22 PICKMAN ST - BUILDING INSPECTION (3) f wNtDmw4KfKdw4 lli APPROVED By Tm
JdSPF =PWR TD A'V=W AId= GRANTED
CITY OF_SALEM
No. o,l,
wwd
Zaw�,o Didw�
okb any In rasatioa of
I "
N Ngotb DIttIIG4 Yu Now
k AWNIV LoomMd In
NN conanvwon AFM? . Yu.No
No
Perron to: BtNLDM POW APPLICATION FOR:
�
(Chck whknrewr apply) Hoof. Retoof, haled S*q. Cart W Do*. Pool,
RNpaidFlsplaoe. Od,.r: �%fe�,✓i,vDOs✓ Tiei.*o
PLEASE FN.L OUr LEG LY i COMPLETELY TO AVOID DILAVIII NI PROCEWNG
TO THE INSPECTOR OF BUILDINGS: '
The undeniprad hereby applies for a permit to build accor %V to the.fodowktp
speowbulow.
Owner's Name /164F1,/6 S/„277—
Address 6 Phan a-2� ST ( 1
Architect's Nam
Address 3 Phone ( )
Mechanics Nam SrA�z /39Gsc� ,
Address A Phone
wr■t in to pWm it ta~ SiO
AA�W W d t dnp7 N a d for how mmy hnfts4
Wm huoft rn non b kw?
Eselrtslad cost Cp umw• ehb ub • 1 0 0`A
ttr Istltaysar�tQ=of##PNWW
�.,c. ,
OF"mm
DESCf T10N OF WORIK TO W DONE
MAIL P8 IT TO:
•:L' a '4 d I P J.r
•~
• .. ..A,
£E%:..',
�' 7x
t.' :f'uwt:4
v ^r r �.
a �»-.
is
DIrIG REG ER�ISOR
/z U UP
B
y J B�ARONSTRI1Cf1oNS
�Icense: 00AB90
W nbef CS
ate•04106119 06 Tr.no: 22ag6
glhhd
ExPI palOpl20
00
Restdcted'. �/
„s•. T' M' Is ones
PQ BSX 570 0 952 Pctm9 0 nm ._
SAI-ISBUR _./"
Pu9UG PROPERTY MPAWMVa
' 12011WiMIN670R 9'1RaaT iROFLOOR '
"LI M,MA 01970
^t TWA- (979)748-9595 [7R.a!O
FAX (978) 740.98A
STANLET J.rUSOVICZ JR — -- --- -- ---
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the Po<oVMM of UM c 4%SK I aclmowlo*dw d a caodWm
of BmM4 Permit/- .aE debris me uftS Dom the comwucdom awry
,ovaned by ibis Bm'l ft Permit abaft be disposed of is a propuly hcu3md solid wa "
disposal facility,as dafmad by MM c��IlL SISGA.
The debris will be ftosed of at: (� 1,t&�
Location ofFaciw �!
9
of
FULLY complete the fon wins Mfo®atiom:
(PLEASE PRW CLEARLY)
.Je¢�iFs =► /�s� sue.. i
Name of Peamit Applicant
Fmm Nmak if amy
Address,City&Sbte' --- --
The above statute requites tbst debris fmm the demolition.rmova wz( rehab or other
alteration of bmldmS or sbucdae be disposed m a propaiy hecmad solid-waste disposal
facility as defined by MM.d.SISOA.and the bu(UdmS j mirror licrosp Are to
indicate the bcadam of the La1ty.
1 � I
�Oml/LO/iWil�Wa Of�aL�ac�tw.ttd
boo yUla�lae.Sze.l
aalap 1 unmee �••I•w ///•u.rr r.lb 02111
workers' Compenssdo0 lasaranar Affldavk
. . wieb a prha*W place of badaeo ass
60
do hereby'cerdy under c)n pabas and pemiNes of pertoirt dooll
() 1 am an employer provUing workers' comperosdea co"Plit for mgr siaploreee working aQ
. tbir
Insuranes Compaq P Number
1 am aLsok proprietrr and have no one working fdr me 10 0117 apadw.
() 1 am a Selo proprietor, general comratao► or homeowner (drde one) sad hew blood eks
comraaors lifted below who-how the following workers' cempensarfoe po8dw
C invoc,K Inwranis Company/Po NombN
Comroaor Insurance Company/Poky N.,
Contraaer Inmance Company/*olicy Nmrtbor
() I am a homeowner performing all the work myself.
I vnawau.e aw r Na,Of Oi aareaw.a of f.n.ara.a ar Or CMica M Iww*M"of Ow DIA 4 co.waq.wliraian ON*A Alois•roe
t~s r ar#tow#*.woe Swim 2fA of MOL 15 2 can We M Ow:rwrio d oilinn asaada"'Oros S'a fiat d M 04'AGOM anwor.ae
ten'inaraen.rw a a O.a rnrrs' r lane• STOP WORK ORDER a"a Am of S IODAO a ea,Wirt ar.
Signed chit . day of �D
:'ce eeiFcrmit iiwlatng Departn.ent
ijcensinf Ecart
Selectmen Office
-itilth Deparmer!
-ecCC Ye : _ ape epc 405 77t
I
FROM :ROBERTS INSURANCE FAX NO. :9786833147 Sep. 28 2004 01:52PM P1
ACQRD~ - I)A1E(MWDDM/W)
CERTIFICATE OF LIABILITY INSURANCE 9 2a 2004
7 Pre01R.IOFR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
P. Roberta Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
{ HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
060 Osgood St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
orth Andover, MA 01845
978-683-8073 [, INSURERS AFFORDING COVERAGE NAIC#
INSURED JAME.q BAG4HM INSVRER A'. THE PROVIDENCE M1M'[JAL FTR16 TN9. ----
' DBA AM&RICAN HOME IMPROVEIRNT INSURER B:
P.O. BOX 5470 INSURER G:
SALISHCTRY, MA 01952 INSURER O:
603-765-8302 .
I INSUR ER E: ----.
i 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
i MAY PERTAIN,THE INSURANCE AFFORDED SY 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.
1 LOA POLICY NUMBER POLICYEFFECTNE I'r1L10YE PIRAI'ION
GATE MMIUUlY AlE UI LIMITS
GENERAL LIABILITY t'ACH OCCURRENCE $ 1,.000,000
X CU_NAIERL'b1L GENERAL LUISILTIY PREM'ES.(EA cT
� PRI MIsrB(Fn P nunn.nl ! 50,000
l CLAIMS MADE `-1 OCCUR
( _ MEDenP(Arnorrepereon) a 5,000
dpp A CPP 0058857 00 04/01/04 04/01/05 PERSONAL SADVINJURY $ 1,000,000
3 .... .. ..... ... . . ... .. .... GENERAL AGGREGATE $ 2,000,000
GENL AGGREGATE Umn APPLIES PER PRODUCTS-COMP/OP AGG § 2 Q00 000
i POLICY �ECT LOC
! AUIOMOBICELIARILITY
ANVAUTO CUMBIN ll SIN0LE LIMIT $
IEe ecGEent)
ALLOWNEDAUTOS
BODILYINJOkY $
SCHEDULED AUTOS (Per person)
t
HIRED AUTOS
BODILY INJURY
NON-OWNED AUTOS (PnrnirnlnM) $
PROPFRTY DAMAGE $
(PereccidmR)
GARAGE IJAWITY $
j AUTO ONLY,G ACCIDENT
UTHER THAN EAACC $
A—OONLYI AGO $ _
1
EXCESSAIMBRF.0 A I.IARII.ITV EACH OCCURRENCE $ •M^
I OCCUR , . CLANC$MATIE AGGREGATE
DEDUCTIBLE $
REIENTION $ .—_.—. ...
8
WOREMPLOY RS'LIABILITY ON AND " r -
� EMPLOYFIt3'LIABILITV _..._�I. ___....kli ......_
ANY Mam1ETOIWnnit�R1E%ECulrv[ E.L.F.ACH AC 1DENT $
DFFICERAEIoEB FXCLUD[pT E..L.DISEASE GA EMPLOYE $
Byy��BB tlBBCflbepflDBf ._.. .. .... .............._ _
SPEI�IALPROVISION.SNeNW E.L.DISEASE-POLICY LIMIT $
ONIER
DESCRIPTION OF OPERATIONS/LOCATIONSI VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
REF: HELENE SCOTT PROPERTY. 22 PICMAN STREET, ShTi MA. 01970
FAX : 978-740-9846
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE OFSCRIRFD POI..ICIES BE GANG ELILED BEFORE THE EXPIRATI
ATTN: SALLY / BUILDING INSPECTOR UAYC I'HFPF-OF, THE ISSUING INSURER WILL ENDEAVOR TO MAILa0 DAYS WRITTEN
CITY OF $ALLM NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE 10 PC 80 SHALT
120 MSHINGTON STREET IMPOSE NO ORLICATION OR LIABILITY OF ANY KIND UPON THE INSURER, 1'rS AOEN'T8 OR
SALEM, MA, 01970 REPRESENT
AIR4IORVED ENTATI
ACORD25(2001I08) OACORD CORPORATION 198E