3 SCHOOL STREET CT - BUILDING INSPECTION CITY OF SALEM
No. roo - — 5 3D ofl
Wad
�+�o owea
Ig
tomatim
in.� r-a Y.k.ae_ �uaaas 35c�- cyo1
Is 040""y Laolbd in
b Oo mraftn Ann► . Yam_110
BULAM POW APPUCATW POft
' Pem►k to:
(chb wAdo wm W*) hum awks Oonwuot D" SIMd, Pooh
PLumPLLOYr Lamy AGOWLATILYTO AVOW DKATiNP -nnUN 0
TO THE INSPECTOR OF BUI DRM- '
The hft appin for a pwmk la huNd a000ad'rnp,to ft.foln
owwo Iftme a
AftM A Phone 3 Scl)cy-�,I ZS+ . C+ (9-�51
AAhkaot'e NWM r U
Addma A Phone 10,)B - + ros) 7-I-3 I5 r
1Aeohenbe Nerve
Addmu A Phone f 1
ww r rr pwp=a www 4-
MOW a mot M a drw■I I br eon armor INit
MIM 4i1dYq oada�a b ra7
fsrllMMd aori 00 314
am Io�o w.rt N
ia) C WNW
almomw Aov�or
a �=Pw"TY'
CR Pomm
OF TO of oil
MAIL PCIoYN r" 0 n mi-- A 100 R _Mn: n 54-APR n�,1j� -
OI`iG0
w � � � ,
a � �e
,,, - �� �
� _ �_ o� � � � �, �
� - � � ��
.��_
. �:���.
o _
�� � ,.
$, .
�,
� "r'IM,'
A « . � .
�.
PUBUC PROPERTY DEPARTMENT
(20 YIfAiNINQTON a�TRraT,3RD FLOOR '
"LEM,MA O t 970
TLL (978)7454595 EXT.360
FAX (070) 740-9446
S4ANLEY J. USOVI= JR.
MAYOR
DLSPOSAL OF DEBRIS AFFIDAVIT
In acaordaace with the provision of MC3L c 40 S34 I aclmow
of Balding Permit g lodge that ea a activity
im
governed by this Buldiog Permit shall bed' �to
W��Y disposed of in a prioperpy liceised solid-wssos
diapoeal ficilitY,as defined by MQL c I!>;S15OA.
The debris will be disposed of at
Location of Facility
cS�g�
FLMLY complete gm
(PLEASE PRINT LE�RLllo ) .
�J �
Name or re=Apphead
Firm Name,if say
�City ,. .�� �Stw
The above statute mgairas that debris fiom the demolition,rmovation,rebab or other
alteration of binding or stractsie be disposed in a
1
ficirq as defined by MCI, ,ca S 150A, and the building permits or1 ed solid waste disposal
indicate the location of the facility. ��� bcenaa are to
c
f RE(WLA"bNS
r Www: CONSTRUCTION SUPERVISOR
' Num . 087554
wr B( 965 i
_ Tr. no: 87554
j a -' u
A tl
PETER BA
28 MARLBORO
r
SALEM, MA 01970
' Acting' m over I .
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 131846
.R Type: Private Corporation
CARPENTRY UNLIMITED Expiration: 9/26/2006
PETER BAGARELLA ENTERP.,RISEah)!� .
122 REAR MAIN ST.
PEABODY, MA 01960
Update Address and return card. Mark reason for change.
++� Ogtfi
Address Renewal Employment C Lost Card
v
k,� The Commonwealth of Massachusetts
k
w Department of Industrial Accidents
Office of Investigations
600 Washington Street
r_ y Boston MA 02111
ten.
Workers' Com ensation Insurance Affidavit
... .. .> 'rqi):;..�.vJa..i>•.:y..:::f::i'[y:i "':[:b::i:..:......ry.. n.tt)>.J.v.:.. Y.A [`RR':
Property Owner Name: 1
L n;4 u �S 1 )t Y1 a-C— 1
Job Location:
City: V t:,1 c�.YYt m Phone# C)n
u i out a homeowner penOlmmg all WO[k myself.
❑ I am a sole pro rietor and have no one workingin an capacity.
_l..u.. ...h...;:
::.[vn.::...i.n[a.
...........:.......
:.:':::�:!n..;.f>:[:
RM
I am an employer providing workers'compensation for my employees working on this job. >'
Company Name:
Address:
City' 11 '^f1 Phone#
Insurance Co. i
�( d Ct,(' Policy#
::.�: :....,:..:.::..... ...:.. :.:.:...:..:.r, :).n..:.. .......... , C:<:n;.:\..,...i:,��ti:;'.i:[R.;J::>3:;Jn>:T.F„J•;rv,,.. ,;:,>..;.;:,...,
. ...:..:�:..:...::............... ..:.y::....,.:,:....,..... :,<.>J.0
......:.......::...::..�..a;.:.,.: .t.[u<
....wuS.,....cS.iJita.....3.x..,:;..>4R4�� i.N ..�. ?f..;;...<,i .:.)ffGx.4,>on.w.>:....>FJa•>;,tyo..[:..\;:>.J.::'.:u:�.c[Jy.!>:.Jv�:R%`: >:::?R::;ti�.:,:!J:i::{i�.
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'
compensation polices:
Company Name:
Address:
City: Phone#
Insurance Co. Policy#
air::::r.)>::;.:.:.>y.�:),.:'.,:...:•
.........-0...... .........i...... ._.. .. .J.,...... .,...,.... ...:...:XX':.»n:.,,:. :.t...... .,q[!1•:3}:R:�:. ,F<'ii c3J4;; :�Mw:.;>:�.:...:.:;;.
Company Name:
Address:
City. Phone#
Insurance Co.
Policy#
......... C. `.�u.T.+'R..._..... .1�.#LEG�4 . ...,,,......n.... ....... ...........:. ..J..>..i>.,.....:..4. ..!i::iva>:>....:i:m.\J;:J>'..o.,.:: `:..::[:.):D: �...
a:us.;J.R;°a.>i::4:.:J;i2yvRi!::I:i'x`,.:ri<::`�;F:R::9:1:n:4>)$.`.;ti'o,Y'.:paiin::3:43!Z�<7::i:'l::[:::>ii J::,.
Failure to severe coverage as required under SeMion 25A of MGL 152 can lead to the uuposition of criminal penalties of a fine up to$1,500.00 and or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwazded to the Office of Investigations of the DIA for coverage verifuation.
1 do hereby certify under the pains and penalties f perjury that the information provided above is true and correct.
- - -� - Came V70/0 t,
Print Name 1"' (" Phone# 9 -92 -3 I5
Offrtial use only. Do not write in this area,to be completed by city or town official
❑Building Department
City or Town: Permit/license# ❑Licensing Board
❑ Check if immediate mcnnnv is renn ❑Selectmen's Office
❑ Health Department
Contact person: Phone#:
0 Other
05/26/2006 FRI 10:22 FAX 781 581 7200 BENEVENTO INS AGENCY 0 001/001
ACORD CERTIFICATE OF LIABILITY INSURANCE DATEIMMDJDIIYYY)
CABIN-1 OS 26 06
FSES4wampacott,
RODUCER THIS CERTIFICATE IS ISSUED AS A MATFER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
eaevento Ins , Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
97 Humphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
MA 01907-
Phone: 781-599-3411 Fax:781-581-7200 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A; PREMIER INSURANCE AIC
INSURER B: HARTFORD INS. GROUP
Cabinetry unlimited Enterprise INSURER C:
Pet or B Main
PreaideaT:
122 Rearr Main St INBURERD:
Peabody MA 019
NSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 188UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEW WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR TYPEOFIN3URANCE POUCYNUMBER DATE M1UD GATE MMlOD LIMITS
GENERAL LIABILITY EACH OCCURRENCE 51,000 000
A X COMMERCIAL GENERAL LIABILITY I-680-d753B409-TCT 10/21/05 10/21/06 PREMISES Eaamw $300 000
CLAIMSMAOE X❑OCCUR MED EXP(My one pomon) 35,000
PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE 112,000,000
GENL AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMP/OP AGO S2,000,000
POLICY JERCT LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT 1
ANY AUTO (FA-wdgn0
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per Parson) S
HIRED AUTOS
BODILY INJURY S
NON-OWNED AUTOS (Per aocWnl)
PROPERTY DAMAGE S
(Paramldml)
GARAGE I1A LITY AUTO ONLY-EAACCIDENT I
ANY AUTO OTHER THAN EAACC 1
AUTO ONLY: AGO S
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE 1
OCCUR CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE I
RETENTION S B
WORKERS COMPENSATION AND X I AMA I T'S ER
B EMPLOYVWLIABIUTY 696UB-7963A75-A-04 10/21/05 10/21/06 E.L.EACH ACCIDENT $100000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED7 E.L.DISEASE•EA EMPLOYEE 1100000
If yBB,deacdbe Imdw
SFECUL PROVISIONS baIM E.L.DISEASE-POLICY LIMIT $500000
OTHER
DESCPJPYION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
CITYOFS SHOULD ANY OF THE ABOVE DESCR)BEO POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TD 00 80 SHALL
CITY OF SALSM IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,US AGENTS OR
1 NEW LIBERTY ST
3ALEM MA 01970 REPRESENTATNE9.
AUT O R RE4 VE
IAN H
ACORD 25(2001108) m ACORD CORPORATION 1988