25 WASHINGTON ST - BUILDING INSPECTIONr
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DATE': /i6
Cttp of 6aZ m fju'#sett
1
' PLtiANS'i4UST BE FELLED NDED A APPROVED BY THE
INS1�E'CT
( R`'PRTOR 1'O A PLRM°IT BliTlG'GRANTED
BuildiaS�NpappiYikppltartiop,.Boi; Locatioo'ofBuitdiu`x5 Scd Al
(Circle whi'ioiiavar aiopilet) Rdtlfl;Aifroof, Irtstgll Sidin)i; ohahtiet'1It; $ ;Poo!
Addition,' 4ltcratiors Repsie/ltepia' Fo
Other s `mWation ` , wrec1titiS
PI 9011 FILL OUT L1fGWLYA COOfft"ETELY TO AVl9idVViLAYS II�'�ROCESSING
n ;
otHifti►dingt{; ..
T)ie t l� °batdtiy spp m fora Permit to build accordin"gltotit fo!!owiag apodflce'Qbns;
ONuery NFAA�e;.� Y , y� Cootraetorrr
str c.��(.S/:[-✓�y Strat" ldt2idG City S'a1,l
State Phone (979') State M�1 Phone(97r) 7�vQ— 05V3
Arei:itect: 4ll City of Salem"Licl( O)v Ill /y¢/ ,QiddiLGc+
Street .City State°Lid1 '
State Phone ( ) HomeoWoers Eiempt Foett%_yes
Stew-take: (g:lease dreiej itt 6e Family, !fluid Piudlyi Other
Eatiaoated Cort of Jobls,,;ISO..�nr
pY rtm t0,U1irl=yes no v
Asbaltjoeiyes. ✓ no
Qeaeriptioo of woriado"� `dome: ,.7h;w �✓6 AA,,O1 j AL,'r,A,,Ie A
1�/)Fr.O. Dili f�lald �',�zhS6ir/ (v��,ctl �B.r4u�/ �l,€c•f�P.cyy�! .�L. .
.Sv/��r,�' �/✓ S�iPJG'1S//�ALT �I i✓�F.,D� � ,/r -�- 4fcr/ _'.
Drtiwin Submitted: no!/ W,,' oeo_c S .urn
MaiiPertaitto:
j(v_&BLv2 g1,l Amv CAI - hA
SiSua' tro`of" "p'rlia ' oa l D ER Th P)IVALTY OFPAIt:IURY
LB1�D 14I 1T!sb( iV 41ii7t$S OF PII MIT 11'11ATE
Depwment use pdy, iAe �'� .
,• �TA�B t!iNapiLot
Pecniit°fee's
M�!
rJ 1 1 {
y ow of f11PII1, II55c`ZL�ilI5P fi
public Vrngrriq i9rgarimrni
$uilbina i9parimrni
c4er esirm barn
508-743.9595 tea. 380
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, 554 , I acknowledge that as a
condition of Building Permit !% all debris resulting from the
construction activity governed by this Building Permit shall be disposed of in
a properly licensed solid waste disposal facility, as defined by MGL c III,
S 150A.
The debris will be disposed of at:
location of facility
9/,6/y
� I Signature of Permit Applicant Date
Fully complete the following information:
(Please printclearly)
XW�-
Nam6 of Permit Applicant
Firm Name, if any
Address, City 6 State
The above statute re?uires that debris from the demolition. renovation, rehab
or other alteration of building or structure be disposed of in a properly
licensed solid waste disposal facility as defined by r.GL cIII . S150A and that
building permits or licenses are to indicate the location of the facility at
( ( ommoncur:alm o/ r4aejacLietb
..Ueparfinenlo��,}ndiufria[C.�Ycciaenfs
c '�F 600 qqWd ljk ytan
rl J'treet
James J.Campoell oelon, yY/aaaac�a elle 0211 1
Commissioner
Workers' Compensation insurance Affidavit
1,
(uaedee,sKemin«)
with a principal place of business at:
(Ory/Suca/Lp)
do hereby certify under the pains and penalties of perjury, that:
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
() 1 am a sole proprietor and have no one working for me in any capacity.
I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() ham a homeowner performing all the work myself.
I understand that a copy of this statement will be forwarded to the Office of Investigations of the DIA for coverage verification and that failure to secure
coverage as reduired under Section 25A of MGL 152 can lead to the imoosnion of criminal penalties corsuung of a fine of up to S I.S00.00 and/or one
Years'imoruonment as well as civil penalties in the form of a STOP WORK ORDER and.a fine of S I00.00 a day against me.
Signed this day of 19
Licensee/Permittee Building Department
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 37S
ommonwea / )4 /
Qa � (... lEl� o� Yf'/aeJachusetb
e:JeparfinertLq�o1��`n
dW nLria[_/icciaerdJ
'l 600 VVaJ4in9LOr: SLreeL
J2 James J.ComOoell odton, MajdarLieffe 02 f l L
Commissioner
Workers' Compensation Insurance ficlavit
with.a principal place of business at:
le e r�h 2 � 54
(Usyrsare/Lp)
do hereby certify under the pains and penalties of perjury, that:
O 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
() I am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contraaor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I understand that a coot'of this statement will be forwarded to the Office of Investigations of the DIA for coverage verification and that failure to secure
coverage as reouired under Section 25A of MGL 152 an lead to the imposition of criminal oenames corsuting of a fine of uD to S 1,500.00 and/or one
Years' impruonment as well as civil oenalties in the form of a STOP WORK ORDER and a fine of S 100.00 a ay against me.
Signed this day of 19
Licensee/Pennittee Building Department
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727.4900 X403, 404, 405, 409, 375
07/26!2004 11:01 9797457386 ROSE INS AGEhiCY PAGE 03
DATA(Nar
ACORfl CERTIFICATE OF LIABILITY INSURANCE 07/20'�1,
7 ao aooa
PAODVOER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Roce Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIMATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND'OR
66 Loring AS Dnue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 556
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIL4
Q 4u*eb INsLRERA,NOV"= C DEDH M
13vy5a Nome Impro"ment INSURER&AIG
68 Loring Avenue INSURER C;Q01II Mutnal
N6VRE R O
Saleun MA 01970- INSURER
COVERAGES
THE POLICIES OF INSURANCE LINED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTVHTHSTANDINO ANY
REOUIREMENT.TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDEC BY THE POLICIES DESCRIBED HEREIN IS SLI"CT TO ALL THE. TERMS, EXOLUSIOINS ANC CONOMONS OF SUCH POLICIES,
AGGREGATE UMITS SMOWN MAY MAVE BEEN REDUCED BY PAID CLAIMS.
I TR IAOD'l FOLN:Y WOOrrY) FVATE WIGO ON
LTR NOR TYIl Or IN6URANCE FOLa'F NUMRBR DATE D DATE ARMS
A i ORACRA,LURILIW / / / / EACH OCCI;RRENCE s 11000,000
I UAPAAAS!I J REN EO
j X COMMERCIALOENERA LI,IAB'•tITV WtEbAiS Ea maurrenea E 50,000
O ,YS MADE I X;OCCURS R0310059 I D6/27/2004 06/27/2005 E)min„ a,F „a, $ 5,000
RERSONAL A ACV INJURY 1 1,000,000
OENEPAL A00REDATE E 2,000,000'
OENL A•70REOATE llNIT API'L`E3 PER'. t PRODJCT6.COMRIOP AGO E 2','000,OCO
I ,POLICY -CT LOC / / / /
c C ' IA SmlE CIAOLm " I A.FVC157e66 04/30/2004104/3C/2005 CONSWED SINGLE UMT IE 11000,000
Ir ANY AUTO I IEe A,zMIm')
ALL OVVNEO ALTOS I ! / ! ! �W014YJNJURY
X 9C;iCWLEO AUTOS
her RslOOII) S
X HIRSO AUTOS
BOOILYINJURY E
X N_WOV^WD AUTOS I (re:�Orm
PROPERTY DAMAGE S
I �� i (Per Ntsl'IBR11
i
OARA06LWLLm AUTO ONLY-EA ACCIDENT E
ANY ALTO / / ! /
OTHER THAN Ef ACC E
AUTOONLY: AGO S
EACL^3EIUMRRRLSA LN816M ! / / /
EACH OCCURRENCE S
{ OCCUR CLAIMSRAACE A00R° ATE S
OEDU•CitELE
RE INNCN E S
a WORKERS COMFENSATRIM AND IWC00768642701 ' 04/11!2004 04/11/2005 X TbR UMR9 E
6RFLOYNTS"LURILm
ANY PROPRIE. ORNA'YINe-JEl_CUTI'JE - E'_.EACH ACCICENT f .100,000
F;tCGtM1EAlEEP.mtUDEV'!
IRyeR,tles•.rim rtler ! / / ! E.L.CYa'E0.SF.EA EMPLOY 100,000
S7MIAL PROVISION$bH 1 oTNER .OISEASE.POLICY UMIT T 500,000
/ / � / / -
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pESDRwTKIN Or OrERATION&lOCAT10MSNEl11gE8'E[CLVSIONe ADM RY ENDORBMNTIZPEOUL pRoymfmm
Cdcpvlery
CERTIFICATE HOLDER CANCELLATION
SHOULD ANT OF THE ABOVE ORSORam P"as sE cANOEU.iD SWORE THR
FXrIMTWN DATE M&REDr, THE R MR, WWRER WILL ENDEAVOR EO MALL
030 DAYS WRRTER NOTICE ro MR CIRTFICATE MOLDER NAMED TD THE LEFT,BUT
Noysa FARSRE TO 00 AO AHAAL R =NO OSLIDAPDN OR LURLLITY OF ANY RWD U►OS THE
mSURER.RTSAOENTR 011 REnlESA71TATNEB.
AUTMO NTATIVE T ,
ACORD 25(2001108)
C ACORD CORPORATION 798E