10 PRATT ST - BUILDING INSPECTION VW80406Mfg*D#40 APPiWYED 6Y T46
WAP=9PUM TOAP.=WAEWG GRANTED
CITY OF SALEM or.
Y��
ft ofo~
M ft"my umm in
ar GNIUMAN AMI Yr�,_No_
BU LOM PERWT APPNCATWN FOR:
Pam ux
(Orde whim&No �ima SW l& Canotw Dods. Shod. Pool,
0dw: Rz44'L-- 1),r-k
ftKAW M-L WT U&MLY a CQUMZ ELY TO AVOW D UAYS W PROCESS"
TO THE L!APECTOR OF Wi LDINt &
The Memom mmby @Pon for a mmlt w bawd aoco w Q to Ito touowup
/0 AR-4-77- 5r, `
Address& PhOM ,=r Sm IPA, 17k1 1 Ga k -y'+y6
Address a Pharos j )
"*wn cs Nanw _Ro Iwo
Address a Pharos �3 i -
Sf Sr a„orr /11� 178J ) 9.k-_f' S7
"Wrso.papasd"dw
y W@w a b~ lva r•wrorrro,ar nor mw mmim4
Wrl bAft oowa.lo won
.��_a4►uorw r N A ildlr r G S o $ S�l 7.?
Lte. I-la��� s
Sip "m at ApWAnt
81Ei = UNDER THE PENALTY
DESCRta qM OF*UK TO BE DONE of PEnwsY
aorcLp�
� vs� n I aki�
MAIL PEAWT TQ l9 Caw ,)L-e `I p,- SG (Pj^ /1Ak
APPLICATION FOR
PEMAT TO
LOCATION
/f �� 7
PEFUT GRANTED
/�gio� I
r i
Depmdwutt oflslasMd Aeelitatts
Offlo e1 �a
6"Wethu row SdrrOt
teinttatrOsarn✓Bdi
Workme Compensadam Insurance A®drAft Ba UknIContrador>t/EledridanwlPfomben
Ann_ nr Inlbrmafl0 nn n pit lriat T.lnibtr
Namer7(�FQT' ....�A
r
Phmeal►e
AIs yaa n cOet trF ' �+ Type orprobd OrotNdrex
1.❑ I am s employer wit► t O I m a meeeal CosMaalr sad I 6. ❑New ooasscdoa
m41 Y�(51andiapatFdma)r bsveltedtlseaYaeYus
s.❑ I ass a solo peoptietor or parmrr- unnd es tra auadted areal.: �. ❑ Ramodelhtg
aNp and 3sw Be amploye" Tbae nab-cmdracem baw s. p DemoMm
w ti1rmai� s Q � .,�0 9. ❑BiIftaddWos No ~
.tom. 1&0 MocdiaaUepars or addidous
3.❑ I m a bomeowsm doing 4 wet oaf 11 11.0 Pimebbg npabs or addi*m
myseK Ph wodmW cm*� a 13?.�1(. ss eLyeao 13,Q Roofrepabs
ioasraoatoofrad,]*: empbyaa [No, 13Z Met
•,�.pp8mmdeamd.ana11mr.rodaa 61•doebdoarovt�art.}e taeop!.gN.poftioamdo.e
txamae..aaM.bmketoaasawit +rsser..Adesat♦.ataadIMb aat�aoritAetairtnaLenaamataaoai dicsshammk
tCaraoara tamcb"d6bas mad altnaad ere aaalked art aavtaa err emasratrt+aa.e.ater.sndt.redttd aa�poBe!iattantrtloe.
a 4►ewOk7�t1Yat aP�i*+�'r 11►a4 tay�fiPiN* Deli b lM�j Call fo1 sdAa
Itotsance cQMPWNMW--42t � ,Q
FoHey r oI Sdf-iW Lk #. L L S-2 V '-19j O gxph adosDaW a .2. /�vo 6
Job Site Addeeae Cky/Sdme2ip
A#wb a Copp*(the worM W eompaaados po ft dedersdos pap(abaw ft the peft ssmbw and eapiraotlan date}
Famue to sewie covis4 s regoi<ed uoda secdos 2sA ofbm a 152tnkWbdwhzwosidomotcrhWudpcnaldesors
f m up to S1,SOO,OO sadfor one-year inwiaoament,n well m dvl pmahia is do tism of*STOH WORK ORDER and a See
ofup b$MOD a dry aSihm ma violator: He advbW AN a Dopy offtb ara0ement my be 9xwatded b me Of&m of
lavadpdma otms DIA!Q iomraoce oovaap vaiSadoa
I Is Aarbj mesadrrrArprbu ra/Osa &a rfoa/srp AM for bjansafox pv f*d abort Ar sw anderrnoeat
zma= e A - Dabs• ZZ4/0 6
G 3-3
-
04%dd atr Mat Do soft Wrft Ix/A&a s,to be cowpfdi/by e!d or am#jk"
Cuy or Towst FermkllJomae N
lusing Authorky(cirde ons)t
1.Hoard of Healer 1.Building Department 3.Chyfrows Clerk C Eleebieal Intpedor s.Flumbing Inspector
6.Other
Contact Fenou none fh
Information and Instructions
(',teed dapfet llSs nquica al , is&I�� mdm under zW of�•
a ��.��s&[seta' _.ter� q
» err ay two err roes
a>soe�doab aaepoa&dos dr omen lepl eati4y.
f6rgoinm 3 me ltola deeettttd mar
receiver or trortea of lad[vidiW. a4oaadas ac otber� >d*"- the aCPitiF'�.:
owner of dWd*9_�havbs f0t mom roes mite io do mainuems aonsttaedaa or�we*a•sad dwaUkg__ botse
ard� orbrald vM bs&ppmk"P mess&ahal mtbecoam and w9bymenbe derstd a be as cg*%yet:»
MGL tepee[13�,� �abet states that-CM7 ai ds err local�AVOWshl vkbb"tY Isnaaoe�
rsanral of a seem err P�a operate a bdsaaa Of tosstsd hasdhap III oemsoanaaltr toe myaWesa 4ccoupgasse w�AS howsaeo coaeraw requkv&"
tbealty,MGL daplw �2K M Oft"?some[me ao®°aaeals ear a•6t�iM Dulil�eat °ere don
(bs the p otpubvc wodt UNA aoeeptbb evidence orooagNasee way the hwura ws
agar lets say aonW4t adtaaoe"cog.=*OW
rgtoitemeots otthis�pftrhawbesptesatad
` the boos mat apt►a yM aitstrdou=4 it
PkM oat the�•�pemadas afl5davit oaatpkotb�.by declm�i wis their caddcM*)of
aeea+aiY.soppb��ouUMMO)s�e(slr addren(es)=4 pbow )alaoi other roes me
baramm; Limited Ralf[cosivotles OLO
munbers err parma%as foe r mat mir aid vk abYbe n the Depatuaast of Iadesum
empioYea,a poliVy>.> Ahio M atl data the aMdav& MW&®davit sbnald
Aoaa�str coadmadoa otioaaas a eovaa as for to>�or Nears i,bcbg Mggu 4 sat ens of
be nefamed n m&dtY err town mat tt}e appNadta me biw ar rryoa are ntpdrel to obab a wsarbew
b &.wM'A. dVIW SWuM yaabave say Qaadoaa nsatdies .
atlllemmbarha0edbebry SelFbasrod'oomup>mdsshooldeafertbeit
�i�aeoe Notase aom�s Nee
ray or Tow&Ofldds
t left and printed lc&(y. The Departmtar leery&aP at the bottom
Please be tent that the affidavit comp tiom has n costae[Yoe mVrdbi the wp&m&
of the affidavit far Y"a 6N out is the event dw OfNae of bnatis&
wbkh w M be used as a referace maib r in additim as Mqueam
place be sure.as 88 in the permNNceme Ncatiass is my��yew,sad o�Y aubma one uHdavit bdicattoy c u vm
that nun sabmdt�b/-" nanimm— M Or
asd undo-Job Site Addtae»me appai�cam sboold wrote all badom is (ciW
1bY» die Am has bets otlid&igr trmrped c[ by �!or awe may be pwvided a the
COPY WPgWeack
�as proottbat a valid affidavit is a file fiir metro permit or Ncaats A oew afldavit moft of commercial v�tme
(is a dos Boom at parch
err qr�a bums Owner or cith m is obtaiebs a Noeaae a pansis rot related.a say bnsioeaa
y a buns leaves ere•)acid pa&os is NOT npirad a compbM mis afedsvit.
The oBoe otbavatisadmt
rvoald MW n thaot you in advance for your cooperation and should you have any 4 �
pleats do no,bcd"a give as a cal'
The Depaconcues addresk tcicpbose and lu member•
The Commonwealth of Massachusetts
Mpatunent of Industrial Accidents
Ofee oftnvesdgatt e s
600 Washington street
Boston,MA 02111
TeL #617-727-4900 act 406 Of 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mm.gov/dia
CITY OR SALUM9 1MASSAGHYlt;TT!
ruRua /ROPCIM o&pAaTUCW
Im i m%vm wlmmm *Maw* Sao Item
S"Amk m"Go mosm ale"
Tnswrewa 87*746-NM a]R. Me
PAM 070-74ssws
Is acomdaacs with the p mvWms of Mat.c 40 3 A a conditim of your
BuMbs Pbmllt is that the debda re� 3 ftas this work 2W bs disposed
of is a properly liceased SON wasts� spossl hoiliti as deflaed by UM
Chapew IM 3130 A.
'fits debris wM be disposed of Iaa
NaU t� cz 47t .ocatloo-of Facility)
313eadtrs of Applicaat
d- -.)-� -off
Data
` 1te 1 n/g lafllons�an ar s
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement ontractor'Registration
Registration: 126273
Type: DBA
i ( s Expiration: 5/10/2008
DR. FIX-IT
ROBERT BAKST M =
49 SALEM ST. ° -
SWAMPSCOTT, MA 01907
( K
Update Address and return card. Mark reason for change.
- Address _ Renewal j Employment I-! Lost Card
DPS-CAI 8 50M-W04-G101216 .
BAf of ft=g Reg1`1A1 7is an""iYSiann&rr 1 License or registration valid for individul use only �I!
_ - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registr.milon: 1262 Board of Building Regulations and Standards
�ati3.�\ One Ashburton Place Rm 1301
Ex pi ation 10/202008 Boston, Mo.02108
DR. FIX-IT -
ROBERT BAKS
49 SALEM ST.
SWAMPSCOTT, MA Ot Depury Administrator Not valid without signature
��ee �aon+niooewra�'o�✓�.aeaa�ueoe!!d'..
BOARD OF BUILDING'REGULATIONS
Lleensr...CONSTRUCLION.SUPERVISQR`P
Number. C$. 085472 -
5
Birth dater 09/2 194 ':
Explreg�09/29/2006' TF n6.'_-85472i`
RestAeted
ROBERTA BAKS7-
4SSALEM ST
XWANPSCOTT, MAAdministrator
ACO CERTIFICATE OF LIABILITY INSURANCE 06/26/06'
A. DATE
PRODUCER (781)581-6300 FAX (781)581-9070 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Quinn of Lynn Ins Corp Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
15Z L nnwa Suite 1D HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Y Y ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 789
Lynn, MA 01903 INSURERS AFFORDING COVERAGE NAIC#
INSURED Dr. Fix - It INSURERA: Safety Insurance Group 39454
49 Salem Street INSURERB: American International Group
Swampscott, MA 01907 INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN(
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 DDA.' TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POUCYEXPIRATION LIMITS
T. DATE(MMMDNY) DATE WMMDNY�
GENERAL LIABILITY BP6774 04/25/2006 04/25/2007 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000
CLAIMS MADE a OCCUR MED E%P(Any one person) $ 10,000
A _ PERSONAL A ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00
POLICY PRO- LOC
ECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO Ca accident) $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: ASS $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND WC8944890 04/28/2006 04/28/2007 WcsTATUT oTH
EMPLOYERS'LIABILITY
B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 100,OOO$
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 100,OOO
yes,describe S E.L.DISEASE-POLICY LIMIT $ 500,000
SPECIAL PROVISIONS below r
OTHER
DESCRIPTION OF OPERATIONS]LOCATIONS/VEHICLES/EXCLUSIONS ALLIED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE DCANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
DAYS WRITTEN T CERTIFICATE HOLDER NAMED TO THE LEFT,
City of Salem BUT FAILURE TO MAI SUCH CE L IMPOSE NO OBLIGATION OR LIABILITY
1 Salem Green OF ANY KIND UPON TS AG OR REPRES NTATIVES.
Salem, MA 01970 AUTHORIZED E TIVE
ACORD 25(2001/08) CORPORATION 1988