6 PEARL ST - BUILDING INSPECTION "PLw+rsilAtl M fiLINkWo APPROVED d3Y TW
JLUPJ:J:MS PROR TO A:PMMT,BEING GRANTED
CITY OF SALEM
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Ckdo whichewr apply) Roof. Reroof, Install onstruct
l Siding, C Deck, Shred, Pool,
Repes/Repisoe. Other
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build aocordGV.to ft.folbwktg'
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Owner's Name
Address 8 Phane AA t (9787 3 7C= 3 3
Architect's Name /��h'�yven P. tJ w+Jy-cJ GO .
Address a Phone 145 -E (�1�/[te f �.ti-Sf.� 1 �'7-3S-o—BW3
Mechanics Name
Address d Phone ( )
Who is to pwpow at b~
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l SWwJum of Applicant
SIGNED UNDER THE PENALTY'
OF PNUURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO: l4S
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CITY OF SALEMv MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
` 120 WASH INGTON STREET, 3RD FLOOR
SALEM. MA O 1970
TEL. (978)745-9595 ExT. 380
GO) FAx (978) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III,S 150A.The debris will be disposed of at: 6 sD� • . �� 0 g
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Address,City& State 0
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIlL S 150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
600 Washington Street, f Roor
4,
/ Boston,Mass 02111
Workers'Com usation Insurance Affidavit: Building/PlumbingfElectricall Contractors
:;emr�.2xirrat�eanitc�n�mmswrr
name:
address:
city stare: ao" phone#
work site location(full address):
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ 1 am an employer providing workers compensation for my employees workin on this,�ob
r Y, � a,. '' F'sai t�,,;'-�,: F..y,. 5�
. . J<. d
Comm
a—MOM
H �tr:' r� *�'Y. �" ,S• .^ 1 � .FS' `� � ".tea psa3,
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
comnam nomr. -
address,• .
city: Dium
w
' . ^•.Ynkiia .'^.ef +'�:�y'd;�9.zl��i!5# '�.'v r F..a„,,,,y � 3 _eYM
address:
cim
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,
F •...J.:. 4
Failure to secure coverage as required under Section 25A of MCL 152 an lad to the imposition of criminal penalties of a fine up to SIAM00 and/or
out years'imprisonment au well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me I understand that■
copy of this stattment may be forwarded to the Office of Investigations of the DU for coverage veriacalion.
l do hereby certify under the psi and penalties of perjury that the information provided above is true and correct.
Signature �..c G�pn p J pate <G'—�9'—� �
Print name-q= i G1��- IV Phone# , - 3
official ute only do not write in this area to be completed by city or tow official
city or town: permioicense 0 ❑Building Department
❑check if immediate response is required ❑ k ong Board
❑sNeclmen's 011ke
contact person: phone a: ❑Health Department
„n,�srp,9sirt ❑Other
SUWIN-1 1 08 31 04
ODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ichard Soo Roo Insurance HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
148 Washington St, Suite 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
3ston MA 02118-2108
hone: 617-338-8168 Fax:617-338-1148 INSURERS AFFORDING COVERAGE NAIC#
TIRED INSURER Penn America
INSURER& Liberty Mutual Insurance Co.
Sunshine Windows Company Inc. INSURER
147 East Berkeley StreeE INSURER a.
Boston MA 02118
INSURER E
)VERAGES
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 PAD CLAIMS.
RNSR1 TYPE OF INSURANCE POLICY NUMBER DATE M DATE(MMIDDNYJ LIMITS
GENERAL LIABILITY EACH OCCURRENCE f300,000
X COMMERCIAL GENERAL LIABILITY PAC 6265650 09/08/04 09/08/05 PREMISEs(Eaacaaerce) $100,000
CLAMS MADE X❑OCCUR MED EXP(Airy ma person) f 5,000
X Add CG 2011 PERSONAL SADVINJURY s300,000
GENERAL AGGREGATE s300,000
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO s300,000
POLICY JET LOC
AUTOMOBILE LIABILITY
(Ea
COMBINED N�TINGLE LIMIT f
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY f
SCHEDULED AUTOS (PW parsed)
HIREDAUTOS
BODILY INJURY f
NON-OWNED AUTOS (per aoad n)
PROPERTY DAMAGE f
(Pa avd.N)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 5
ANYAUTO OTHER THAN EAACC f
AUTO ONLY: AGO f
EXCESSDMBRELLA LIABILITY EACH OCCURRENCE E
OCCUR CLAIMS MADE AGGREGATE f
E
DEDUCIBLE $
RETENTION f E
WORKERS COMPENSATION AND TORYLWiRS ER
EMPLOYERS' LITY
ANY PROPRIETORIPARTMER/EXECIJTNE �WC5-31S-311884-023 09/16/04 09/16/05 E.LEACHACCIDENT $100,000
OFFDERMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100,000
Wym fte urger
SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $500 000
OTHER
SCISPTKRJ OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
for, window or assembled millwork installation
:RTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
N0710E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES
AUTHORIZED
Richard o
:ORD 25(200108) _ ..__ -ram - TION 1988
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145 EAST KRKLCV'k: ... e�rtu✓ `
BOSTON,MA 02118 T AAndatstfAer
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