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6 SMITH ST - BUILDING INSPECTION fLlIIS1iAtl6T�EfKisPlM1D A.iPPiiOYf� 8Y TiiE 1dSRiEOIOB PRIOR 7D A P.FA1 t AE" GRANTED CITY OF SALEM D" n.�o�wor?� rat_No_ a us�.s Of ,� Is PNP"L oll"In so Oorowto po Awe? Yam No_ BIALD" PERWT APPLICATION POR: Permit to: (Ckole whWwwr apply) Roof. Rand, Install SkIft CarWf" Deck ShW, Pool. PLEASE FILL OUT LEGIBLY a COMPLETELY TO AVOID DELAYS IN PROC9861IN i TO THE INSPECTOR OF BUILDINGS: The underagred hereby appals for a permit to build accordkp to the foBWMV ONW& Name A 4 4w ro/t oi//i f!-A/ Address a Phone 4 Sin 17-# sT r 0/7I�9`t- gy/ ArcWtoWs Name Address a Phone Madmics Name 4-90 Address a Phorw /1.3 CC-W 15r IVItJ ,P/J i157 (TOO ) 733-773) v"is na parpoaa al bWIOYie? I F�r,r►�I-� MNnM of bYYdYlp? M a ri "' n,for raw many bmin?T� wrl b Aft=dam to law? AobMft? Illaum od z52M°o CRY Ua r N A VAN Uaaw• r/. � 6 � ` Sipnatune of Applica SW= UNDER THE PENALTY OP PEUM DESCRIPTION OF WORK TO BE DONE /�1Si✓9�� ia�•-��:�C�i��yr" U� � NDo�v .� 'w r r�- nr� STt?v�ci MAIL PERMIT No. APPLICATION FOR PEW I TO (�S�Qtt ��LAGE�iFeL! i,�.,✓�rs LOCATION (p S41 /TLF Sf . PERMIT GRANTED APPOOVED q OF BU1 Mi-3 CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 Salem Buildine Department Debris Disposal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. /The debris will be disposed of in: (Location of Facility)//3 C&A2 ST J!IIGr'dICD Pt4or'757 Signature of Applican Date Ii Board of$uildingAegulatioas,and Standards License or registration valid forindrvidul use only HOME IMPROVEMENT CONTRACTOR before the expiration.date. If found return to: Board ofBuddmQ Regulations and Standards Aegist2tian: 120456 One Ashburton Place Rm 1301 Ig- 1zL2006 Boston, MiL U2105 a — n —nj lement Card _ Ile=--���� . . - B1L-RAYALUM%tTM P e Paul McDonald ' 40 F1NT R tVIDD: �i„�� ELR�ONT NY110C3 %idiwmstrator� :119otclhdsiatltautst��nafure , i REM The Commonwealth of Massachusetts Department of Industrial Accidents jp ®ffce of Investigations t600 Washington Street w Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/,Electricians/Plumbers Annlicant Information Q / Please Print Lezibiv NaLne (Business/Ocganizati�on/Ifndividua]): T�I I`1�(e c l f'1 F'�" Address: 113 l c�Q[n�t 5 City/State/Zip: 11, 1 C1 a s U l Phone #:7 3 72 Z. Are you an employer?Check the appropriate box: Type of prolject(required): 1. µ am a employer with 4. ❑ I am a general contractor and I 6. []New'construction emniovees(full and/or part-time).* have hued the:sub-contractors _.❑ I am a sole proprietor or partner- listed on the attache3 sheet. # T ❑ Remodeling ship and have no employees These sub-contractors have 8: ❑ Dem ution working for me in any capacity. workers' comp.insurance. q_ ❑ Building addition o workers' comp. insurance 5. ❑ We are a corporation and its � P 10:❑ Electrical repairs or additions required.] officers have exercised their I 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] {Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infmmaiion.1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a newaffidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company an Name Policy#or Self-ins..Lic.#: Loc 10 15-9 f :3 Expiration Date: / —z O c/ Job Site Address: S/4 ZTH -5T City/State/Zip: a(9 70 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded,to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and penalties ofperjury that the information provided above is truue and correct. Siffiature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: _ Phone#:_ -_ 99/14/2005 16:24 5168295U57 - SCS �', PAGE 02 DATE ILIMIDDrerM AeoR.o CERTIFICATE, ©F LIABILETY INSURANCE sx013t � D9114/DS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA'TSON PRDDUDEA ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SCS Agency, inc. HOLDER,THIS CERTIFICATE DOES NOT AMEND,EX7z-ND OR p.0. Box 220493 ALTcRTHE COVERAGE AFFORDED EYTHE POLICIES BELOW. 11 Graae Avenue - Suits 300 Great Neck NY '-'-•DZ2' �'93 516�829-5857 INSURERSAFFORDINGGOVERAl HAIC i� ?hoaeeEl6-4'a6-6007 ax: INSURED INSIIR�LA: wffi1.Ae5v xvaucmes raraoesY INSURER Bt I 19305 � INSURER C: AuvLvb•Aavasv�e itlxW.�� �.� B'jj Ray T«�= Siding COvp. INSURERM 40 Elmont Road Elmoat NY 11003 INSURER E: COVERAGES THE POUCIEs OF INSURANCE LISTED BELOW HAH✓=BEEN ISSUEC TOTHEINSUREDOME NAMED ABOLS FOR POLICY PERIOD INDICATEC NOTESUBD ANOINE ANY R-MUREIENT,TERM OR CONOrnON OF ANYC KM--T OR OTHERDOCUMENT WffH fLBPcCTYCWHICHTHL9CERTWCATSMAY BE195UED OR MAYFERTAIN.THE INSURANCE AFFORDED BY THE POUCIE9 DESCRIBED HEREIN M SUBJECTTO ALLTHE TERMS.ELUSIONS AND CONDITIONS Or SUCH POLICIES.AGGREG0.TcL1MITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS. - LPrtI'9{ LTR INS TYPE OF INSURANCE POLICY NUMBER DATE IMI IMMJDDIY' =CwA DATE EACH OCURRENCE 5 l r D D 0,D D 0 GENERAL.Ti F. TN sEs EACren YVM lu GENERAL LIABILITY O9/25/05 00/25/06 PREM CounuuoLL M©EP IaA S lO tl,OO D �E 5,0QD CLAMISMADE OCCUR PERSONALS ADV NiJURY 51,OD0,0D0 ' GENETWLFOOREFIATE S3,ODD,DOG PRODUCTS-OOMPRJPAGG s2,OD0,000 GE+LAGGREOAW LIMITAPP^GEES PER! n POLICY fIR ILOC COMBINED SINGLE LRAIT AUTOMOBILE LIABILITY (Ea aWdCA�J § ANY AUTO ALLOWNED AUTOS BODILY INJURY 5 ' (PC person) SCHEDULED MJIOS HOOILYINJURY 1E HIRFDAUTOS (Perapal09r10 NON•OWNEOAUTOR PROPERNOAMAGE E (Pat aSleepi) AUTO ONLY.EA ACCIDENT S GARAGE LIABILITY AUT O � I N EA AC i ANY AUTO DCNL'Y: AGGI5 EACH CCURRENIF E EIICESSNMBRELLALIABILTTY AGGREGATE S OCCUR CLAIMS MADE y DEDUCTIBLE s RETE31TION S r TORY UNITES ER WoRKMOoWeNSATION AND 6 sL EACH ( . $ I EMPLOYERS'LIABILITY NC93A5913 09/22/OS 09/25/OAcroEHT 310D000 ANY PROPMETORIPAIU11110=11.NE E.L Ot5E5SE•E4 EMPLOY 5l00000 OFEICERIMEABEREXC Do? ELDLS'EASE.PODCYLIMIT S 500000 "am das'!sA render 9PEl.1AL PROVISIONS 6slw OTHER C Disability 1794C36 10/tll/05 10/01/O6 SI`atuta-S i D'e9CRIPi IDN OF DPENAi IONS/LOCATIONS I VEHICLESJEXCLUSIONS AOOEC BY ENBORSEMENT 1.WpECIAL PRON910NS I CERTIFICATE HOLDER CANCELLATION TDffl:'IOMZ SHOULD A7JTDF THEADDVE O'3CWDm POWDIE98ECANCELLED BEFDRETHEE%PIRATION OATETHEREOF TNEI35"'OINSURETt WILL ENDEAVORT>?MAIL 3D GAYS WRITTEN NO IDETO THE CER YRUTE HOLDeLNAM®i TOTHE LEFT'5UT PXUmETD D090 SHALL WPCsENo OBLIGA77ON OR LLOUTY OF ANYiK HD LIFON THE INSURER,RS OEM OR REPRE9ENTATNPS 1 - AUTiORREDREPRESENTATME/ ! 0AC01DC0RP0RATION1988 ACORD 25(2001108) I �I;�;�i11/' h11GH R-RFORMANC�Ya1NDPN'&PPPR SYST'MS I - , � /,%.n�nrcn pm�ymPunmem . "Fqual Sid #T n Dpfle Numg GIN r11t�ow AR Eoer�ysayi�9sw�lldepe�d3ee. 11rSPe tG Mnuseandi�siyJe Fnr mn rtin�natiorl,^�115=BIXt 1E2 a 1' cv sdNr�C#s web ti Ift • muuevc'n3�0IA - - - { So7ar'He�Ga�n vcltiic L9-- Al . XSJ 1-GoefirJe� 41 7ransmittan�z '. . . ®ersuoWa she er gs.mmmm aPP dim - whole Produ�®etgy PerfoPPapee.Nr C tsbn_ � sns�dsos.m.:�d��• -�. cogdlu_ � e i