17 OSGOOD ST - BUILDING INSPECTION 01/2B/2008 14: 16 978-777-9804 JOHN J DOYLE INS PAGE 01/01
AD-OW. CERTIFICATE OF LIABILITY INSURANCE oxi22/20 81
PRODUCER (978)777-6344 FAX (978)777-9804 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
John J Doyle Insurance Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
85 Constitution Lane HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers, MA 01423
Molly Crowell INSURERS AFFORDING COVERAGE NAIC 14
INbu D Ge somini Construction LN$uRERA: Insurance Innovators Agency
43 Dartmouth St INSURER S.
U Beverly, MA 01915 wsuRERD:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED 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 SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD TYPE OF INSURANCE POLICY NUMBER PCUCYEWECTIVE POLICYEXPIRATION PATE INNIMMOOD DATE IMMMOMI LIMITS
GENERAL LIABILITY LGL0714463 12/12/2007 12/12/2008 EACH OCCURRENCE S 110001000
COMMERCIAL-CENERAI-LIABILITY DAMAGEPRPMI
TO RENTED $
CLAIMS MADE 7OCCUR - MCD E%P(Arry PnA persbn). s 5,()()
A PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,00
GEN'L AGGREGATE LIMITAPPLIES PER; PRODUCTS-COMPIOP AGO S 2 000r OOD
POUCY IF-C LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (E?>r�idenq $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per xrem)
HIRED AVTOa
BODILY INJURY S
NON-OWNED AUTOS (Per eec,denl)
PROPERTY DAMAGE a
(Para�udenq
GARAGE LIABILITY AUTO ONLY•EA ACCIDENT a
ANY AUTO OTHER THAN EAACC S
AUTO ONLY', AGG S
EXCESSNMBR£LLA LIAOILITY EACH OCCURRENCE $
OCCUR O CLAIMS MADE AGGREGATE 5
a
DEDUCTIBLE S
RETENTION S S
WORKERS COMPENSATION AND NEW BUSINESS PENDING 12/12/2007 12/12/2008 wcsTLZU I 1CTH-
EMPLOYERS'LIAOILITY MASS WORKERS COMP BUREAU E,L EACH ACCIDENT a 100,00D
A ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 100,00
IF eedesttber der
SPECIAL PROVISIONS beIPx E.L.DISEASE-POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES t EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIGNS
CERTIFICATE UOLDEE CANCELLATION
SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
SALEM CITY HALL —C—DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
JOSEPH BARBEAU BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
120 WASHINGTON ST OF ANY IOND UPON THE INSURER 9 OR REPRESENTATmES.
SALEM, MA 01970 AUTHO REPRESENTATN
ACORD 25(2001l08) FAX: (978)740-9846 OACORD CORPORATION 1988
CTTY OF SALEM
PUBLIC PROPRERTY
DEPART-MINT
..y:+at aY•"�.aYl
'ht:Y7'aJ��9I!�fuC 9t/aJ�6lW
Construction Debris Dbpossi• Af 1dsvit
(required fix all demolition and sonovation wort)
(p aoeonlunee wish the six&edidan d the State BtWdint Codes 730 CUR salon It 1.5
Debris,sad the provisions of MtGL a 40.S A
9uildies Permit 0 _ _ is issued with that condition that dw debris readdns tiro
this wort shall be disposed of in a property licensed was dispose[ facility ss dented by%IGL e
I l I.s 15OA.
The debrilIs will be transported by:
hrr r dry Ou✓1
home o(hoYtM
rho<kbrisi will be disposed of in :
WOO wGISllc
(,lass/of fxd,ty)
,...M:f,nt.. ui Yx:Ltyt
1 a � 0$
CrrY OF SALEM
PUBLIC PROPRERTY
DEPARr.vIEMP
?L.�•a 13C t/.�N::Jltf 7ttT f uuw WA+twr*4
�t:'t0►7a�t9M�f•�t 9atJ�6listl
r-
Construcdom Debris Dkpood Aftldsvit
(mquiml lbr all danolirios aid tenovaties wont)
1s aoaonkme with dw shth edidos of dw Start Building Cod4 7W CMR soetim 111.3
oaria6 wA dw pmvis(ons of�tCL c 44 S Sfk
SWldinS Po* _ _ is issswd wilt rho coodtties thus the debris resd&g dots
this walk shalt be disposed of in a pt:opsrty lieensed wsm disposal nteility as dented by MOO e
lit.1115"
The debris will be transported by:
taoma of MWM / r
rhockbris will be disposed of in : I�r C
Gam'' �w1 n e�
011
- -- -------- - CITrOF SALETNI
PUBLIC PROPERTY
DEPARTMENT
/:I�W'S_�Ot1fL'l7LL
�/wYOt 130 WA5MN1GWW h'r%E"•YLLtJ1,\rASSAO/l:5!'1"IS 0197e
141:978-745-9S" •FAX 978.740-95"
APPLICATION FOR THE REPAIR RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTING
STRUCTURE OR BU"LNG
1.0 SITE INFORMATION
Location Name: Building:
Property Address: 1 G s '-1-004 s
Property is located in a;Conservation Area YIN Historic Dh*iat Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: rj L
Address: /-7 C�S cj at1 S
S Ci le�l
Telephone: cj-7
3.0 COMPLETE THIS SECTION FOR WORK IN EXIMM 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
of existing building New
grief Description of Proposed Work:
let( e
L)3 2
Mail Permit to:
What is the current use of the Buil ing?
H dwelling. how many units? �-
Material of Building?
Will the Building Conform to Law? _
Asbestos?
Architect's Name
Address and Phone
Mechanic's Named
Address and Phone 4Q47 C2l c7lf
Construction Supervisors Uceenss,e>< �Q" —HIC Registration N %�7
Estimated Cost of Project S Permit Fee Calculation
Permit Fee$ 7- Estimated Cost X$7151000 Residential
Estimated Cost X$11/i1000 Commercial
An Additional $5.00 is added an an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to GU to-,tbe above stated
specifications. Signed under penalty of perjury
Date ! 02 —G
0
o U - L 3
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