9 OBER ST - BUILDING INSPECTION (2) -PL1tf IMtST-SE fiLfgi APPROVED 8Y 774E
JMSPWTDR PR1GR TD A PERMIT MNG GRANTED
_ CITY OF_SALEM
No� \ Date
Warr)
ZoNng District
i
Is PMP" Located In Location of
the Historic District? Yes No Building 10,EZ� S
Is PrOM Y Located in
the Coneervadoo Area? Yee_No
Permit to:
BUILDING PERMIT APPLICATION FOR:
�I
(Circle whichever apply) Roof, Reroo Install Siding, Construct Deck, Shed, Pool,
Repair ca, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according.to the following
specifications:
Owner's Name GS�y Ike z- /vl�3-9L 67
Address & Phone f Oa'�i� S i
Architect's Name
Address & Phone If
Mechanics Name
Address & Phone poi t she
What Is n»Purpose of building? /2�S
MMNW of bonding? 1--c,o If a dwellft,for how many famWes?
WUi balding conform to law? Asbestos?
Estlmated cost 3 ��� CRY Licanea a Stab Wanes N
Lie. 3
Signature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
,_C A�F
MAIL PERMIT TO: G Pti(1,�
! J
NO.
APPLICATION FOR
PERMIT TO
LOCATION
1
PERMIT GRANTED
19
APPR7D
INSPECTOR O BUILDINGS
PUBLIC PROPERTY DEPARTMENT
-. 120 WASHINQTON STREET, 3RD FLOOR
SALEM,MA O 1970
TEL (976)74d-9598 E)rr. 980
FAX (978) 740.9646
STANLEY J. U6ovIC7, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MQ,c 40,S34,I w3mowledge that as a condition
of Building Permit 1I .all debris resulting from the construction gamly
governed by this Building Permit shelf be diapaaed of in a properly licensed solid-waft
disposal facility, as defined by MGL c III,S150A.
The debris will be disposed of at w✓ 57-P
Location of Facility
Sigoatlue of Permit Applicant Date
FULLY complete the following imf ion:
(PLEASE PRINT CLEARLY)
fo�71L/9c T'.w
Name of Permit Applicant
i Firm Name,if any
/42-
Addrew City&State
The above statute requires that debris'fiom the demolition,renovation,rehab or other
alteration of building or structure be disposed in a PrDperly_licensed solid-waste disposal
facility as defined by MQ,cM S 150A, and the building permits or license are to
indicate the location of the facility.
i
C.oryn,►monwuIofr I'I/c`wachuasfJfd
b �apa.Isa.al a�.7a/r�iel�stisia�' i
boo W..,#e SL.J
ism"Iaaoa+ M..as" 02111
ca4naaawf
Workers' Urnpensadow Insurance ANidsvh
l9 ntifl✓➢ Gs�i�[�c.T.ti�
. . wkh. .s princiosl place of business a>c
do hereby'cerc#y under the pains and peaaA" of pa*y, don
O I am an employer providing wo►k=*, compansaskn coversts for my einployow working as '
Insurance Company Polity Number
I am a sok proprietor and have no one working fdr use In any wpsdey.
1 am a sok proprfeter, general contractor or homeowner (drde one) sod hew hired tine
contractors listed below who•have the following workers' compensation polidssi
FI\S �-G� S
Contractor Insurance Go m try/Pop�r Number
Coetracw Insurance Company/Po Number
Contractor Insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
•I I adpoase awl a call of di Awesee vn k fwwwoed ao dw Of ics a wrowgnew of ON DIA for cee and.wiacadea aw an facile■rave
cane4re as reowto soar Seim SSA d MGL 152 can kid r ow' a/oio w>r ecamin eenea6w el a tier of a=41 SM moor am
+�+�':soreeowwnl a sA a dei aemrmie in dw kma of a STOP WORK ORDER aw a iw of S 100.00 s a"apiow aL
2�
Si`ned this • a3 day of
All
.iccrsceiFcrmitcee Building G pa n.ent
icensin; Ecard
Selectmen Office
riealth Depsrttner:
_ . _ —.eccr _ cpt epc ape Tic
i
go ryucB+ 6 coNTRWOR
IMPRoV"N
E „. *"38
I `tom
fING
MIKE PUMA GENE
J 192 W INNICUT
S ATNAM,NH 03W
l .
fabio romulo da si Iva 617-387-1972 p. l
Bare of B:IemR Rq{eLeom ane Shmearer
--/ NOW MPROVEYEYf CONTRACTOR
�^•,���,,/• ExplratlnB: 411372006
Type: DBA .i
FRS ROOFING 8 GUTTER SERVICES j
FABIO SILVA
50 NORWOOD STREET e3 -�
EVEREIT,MA 02149 ApminjRraor ..
i
I
F:WAA!' IWILIRANCE AGENCY INC. 6177830010 03/16!'-AI)0a 12:12 #036 P,(P)l/i.
CO MMONg"9. LIC COVM GE is provided in rAwp8flSTf.,3iackia.d
rNMTHFIFLDiNSURANCE COMPANY
Mendota Heighm,BAN W120
Pdicyw- CP480505
Agency No: 422002 Produm-No: 380130 Prevlous Pa"NO: NEW
9aOUCYPERIOD. From 09/19/2003 To 09/12/2004 Term: 1 Year
at 92:01 A.M.Stastderd Time at your atalling riddrass sham below.
Named Insured: FABIO ROMULO DASTLVA ABA FRS ROOFING GUTTP-R
MallingAdSress: 50 Norwood Street, #3 Evexett MA 0 149
C41Y stew BP Coda
sveso naera-x
SLONESSIDESCRII'MON: Roofing & Gutter Contractor
IN RETURN FOR THE PAYM184T OF THE PREMIUK AND SUBJECT TO ALL THE TERMS OF THIS POLICY,
WE:AGREE WITH YOU TO PROVIDE THE INSUAAN4CC AS STATED IN THIS POUC'Y.
THIS POUCy CONSISTS OF THE FOLLOW NC COVERAGE PARTS FOR WWCH A PREMIUM IS ElVOIGATED.
THIS PREMIUM MAY E3E SUBJECT.TO ACLJUSrMENT.
PREE3e1EtBE+B
Commercial Auto/Garaga Coverage Part ............... _ --
Commercial Crime Coverage Part .........'.............. .. .. ..................I ..... $,.,_._
Commercial General Liability Coverage Fart ...... ............ $ s ;sue___
Commercial Inland Marine Cc merage Part .........
Commercial Professional Liability Coverage Part ............ ........... ........... S.
commercial Property Coverage Part .... .............. . .. ......................... . b
Premkim Total S 5 _'-20-A 0
Dthsr GhargaS STATE TAX (W : $231 .6 _ ... S _ ^ 3 61. 6 0
POLICY: 50.30. INSP:80 .00
Audl Period: Annual unless atherv*a 2mt2d: TOTAL S 6: 1 v 3. . 6 G
Forms and Endorsements:
S7.J-1L (12/98) , S2616-IL 11/03)11, 5489-II, (8196) , 51030-IL (6/94) ,
S3D-CG f7/02)
Agar-cyNamejAddress: POLICY SUBJECT TO AUDIT
S. H. Smith & Co. , Inc. A.A.W. Ineurance Agency
061 Highland Ave 373 Wa 'wr:1 ge St et
Needham Heights, KA 02494 Allst , M.A 02J
tsunt®retgnsd: L0112003 KRi C0 6y b p
E9mto AUOnai p kB�rV$t#fe
(needBeugyrighfari IMRmW aF I,rtY,m<u 4aM1iceY UA:as.inc,,dW d8 asmt�<oa.CDp�rst¢he b,s.,ranm 8av�?OIII�7IL..5�a
St'J lL(8/99) PRODUCER
LARATIONS
farm CONTRACTORSCADVANTAGE SPECIAL PAGE 1
TFamily
Casualty Insurance Company POLICY N0. 2808X0239
Glamwi;New Yak
NAME OF INSURED AND MAILING ADDRESS: AGENT NO. 2497 OFFICE NO. 2497
MICHAEL PUIIA ROBERT B ROBERTSON
192 WINNICUTT RD 569 FIRST NEW HAMPSHIRE TPRE
STRATHAM NH 03885-2438 PO BOX 498
NORTHWOOD NH 03261-0498
603-942-5014
NEW BUSINESS TRANSACTION EFFECTIVE 05/18/04
POLICY PERIOD FROM 05/18/04 TO 05/18/05 12:01 A.M. STANDARD TIME AT THE LOCATION
OF THE DESCRIBED PREMISES
THE NAMED INSURED IS: INDIVIDUAL 0AIC 4'1 tit"hlY✓
BUSINESS OF THE NAMED INSURED: CARPENTRY-NOC
LOCATION OF DESCRIBED 192 WINNICUTT RD PROTECTION CLASS IS: 09
PREMISES NO. 01: STRATHAM NH 03885 CONSTRUCTION IS:
FRAME
PREMISES 01 BLDG 01 BUILDING MATERIALS / EQUIPMENT STORAGE
BUSINESS PROPERTY COVERAGE: LIMITS OF TERM ADDL/RTN
INSURANCE PREMIUMS PREMIUMS
BUILDING 0 0 0
BUSINESS PERSONAL PROPERTY 5,000 111 111
BUSINESS INCOMEE AND EXTRA ? ACTUAL LOSS SUSTAINED NOT
EXPENSE EXCEEDING 12 MONTHS INCLUDED INCLUDED
BUSINESS LIABILITY COVERAGE:
BUSINESS LIABILITY - PREMIUM IS SUBJECT TO AUDIT
BODILY INJURY/PROPERTY DAMAGE 1,000,000 PER OCCURRENCE
2,000000 AGGREGATE
1,000000' AGGREGATE FOR
PRODUCTS - COMPLETED
OPERATIONS HAZARD
MEDICAL EXPENSE 5,000 PER PERSON
FIRE LEGAL LIABILITY 50,000 PER OCCURRENCE
CODE DESCRIPTION PAYROLL ERM PREM ADDL/RTN
91342AA CARPENTRY-NOC 20,000 657 657
THE LIMIT OF INSURANCE FOR THIS BUILDING SHALL BE AUTOMATICALLY INCREASED
BY 0% ON AN ANNUAL BASIS DURING THE POLICY PERIOD.
ACTUAL CASH VALUE (ACV) - BUILDING OPTION DOES NOT APPLY.
DEDUCTIBLE: $500 DEDUCTIBLE APPLIES EXCEPT WHERE NOTED IN THE POLICY OR ENDORSEMENTS.
COUNTERSIGNED BY:
BPFFM-401 INSURED COPY PROCESSED DATE: 06/09/04
� ttrfnaettf of %tfr
CERTIFICATE OF REGISTERED TRADE NAME
OF
ON CALL CONSTRUCTION
This is to certify that MIKE PUIIA, 192 WINNICUT RD, STRATHAM, NH 03885,
registered in this office as doing business under the Trade Name ON CALL
CONSTRUCTION at 192 WINNICUTT RD, STRATHAM, NH 03885 on June
1 Oth, 2004.
The nature of business is GENERAL CONTRACTOR (BUILDING).
Expiration Date: June 1 Oth, 2009
IN TESTIMONY WHEREOF, I hereto
set my hand and cause to be affixed
the Seal of the State of New Hampshire,
this 11th day of June, 2004
William M. Gardner
Secretary of State
File No. 301507
Form No. TN-2
RSA 349:7