3 ROSEDALE AVE - BUILDING INSPECTION (5)f
-ft-*ftSIIAOST-BE+11L-E� APPROVED BY T44E
WSPECTDR PRIOR TP.A PERMIT J39MG GRANTED
CITY OF SALEM
Date 1 (, o S
Is Property Located In f Location of
the Historic District? Yes_No_ Building 3 4.o wc6 l e t}1 t
/ v
Is Property Located in ✓
the Conservation Area? Yes No 5. ke -N
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
epaidReplace, Cher:
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 A o v i /30/v^ii e P s-e...
Address & Phone 3 Ru s"Ja l e Atr-e (971) 7 YS i/ i -7
Architect's Name N/4
Address & Phone �l
/ �fF ( )
Mechanics Name �1 40 fvo
9'11 V 7 6 1-6 6 / 5 X7
Address & Phone -?5-3 C /die•/ Sf �or�r{7l+tin/ (97h 77/- ia73 F e,e✓q
What Is the purpose of building? /!UM
Material of building? Cu o o cQ If a dwelling, for how many families? 1
Will building conform to law? Asbestos?
Estimated cost#/7SI-0 City License a M/A State u arse n C s °r6 y3 2-
/ti1cb.tt Bane II rovement
Lic. I /// 3 X
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE
�K7�•�f'BE DONE /
/�P�o yr- PX f f jP Alb fS 7WIC OM1C9�(I 1Af4eY '5/S� IV-e( ' S.34sy^
f�✓1i-�► Ittt%Ii C � -e/ecA-r / '� torn iots-�// NTw
tO�yeY i C8 �45 nn 7" R �o wlY /S�
MAIL PERMIT TO: ad�� /� �""�
No.� — V
APPLICATION FOR
- PERMIT TO
LOCATION
P RMIT RA ED
\ \� 2.0
APPROVFD
ECTOR OF B ILDINGS
an 11'-211 8
1-011
3'-0"
2'-6"
bench linen O O
cabinet a O
0 0
1
{� ✓/re"f0oaninzo�ttova ac�tuoeCfa �•
BOARD OF BUILDING REGULATIONS �ttE
License CONSTRUCTION SUPERVISOR F�F
:4 Number CS1 056432 -
r Btrrthdate 13 111962
Ex Tr.no: 1322.0
a' Restricted:,1G�,�"
t -F
KEITH A MACDON�ALD°.;=,
253 CENTRAL ST �` /!y q;
ii GEORGETOWN MA Ot833-
Ii•� Commissioner
r .._ C
✓�ze einivnam<aeaId o�✓Glam '-._� ,� ;�,
\ Board of Building Regulations and Standards _
I' HOME IMPROVEMENT CONTRACTOR t
F Reglstratidn 111834
Expiration: 2/4/2005
Type: DBA
KEITH MACDONALD CARPENTER/WOODWORK j
KEITH MacDONALD F
253 CENTRAL ST �,��.��r�'✓
j GEORGETOWN,MA 01833 ,
t Administrator
1
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Workers' Cornpenudoo lastsraaeu AffUlwk
1, of 11 G( 0M
. . widl.a Principal place of bminew au
ZS3 Co,".�,-z..l 5� t�ewse-fvt,no Yti�r�- � ••.
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do herebr'centy under T)a pains and penshtd of pw*y, clop
(Y ' am an employer pnwWl+i workers' eompemadgm coverais for my dayloreo workin eR
WC /.
bsura Pe Humber
I am a sek propriewr and haw no one we kbtg fir me lo any ooadiW.
() 1 am a sok proprkmr, general comraetor or homeowner (drde am) and haw Iced da
contractors lined below who•hays the folk+wimg workers' compen:acloe Pon"
Comrs"or Iruurancs Compaay/►oew Number
Contraeeor Insurance Com. ns parry/Po Nunebar
Concrauor Insurance Company/Pokey Humber
0 1 am a homeowner performing all the work myself.
1 redo,taad am a Can of di awnrt we be forwarsed • w Chin A lm"* awe of"M kr eaTwap w new a"dam flare o sedan
es.wate of ndwn rya Saone SSA of MOL 1 S i tan kae r w ireeadiae wow — @ands CWM&K of a it of n aai I.S00;00 uWer so
teoY i%wwm m a va r dd sam io in ow bee of a STOP WORK ORDER and a nee of S MAC a an gahst a L
S1gne this . j day of Tr" LA
:,ceraeei F trmittee ljofiNj Departs. nt
. «nsinf Ecard
Selectmen Office
=calth Departmen-
- - _ - - - - -.a5Cr ;e , _ e04 4ye 40e• 17e
f
, 1
GRANITE STATE INSURANCE COMPANY 21397-0000 WC 827-49-61
13102 013-66-o6o4-00
- PENNSYLVANIA
KE I TH MACDONALD Member Companies of
253 CENTRAL ST.
GEORGETOWN, MA 01833-0000 tic" American International Group
EXECUTIVE OFFICES:
70 PINE STREET, NEW YORK, N.Y. 10270
SEE NAME a..r) ADORES' ULE - WC990610
TARPEY INSURANCE GROUP
•9KERS COMPENSATION AND EMPLOYERS Po BOX 561
BILITY f'Gt " 'NFORMATION PAGE WAKEFIELD, MA 01880-0517
INSIJ Pain Vl-)uS POLICY NUMBER
IND1 , _ I NEW
OTHEE TOWN ABOVE: SEE NAME AND ADDRESS SCHEDULE - WC990610
ITEM 2 tandard time at the Insured'a
FROM 06/10/04 TO 06/10/05
ITEM A. P.o !.o ipensdtion Insurance-. Part One of the policy applies to the workers Compensation Law of the states listed
hen:
,
tt�
B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A.
The limits of our liability under Part Two are: 100,000 each accident
Bodily Injury by Accident $_
Bodily Injury by Disease $ SOO.000 policy limit
Bodily Injury by Disease $ . 100.000 each employee
C. Other States Insurance: Part Three of the policy applies to the states. if any, listed here:
SEE ENDORSEMEN . - WC200306A
ITEh14 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Estimated Total Rate Per Estimated
Classiticatlons Code Number Remuneration $100 OF Re- Premium
❑X Annual El3 year muneratlon Annual ❑3 year
SEE EXTENSION OF INFORMATION PAGE - WC7754
TAXES/ASSESSMENTS/SURCHARGES $ 110
EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $264 MA _
MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM $3,252
It do tad below, in.n,rd adjustments of premium shall be made.
11 Semi-Annually Ceanedy Monthly DEPOSIT PREMIUM
ENDORSEMENTS(FORM NUMBER) SEE ATTACHED FORM SCHEDULE - WC990612
08/28/o4 ASSIGNED RISK — 66
ISsuiny OHke Authorized ncpresentativo —NC 00 00 et
Issue Date
19917
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