96 SWAMPSCOTT RD - BUILDING INSPECTION (3) r 30
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�5 fL1►NS1iMWfi-BE fi �NND APPROVED BY TiiE
° ter, pB•PWR TD A.PEMIT BEING GRANTED
CITY OF SALEM
No. Date
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Is Properly Located in Location of
trw Hidodc o dd? Yw No V enildins % 5wAWO cr .
is Property located In
m Canenatlon Ma? Yes No
BUILDING PERMIT APPUCATION FOR:
Permit to: Deck Shed Pool,
Roof Reroof, Install Siding, Cons
truct I ,
(Circle whichever apply) Other: T
Repair/Replace,
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 AA LIB' 45TS ' 11
Address & Phone iG "-Th Y k\tu� , �'�lu+$ ��8 9Z� Zl 2 l
Architect's Name 011 LW kw\— �s
P' - - ��f 70 3a
Address & Phone 6�P\fttl R�I�
Mechanics Name
Address & Phone f
wh t is Ito pupme a a,kW l-6 T try vJS-1 T=1A11
M"M a buYdirg?S1W— 4-1.62-tq:j�-ftg n a dweow,for row many tamwas? Ng
vNn bLdmft=Voan to law? ��5 Asbestos?
EsMOW COill 12, . CG-D CRY Warm e N A slaw um" 0 Q d 6 //p2
Rona rpro.eant '( !/O!!�
`' /, nature of Applicant
L,SMED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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lrrcG-CIBt�
MAIL PERMIT TO-
No. ,G
APPLICATION FOR
PERMIT TO
LOCATION
94,
PERMIT GRANTED
2.0
A ROVED
INSPECTOR OF BUILDINGS
CITY OR SALZM9 MASSACHYSiTTS
PtJEUC PRCPtRTV 0tPARTWKt4T
120 WASHINO MM STMXCV Silo iwOs
IALLM. MASSACNUS;; O 01070
TtltPMGAIW 976-745-9590 W". 340
FAXI 97/-7409644
Debris Dlsneed l 01M
In accordance with the prnvWO= of MGL c40 S 54. a condition of your
Building Permit is that the debris resultlag 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:
�A1-1k IVAJJI-t (Location ofPacility) o
Signature of ppgc
Date
DESANCTIS INS Fax: 7819335645 Jul 25 2006 9: 59 P. 01
OP ID L N DATE IMNDIYYYY)
AGORD_ CERTIFICATE OF LIABILITY INSURANCE 07 25/06
IROOUCEE ONILY ANDICONFERSINo RIGHTS UPON THE CERTIFIICATE IIUN
),Santis Insurance AgeY, Inc- HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
36 Cummings Pork
Roburn MA 01801 NAIL#
Plione: 781-935-8480 Fax:781-933-5645 INSURERS ;,cadj Insurance
INSURED
INSURER A: Acadia Insurance C any
INSURER W. G®Ierw ZndWtry Tne. Co.
INSURER C:
G.V.W. , Inc.
E1200 ast Bostongton NA 02128et INSURER D.
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED.NOTWTTHSTMIDJNG
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To WHICH THIS CERTIFICATE MAY BE ISSUEO OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN LS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. P umITS
LTR HSR TYPE OFINSURANCE POLICY NUMBER DATE MNlOD TE BMID EACH OCCURRENCE S 1 000,000
GENERAL LIABILITY a 250 600
A X 06/18 O6 06/18/07 PREMISES FP I>CaIIe+I>e
COMMERCIAL GENFJTAL LIABILITY OPADO9215913 / btED DO'(Mycrle pelsanj S10,000
CLAIMS MADE ®OCCUR ; ; PEpgONgLgAW IalU1TY S l DDC 000
GENERAL AGGREGATE s2,000,000
PRODUCTS-COMPIOP AGG s2,00b,000
GENL AGGREGA'm UNIT PER!
APPLIES PE !
POLICY X JECT LOC
AUTOMOBILE LWBILRY OE.secIdGl)INOLE LIMB S1,000,000
ANY AUTO
ALL OWNED'AUTOS BODILY INJURY S
A g• -SCHEDULED ALTTOSb1p,A009213813
06/18/06 06/18/07 (PF`F—)
BODILY INJURY S
X HIRED AUTO$ (PC scddeAU
X NOH•OwwL0 AU(09
PR
OPERTY MADE S
AUTO ONLY-EA ACCIDENT S
GARAGE LIABILITY EA ACC S
O7HERTNAN
ANY AUTO AUTG ONLY: qOG g
EACH OCCURRENCE S 10,000,000
EXOESsrUMRRELLA LMU31LTry $10
O6/18/06 06/18/07 AGGREGATE
A X OCCUR ❑cLAIMSMAOE CUA009216213 S
a
DEDUCTIBLE ' - S
RETENTION S X TORY LIMITS ER
WORKERS COMPENSATION AND p7C9686�93 07/18/06 07/18/07 EJ_EACII ACCIDENT S500.,000
EMPLOYERS`LIABILITY
-EAPLOYIE SSOO,ODD
B ANY PROPRIETORPARTNERI61ECUT'VE E.L DISEASEEM
OFFICERIMEMBER EXCLUDED? MA EL DISEASE-POLICY LIMIT SSOO.ODD
Nyyaae, Ie b�undw
SPECVAL PROVISIONS below
OTHER
NS
0ESC JPTION OF OPFRAYION9 ILOCATIONSIVEHICLEv�h#7u^ODE Exterior Overlie ED BY E dPRand Egress Doors,
PROJECT: Ssmatek-SYstems Toilet Roomsand related Plumbing,
Interior Partitions (non-load bearing) ,
HV-ELC, Electrical and Fire Protection
CANCELLATION
CERTIFICATE HOLDER 3O . DAYSS WRITTEN BETAT-1 SHOULD ANY OP THE ABOVE DPSCRBEEO PDLICIa4 BE CANOBLLE°BEFORE TRwRnTIEN
DATETHERBOF.THEMiANOBNSURERVALLENDBAVORTOT"L
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO Do SO SHALT
gematek-Systems Inc. IMPOSE NO OELM.AY10N OR LIABILm OF ANY IGNO UPON THE INSURER ITS AGENTS OR
16 Hathaway Ave. REP TIVBS.
Beverly HA 01915 A �PRESENrgTIVE
®ACORD CORPORATION 191
ACORD 25(2001103)
CONSTRUCTION CONTROL AFFIDAVIT
Project Number. Date: -(' 2k • D(e
Project Title: s`f 5-MM S , L�MT # -7
Project Location: `r(e
Name of Building �5P6ktA Grd M h!I �'fNa-K
Scope of Project: 42F-FPLV rlT U NSIT nr_- LAGW' [1RVJ8-74ArL-
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
W LA-A hrm fit• 6<15 MASS. REGISTRATION NO.33bCa BEING A REGISTERED
PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY
SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND
SPECIFICATIONS CONCERNING:
Civil Architectural �_ Structural Mechanical
Electrical Fire Protection Other(specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
1 FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS
APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING
AS SPECIFIED IN SECTION 116.2.2.
1. Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required control materials.
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix I.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PR T
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDIN I ECT �Mf?
OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS SATI PL Q
AND READINESS OF THE PROJECT FOR OCCUPANCY. TON.
Signature pay�A�T„or M�SS��rJ
SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF 4
My commission Expires:
Notary Public
WILLIAM A. YUHAS AIP3C�IIIIIIIII�C��
TRANSMITTAL
DATE: S 3 •O Ce
TO: J fie, CR7Re-mvaq 15
FROM: 5
RE: TE)c_ U 1.S�T # / I I(D !SUJ" ,j c,... I pa"
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