73 TREMONT - BUILDING INSPECTION IN MrsiMNTISE flL 19 AND APPROVED BY 774E
ASPJECILIB PWR TD A PERMIT WMG GRAND
CITY OF_SALEM
V� \ Dab zq O N
j,
Ward
Zonkq DMIct
Is Pr0Psrty Located in Location of f/
to HW tic District! Yea No C�_ >loi7dina _13
Is PMWty I In /
the Caaervatlon Ana? Yee No ✓
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other k*At)6v t3A- R RODW17
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: 1.
The undersigned hereby applies for a permit to build accor&ag,to the following
specifications:
Owner's Name E t��E<J 1, V i C Tm-S-� /
3-7 Address & Phone -43 T1REVY),61JT ST. fq N20 M?-
\a Architect's Name PIA
Address & Phone NIA A
aMechanics Name &a E GOfuu-1 Co Rgt✓lL'
Address & Phone 5ikE�0611—VAST r- L&EC. CSSExc �8rS'� 5
wha tome Ptepoae or bwtdNg? 2t;Sl0 Eac.c�
M WW of httlldYtp? WC61D B a dweb ,for how many tamaea? Z
Wa bAdkV cantonn to taw? V65 AWeetoe? N O
F.alimaw coat , 65o GN ucaw e IKSLI a to uo.w.e
same 1"Mm meat
Lie. 1 124 Z&A
Signature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: EU�I:a is t CTcJQ N 13 T12 C mo�'C �T• s 0 W01,-6
NOM y�
APPLICATION FOR
PEFWr TO
LOCATION
�^ b
PERM
F�GRANTED
AP OV�D
G
INSPECTOR F BUILDINGS
`V
w
J
_� - �ONt/ItO/LN/s� Of�G1dGCAM8i�0
1Jepaslwa.f�����
too UI..�1a..S1N.i •
.on..l ca..e. L 6&n. X....A.& 02111
c«w.me.
Workers' Compensation insurance ABidsyig
1, C�R-� Fs[s(�-t �o cZ p,E tip-• '
. . wigh-a pr6climl plasm of business ac
5 A P AI�T Lk RE L I}" G55 (FX ; AA t g 2cl
do hervby'cerdly under t)w paints and psmiMes of pwjerly timta
O 1 am am employer Providing workerso compensation covep fe for my eia� working M
tab pk
Insurance Compaq Follow Nutnbw
I am a sole proprietor and haw so one working fir an In any capedq.
() 1 am a sole proprietor, general corrtraesor or homeowner (drde ones) and bee" aired tam
contractors listed below who•lune the following workers' compeomishi s po8elM
Comracwr Inwranu Cempanry/Po Number
Contractor Insurance ComParry/Po Number
Conuactor Insurance Company/Rft Number
0 1 am a homeowner performing all the work myself.
•1 rweeeasee Ou s uer Of 06 su MON.s be lorwsr.tl m ON Ocoee 61 Meedenae of ON MA kr eo.wate nrWW"aft OR tteiw m snare
eonersrr a peewee~Swift SSA e/MGL 152 oat kN WOW Wmandee of aurae seam"tensed" .f a tea of n 04150 s.Uor w
rrsq'i..roel.wn.a,p y d.n vamid&in tlu ben e!s STOP WORK ORDER awes he of S 100A0a an apba=L
sinned this . Za day of Ju L ?,c3v
.iCersetiFermittee u114tn Department
Censinf Eaard
eiectmens Office
;eatth Gepar:mer:
-.:_ : -.scCC ye : _ 904 e(+c ape Tit
PUSUC: PROPERTY DEPARTMENT
120 WASHINGTON S711M. $NO FLOOR .
SAL ZM,MA 01 Y70
TEL (979)745-MOB EXT.ado
wUsOvIC
FAX (Y7S) 740.96"
STANZ, JR.,
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT 1
In wcordaaee with the provisions of M(i3,c 40,SK I aclmowiedge that as a condition
of Bm'ldigg Permit 0 .aD debris resulting from the oollst(ncbm actly*
governed by this Btrildiag Permit shall be disposed of in a properly licensed solidrwaste
disposal facility,as deBoed by MGL c HL S150A,
The debdo wM be di posed of ere 5 A LW X fOz- sTftl-iN
Locafm ofFacility
SiVIS M of Permit ANbca t
FULLY co=4)left the foflownig(PLBASB Pitm C ARLY) mso on
G-K, 0Pf (v e-gCl(,
Name of Pemnk Ap HcW
GEa �YN�thn t�s
Film Name,if ary
_5►� aK PAs c�2C �flNt✓ , C5S6?c MA • 0 ca ZQ
Addlesh City dt State
The above
statute reXryires that debris from the demrolidon,renovation,rrhab or other
aReradon of building or sh mun be disposed in a propaly-licensed solid-waste disposal
facility as defined by MM cID, S130A, and the building permits or licenses are to
iudicaLe the location of the facility.
AGAR—D. CERTIFICATE OF LIABILITY INSURANCE //a23 oAGAR—D.
PRODL% EP (9"8) 927-9420 THIS CERT1RCKM 6 ISSUED AS A 911TTFR OF ORFORNIITION
ONLY AND CONFERS NO R16fIT8 UPON THE CERTIFICATE
LaTuanaeno Insurance Agency HOLDER. THIS CERTIFICATE DOE$ NOT AMEND E%TEND OR
107 Dodge Street ALTER THE ERAOE AFFOROEO BY 11
Haven MA 01915- INSURERS AFFORDING COVERAGE NAICB
A41MEC INSPIMlA:'17Le PraWidenCe 14TI
C$O Dynammas 0;4ra"Is"
5A 181 PastuATr Lt cz
Essex Nh 01929- e
THE POUCM OF INSURANCE LMO BIM HAVE BEEN 18SI TO THE INBURN)NAMEG ABOVE FOR THE POLICY PERIOD INDICATED.NOTTATHSTANDING ANY
RSAUREuEM.TERM OR COIVONION OF ANY CONTRACT OR OTHER OOCWW VATH RESPECT TO WHICH THIS CERNFICGATE MAY BE ISSUED OR MAY PERTAIN. ^•
THE 04SURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERUS. EI(dAAStONS AND CLN OITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN WWAY HAVE BEENREOIA'ED BY PAID GLA ING.
am TYROF ! POLCYtlUUMI LIMITS
A x D0I41IAL LLMI / / / / s 1,000,000
x LuOAm �_, s
cLANn otan SMS305771 07/28/2003 07/29/2005 IMpm amen s 10,000
f 1,000,000
! ! ! ! 001 IAOAN TA $ 2,000,000
OENI AGBAECATELMIT AP/LES/Bt •COHTWP f 2,000,000
AHfOYDNLEIMHI.M / ! / / COfeN�aM1R,EUMT f
ANY AUTO IA ARaNIE
ALOIMEOAUTOB
BGFOULEDAMOS WA�PNToA
UnW AUTM / / / / HOpf.T INAM
L
HDNaYaauAumE
PROPERTY DAMAGE f
NAw AWI114
Q^uas LIAOIITY AIJTD V.FAACGIpOVT f
ANYANTO / / / ! or,"THAN EAW f
AUTO WAr: AIM 1
0=0 ❑CLAPI$MADE AGOREGATIF S
s
RETENTION 4
H COMMINUTION AND 730vwT03 06/12/2084 06/22/2005
ANY PROPRIETOPPARTNEREI ELEACNAoOEoEHT 1 100,000
w=WMEMIRRIECLUDE°I 500,00o
Tytl,NNONe.naer
6{ cYLIYIT s 100,000
A oTTEA PrOParty SM35285771 07/29/2003 07/26/2005 50000
-A.
CKH"FrA
OEK R►'IION OF OEMtATIOnfA.OGTf DI�ICL�LIN�I AOQO IY pAL F�YOdtl
1
TE HOLDER CANCELLATION
"0" ANY OF TIES MOVE 013 MM FOX= BE CAICELLiO DIPORE THE
CMAATDI I THEREOF ne IIf>WM AEUREH WAL ENOVAVOR TO OAR
Eugene Victory 20 oAYi uRlnEs nee TD na CENnNCATE WLDER/Meo TO THE Leff,OUT
73 Tremont Street FAAEET000SO No CIU7ATIoN O um at: N ANY HP woo THE
Salem,MA 01970 O° ro
WyORD 29(200N08) CAC CORPORATION JUS
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