��
License: CS.062349
—�
EDMUND F FOG ��
2801DRASWEZL
MIDDLETON MA Old J�
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Expiration
Commissioner 07/242017
C�xe �pomvnxoru�,�l�o��acLeernelt
�\ Office of Consumer Affairs&Business Regulation
0 HOME IMPROVEMENT CONTRACTOR
Registration _ 1:11772 Type:
Expiration `K9/2018 DBA
TtAM ;
E.F. FOGARTY CONST CO it !
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EDMUND FOGARTY�t -
28 OLD HASWELL PARKRD- _....._
MIDDLETON, MA 01949``— Undersecretary
C$TY OF SALSA MASSACHLSEM
a I Bt aDmGDEPAR7mEw
120 WAStmvGli0A1MEET,32DROOR
ML(978)745.9595
PAX(978)740-9846
BIIvIBERLEYDRISQ7LL
MAYOR TrxCMAS ST.P SM
DntEcicatorFuBucPAamm/BumDm amnmuomR
Construction Debris Disposa/Afdavit
(required for all demolition and,renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL coo, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
SignAuie of applicant
Date