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108 MARLBORO RD - BUILDING INSPECTION i a,.Ihloilo is pospow�oorM r 8U&NO pUM APPNCA7M PD1a MWtY aldYip C M Pool. Pamillo: book alM4 (Ciida vAiid�r apply),9oo1��� PIrEA1 Ir"OW 1 WMV 4,CV 4,CM XM-f TO AVOW OaL AV&W PFA=S@ q TO THE R&gaM OP aIA *MOL TM hwft tppm for a PW q baud tooadt 10 so WAWA" oproipaolior� ca C � Ad*m&Ph= U Mol bwft N.m. Address t Phone MtohW t Now %��� c_ / ylv Address•Phons — memo a anana* /iijr�/� a dwsrw� nsM wnsl � ------- wr wroro oa+a.a rwr �.5 z 7/C� N A trr • 7 ilrlllll�d o0M ������• Lis. SlpiWw�of ppN�tVIpItTiME PMALTY OFPWSAM OF WORK TO U DONE ace/ o ,ot"e ac_ MAIL PfdW �r FOR LOCATX H los M,4415trdLo ( PEF*ATGPANTED 2AJ 4,f e The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfigadons 600 Washington Street Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Elect idam&lumbers Amlicant Information Please Print Le�bly Name (sasineswUrpnization/Individaan: fL6 C.T,✓`S (0.{/2C� IfU S 6)e76,46c C uc Address:- City/State/Zip: lx=�� ` AX O<�Phone# l Are you an employer?Checir the app priate box- Type of project(required): 1.Lid 1 am a eatpbyer with�( 4. DI am a general contracsor and I 6. ❑New consnucuon employces 0til and/or part-time).* have hired die sob-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sleet t 7. ❑ Remodeling ship and have no employees These sab-contractors have 8. ❑ Demolition working for me in any,capacity, workers' cone. insurance. 9. [] Bolding addition [No workers' comp,insurance 5. ❑ We are a,Corporation add its, required.}_ officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a bomeowner,doiag all work right of exerrtptioi%per MGI 11.0 Plumbing repairs or addition myself. [No workers' comp: c. 152,§l(4 and wehave na . 12.❑ Roofrepars insurance.required4 t. employees. [No wtitkcAl ; comp.insurance tegnved j 13.❑ Other Any applicant that checks box#1 inset also fill ontihe seWon below showing thec.,weakt n'oorapeasetion Dolicy infomtatiott: t Homeowners who submit thin et$davit indicating they an doing all work and ffien Lne`mW&contractors iiiimmit t sub a new affidavit indicating such. tcontrwtm that cloak this bbti`rmta at,ched in additional shot showing an nwm n eke wbootni etors and ffiea wotkem'comp.policy information. T . I am art`employer that is providing workers compensation hauroncefor my enip►dyees. Below Is the po&7 and Job site lnfonnatton. Insurance Compatty Name: /0-0— / At, Q Policy#or Self-ins,Lie. #: 7 / Expiration Date: l 2 Cb Job Site Address: f ® E �Q City/Stalazip:S 'I Attach a copy of the workers' compensation po declaration page(showing the policy number and expiration date). Failure to segue coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year fin risonment,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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ' coverage verification 1 do hereby ee r;t and ofper/ary that the information provided and correct S tare: D Phone#: O,Q'ledal use e* Do not wrke in this area,to be conVitted by sky orYo m g89cki City or Town: Permff/Llcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityflrown 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"...everyPersou in the service of anotlmr under any contract of hire, express or implied,oral or written." or An empooyer is defined as"an individual,parmaship, association,corporation or other legal entity,or any two r t more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased emploYer,or the th ,partnership,association or other legal entity,employing emploYaa However receiver e of an individual owner of or trustee a dwelling house having of 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 of because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"ever'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 consmosweaHh for any applicant who has not produced acceptable evidence of compliance with the[asurasce coverage required."shall Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth or any of its political subdivisions enter into any contract fror 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-connactm(s)u me(s),address(es)and phone mrmber(s)along with their cadficatc(s)of insurance. Limited Liability Companies(LW 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 Depmvnent of Industrial Accidents for confirmation of insurance coverage. Also be;sure to sign and date the afftida swot the Dep The davit ss ou ld be returned to the city or town that the application for the permit or l aw or i yo u ed to obtain a workers' of Industrial`AccideaM Should you have any questions regarding or compensation policy;plow call the Department at the number#sted below. Self-insured companies should enter,their self-insurancelicensi mnber on the line. City or Town Oflltials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of flu 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 permittlicense 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 of relate4 to any business or cormrercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would hire to thank you in advance for your cooperation and should you have any questions, Please do of hesitate to give us a call. The Departnuot's address,telephone and fax amber: The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mns.gov/dia � �ife Pio�israowiea�s o�•/�aoa�..4�ael° S'. BOARD Of BUILDING!REOULATIONS' Ij ' License; C� NSTRUCTIONSUPERVISOR;, NurllbeM 0553M Blrthdate 05tZ31 atn �t Tr.no:. 24307< < Restrict d'"0_�,� PETER C DESJARDINS 333 ELLIOTT ST BEVERLY, MA 01915 commissioner.': :///�r�loQ 9_!`,'�p (/(�./g/►..0jp tan a'rai w BOarO I Da�'u'�6 '_BOOS O • 8n ! CTOR, # : HOMEIMPROVEMENTCONTRA... Regis . : 103W Eupiteti 612006 fi;Qa1e Corporation PETER C.DES ° s n•aldm "•Ge4er 6es! 333 Elliot St stor MA 01915 Admim str Beverly,. NE HERITR6E INS. Fax:7814385028 Oct 4 2005 16:55 P. 01 ACORD ' CERTIFICATE OF LIABILITY INSURANCE pX00 �R DATE(MIDYTY 04/200S781)438-5000 101 - ATE IS A MIATT OF INFORI"'nOW-- Now England Heritage Insurance Agency Croup, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 33S Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Stoneham, MA 02180 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC 8 De33ardins, rotor C. Contractor 0.—Inc INSURER A: American Noma 333 Elliott Street INSURERS: Beverly, MA 0191S INBURERG; —`-- INSURERM. _ IN$UFtR E: �- COVERAGES THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED,NOTWITHSTANDM A.NY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFlLATS YBEI ISSUED OR MAY PERTAIN,THE iNSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AMID•CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. q LMw TYPE OF GENERAI.UABIUTY Nu POLICY NUMBER DA E MH/0 GATE - 'UMITS EACH CCCURRENCE 3 COMMERCIAL GENERAL uAalurY - PREMI S U. CLAWS INWE O OCCUR hEO FJP fMYme pmgn) d j PER90NAL8 MVIWUNY 3 Ir GENERAL AGGREGATE.:�11 .S, OEHL ACCREGATELRJpIIT.APFUESPERt PAOd1CTS COMPlOP AGG .r V . ' F'OIICY Jz6CT LOC .. AUTOMO&LE LABILRY ANYAU70 CONFINED SINGLE NEDSINGLE LIMIT, $ ALLOWNEDAUTOS ) T SCHEDULED AUTOS BODILY INJURY a 3 ' (Pwpmm,) HIREDAUTOS NON�CWNEOAUTOS BODILY INJURY f ,. IPw aotide�i) � _. PROPERTY OAMAOE $ LPn 90WI) GARAGE LVL WW ANY AUTO AUTO ONLY-FA 0.CCIDFNT 3 OTHER THAN FA AUTO ONLY. 4GG 3 EXCESSIUMBRELLA LABILITY EACH OCCURRENCE S OCCUR a 4.AINS MADE AGGREGATE E R DEDUCTIBLE 3 d RETENTION 3 MRKed IMPLORSCOMFENSA.naN AND WC 670-56-99 06/14/2005 06/14/2006 EMPlO:'ERd'LWIUTY UMR$ FIS A ANY PROPRIETORIPARTNEIVDIECUTNE E.L.EACH ACCIDENT S SOO.00 OPFICERMEMBER OICLUDED? Mye�dwflBEuntler E.L.DISEASE-EAEMPLOr S 500.00 SPEO4l PftOV1910N3 yoo„ E.L•OISFASE. 500,000 p POLICY UMIT S r ON Op OP NS SPECAL PROV1.0, ter/Galeral Contractor.ICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE VESCFURED POLICIES BE EXPIRATION DATE THEREOF,THE ISSUING NSURER WI YA BEFOREELLED THE pEAVOR TOMaL 1 --� // 1g_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEI, Kare er (d�G�Cod BUT FAILURE TO MAIL SUCH NOTICE$HALL IMPOSE NO OBLIGATION OR LIABILITY 93 N On Way ^_�n OFANYHND UPON THEINSURER, A ATNES. RO , NA 6):3 N...Ate— AUTNOR6ED REPRESENTAIT4 , . ACOR025(2001/03) FAX: (978)922-5147 - ©ACORD CORPORATION 1988 �, . I ..t hl� TH�emA.-f�✓ F bea.Glars pla if c# R&,41NSr 0006 E ax(0 ter 09 O.C. supogr {2gll ? �pou 2 3000 PST cvn�c . PT. y ,b 02 STE Ps /Oyu-�i�- (3 Elpw Gr;ADc 3 R,se2s 7a �f - �o U2 300o PS C-orvc r�d Fo 2 sT'r�«z.s To I-�.u-d ov STrtY ,�y� rw b �a ekg o j-5!p�►Fi2oneir oG r/-/AA/ 11 5 S ��ud Rai is 3y �in> � �glivs� S�ce� � oFs'/osCi� ol'e ��a�/ Ake 5 O,G, v� derma 3o F� 44tud Q Gc,, D G� e`lllc �k� 0/ e � - - L:3j/0 s4e,zs ?ROF05ED wOR.L i41- RRY W6,51derv6r� o s rn 1 M K! orZnvG � R ' CITY OF SALEMO MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 40 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOYICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 7 Salem Building Deuartment Debris DisrWal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. The debris will be disposed of in* �rvo ( ation of Facili �. Signature of Applicant V Date ®�n�J /vim l0 7d