72 WASHINGTON ST - BUILDING INSPECTION (3) , m►sEt `T//3/� �
of �arEm, a5�at�ju�ei�
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Building PeraU Applkatoo For I.otatioa d BuUdfaf_� ��iii� e �J`
'(Circle whicbem applies) Roof,Remof, IrdmH S' Cwu t DecIC,Shed pod '
Addrtum, Altenu°o'�:epou/Reyla�F°undau°°OdY.� �
Otber. ��
PLEASE ELL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS W PROCESSING
To the litapeaor dBui)diop:
Tbo tadU4wd baeby applia for a permit to build mmdwS w tba Fo4owioj apocisatlaoa
Owned Namc e o.G/rg E,Q.t� 7--
City
S_�P Stat 1 . oa t Cf City Saf'
fie, '( l, Phone ( ) Sutej�= Phaoe
Ambiteot: City d Saba Lkrit � /S'�5, 7S'—
Street City State LiciYo 60
BIP M
Suu Phase ( ) Homommen Eaeapt Fora�roa no
Stnmum:(plem circle) Single Family. Multi Fataily
Eatiaated Cad of job S /9--�—O
Will bdwkg emam to 1gNq . L ; o0
Aabutoo?_ ya ✓oo
Duedpdoa of work o be dNr
Drawiap Subaitted:,._yea Mail Perch to. /
sipaatro o $ GNED UNDER THE PENALTY OF PERJURY
CONITR;ICTIO,y . o'"Cim�'LE r Eu i`reTriiN Sp); MONTIS OF PERMIT ISSUED DATE
Dep.rtmem tree ady i zoa(trg I�p/t oc
Pmmit fee
COmms: h I1
ilk
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CITY OF SALZMq MASSACHUSETTS
PUBUc PIIO►E1 w DerAnTMENT
' 120 wA HimaTON aTMM, 340 FLOON
811LSM.MA OI 970
TIM (87E)748-95M CV. 300
FAR (870) 7441-""
STANLaw A UnOv1c=. JSL
MAYOR
DLSPOSAL OF DEBRIS AFFWAV1?
To ammdaom with the peoviaiaoa dMOI,a 4%E I acimowledp that u a mad dos
of Bml ft P m '- -sd debris,mulling tsnm the omdn"m asmvity
pvamed by this,DwI ft Pem>it steal be dlgm d din a p mpmiy liea ma solid-wum
dLpad bi ty,u dedoed by MM c DL SISOA.
Tho debris,wiD be Rand d ae . _5��ti1 �✓�r,� ��
Loaden dF
sip Ire df Pam6d. Applicant Daa
FULLY ecmplaos,the following information:
M.EA/SE FRDff CL WILY)
/�///C� ��aGuhKo2✓Sf�/
Name of Ecaot
Fin Name,if aoy
�-lG-
Addmsm City dt Staa
The above,moue requires that debris fi m the damohom rawvaw% rehab or other
altaidoo ofbuilding or stt wun be d VwW in a pmpaiy-Deemed solid-wute disposal
fachly as,&&W by MGM c1M S 150A, and the bWWing permits at licomm me to
md"s the location of the fealty.
Deparhnent ojlndasWd Aeddenta
0,f 4os elkyeseem iss
600 Waslnatow Street
Boston,MA 02111
trwtnntoudoa�dfi
Workers'Compensation Insurance A®dn* Bnflders/Contradors/ElecMdsns/Plumben
AuDHcmd In=&tioa Please Print Legibly
Name
Address:
0*AtaWZi� Phone 0: 97X, 3 7S=2.2S`8
Are you an m f0mr?C3eek tkiEapproprlrte loco' Type of proleet�dred):
1.0 I am a employer with 4. (21 am a general contractor and I 6. 0
N
rconstlucuon
a y�bYaa(&nand/orpaMdm4* have hkedSo ac"n
2 I]�'I am a�b pwFi.-fir or partner liaoed on the attacked sheet i 7• ..
ship and have no employed Tie sub-cmdraaon have 8. ofmmolition
wodit far ma is a>4tenz►acuy.. 1' tas mct 9, q Building addition
(NO wbrken,may, 5. p we ere a borptirauomi allot ifs'
ofiicat l sye then 1&0 Electrical repair=or additions
3.0 I am a homwWaff.doing as weuk Twofes-emptKaPermaL 11.0 Plumbing repairs or addition
MWA Ric Wodretti COMIL a 152,41({ 8104iehaveiao 12.p RoofrepaM1
imaorasoarequaod:�t: �101 ,�r. 13.p other
•Any appollcaot t♦dt chats boat 01 nod also 6fl oA*notion below **w yp y
t Hondwms w7w athmil mYsvit a�d iadlattta msy as doing as wottaad dints ttjWoadA aroai�edotsiodaR sataodr a am sew"indicating each
tConamwe that ebeek d6boa me anaeked r addidonTdM sbowbq So mertifinedabmatncyoea odd"warbew comp policy bA ntddioa.
low qr sisploysrrAat h providbdg wart srs'eoaepauadon bdaruw�ot ja adP mpf6pefs Detorr b rJFtplle�auf Job a!b
IAja�sNaa
Iaseaance CompsayNanw. C%2 1JeezcO 7
Policy#or Sel in.Lie.A Expiration Date:
Job Site Address 22 Z✓GS�i ih���/ f CityiStgo0p:She -(
Attack a eopy of the workers'compensation policy deelaratiou page(stowing the policy number and expiration date)6
FaOaue to sccon eoverw as req'ed:mder Section 25A of MOL a 152 can lead to the imposition ofcr®al penalties of a
Pone up to S 1,500.00 and/or onc-yew iniprbOUM ,0 well IS civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a dry agaiast the violaft Be advised thst a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
As Ambyeardp underAe pa na be andpe ajPalnrp Am tits wwadon provikd oboes Isaw and ceffe"
Sisraatttre � Date �11316C
pbm*%_
OBleW use&* Do not wr&Ion Ah and,to be evxW&, 4b)ebro►baw O&W
City or Towns Permit�i lees'!N
Inning Authority(circle one):
1.Board of Health 2.Building Department 3.Cky/rown Clerk 4.Eleetriesi Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone 0:
Information •and Instructions
Geaaal Laws chapter 152 requua an emPloOiM V P?'* n fa their off
" in me savtcs , amotha saner a"
Pursuant m this stamta, an is defined ar ...every perms .
amprasa of implied.onl of written."
assodmi^oapwation dr otha legal entity,at any two or mole
An aNploym is defined as"am indf
gy vidna�,parmaship, a decated etapbyW Offt
of ftthe foregta mL p&is a joW en1p ; ise,sad mclvdiai the legal M amtatna loY� � ,a
of receiver of ttmtea of an individual,partaashp,aaowanan or other legal entity,employing cop �,
owner of a dwcft louse bsviat not metre than thra apaamemta and who mina f Tcp* Of dwe�hoard
dwelling house of tmotha who employs P�D°s to do maintenance,construction or��b be ffi ampbyet"
or on aloe roue&orbtdldrag sb�not beams of such empbymnent
he boa
MGL chapter 1524125CM ahto shad that"every state or local&eadag ages""w whhYoW t 8 as
or P to operate a buslsera or is cOmOmd
resuwai d a neease am bdldlap V the eommoawahh forr an7
ere wMesea d compllae mce with the la maw toverags required'"
pI wd o who has wC Parodaeed MQ.ch*tw 152,12XM states"Neither the c000monwedhh no day ofifa political mbdivisiams ahan
Additionally, contract Sur the perfom�e of pubffc w0A until ameptabia evidence of compliance wi&the i ammuca
eater mtD any to the coatatxmL.au*w*� "
fcquIIemeats of this cbaPx+Lave ban pramted -
APPlkaate
at8dsvit completely,by chedba dw boxes that apply 0 Your atmad and'ai
ply f'2, the worker'compeassdom s wife their catiBcata(a)of
necessary,supply sub- a O)name(:),addrera(a)utO P a a100g with no employes otba than the
memffiee; Limited Liability Compaain(lLp or Limited Liability Pa<metab�aLP)
members or partaaf,are not required to airy workers'coatpensation msuraum If ffi LLC or 112 doer have
Be advised that this at67.1vb my be submitted to the Department of lndostrial
emph lem a Po�Y is�u ud date the afHdavft- The of fl a should
Accidents for confirmation of ice covaage. Afro b0 fare alga of
be reotrnad to the city or fawn that�e application for the pemtit or license is being requested,ad to Departm�
be reur mud,to die city
ls, have any"nation regardhtg the law or if You are Acquit d to obtain a workers'
comP=Ud m Pala Pk can the Department at the number below Self-iasmred oompffiia sbaald inter their
ulf-insurance lieeaae ember on the to hm►a
city or Town OfIIdals
see that fed afbdavit u Mete and printed le&ly. The Department has Provided a space at the bottom
Piesse;be of the affidavit for you to®out in the event tie Office of Investigations has to contact you repadiag the applicffit
Please be sire to fell in the pamrt/liceme number wbich will be used as a reference number. In addition,an 2PPlic8d
that most submit multiple ParoW ifenae OPPhcationa m any given year,need only submit one affidavit indicating current
policy mEorrnanon(if necessary)and tuda"Jab Site Address"the applicant should write"an locations is (citY of
}}"A eaPY of the af9davit mat has bu city atotl<crosib samtp oimadwd by die ar town may be provided to the
avP> s proof that a valid affidavit is on file for fhwe permits or heases. A new dflidavit rundbe fined out each
year.Where a home owner or dtirtea is obtaining a lioeme or P�not relate,to amy businw or ommvacisl veamre
(i&a dog license or permit to bun lava etc.)said person is NOT required to complete this of ldsvK
The Office of tnvestigatiom would Me to thank you in advance for your cooperation and should you have any questions,
picric do not hesitate/D give m a a1L
he Department's address,telephone and fa:mamba:
The Commonwealth of Massachusetts
Department of Industrial Awideuts
Office of Invesdgedonm
600 Washington Street
Boston,MA 02111
TeL#617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
MR. SHAW INSURANCE Fax:9787458584 Rpr 13 2006 9::L2 P. 01
ACORD. CERTIFICATE OF LIABILITY INSURANC�YOPID DATE(MM(Db/YY)
YMI1 04/1.3/06
FRODUCER a - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
z , M.R. Shaw Insurance Agency 'Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND 014
P.O. Box 4428 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Salem MA 01970 —
Phone,. 978-744-4540 Faxt978-745-8584 INSURERS AFFORDING COVERAGE
INSURED INSURER AI One :Beacon Insurance Cam anYINSURER BMichael -PKdynkowski IN5URBRQ9 Brooks metre t INSURER OSalem MA 0197�
.� INSURER E:
COVICRAGES ----
THE ROLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING
ANY REQUIREMENT.TERM OR CONDInON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS A14D CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE POLICY NUMBER DATE MM/00 DgTE MMlDpm LIMITS
GENERAL LARUM EACH OCCURRENCE S.3D0000
A R COMMERCIALGER&RALLIABILOY FBlU07012 06/15/05 06/15/06 FIRE DAMAGE(A yo�efire) $ 300000
CLAIMS MADE EK OCCUR MED EXP(Any apc paraonl $ 5000 _
- PERSONAL&ADV INJURY. ts300000
GENERAL AGGREGATE I S 600000
GEN'L AGGREGATELIMITAPPLIESPER:I PRODUCTS•CUMPlOP AGG S 600000
POLICY JECT LOC _--
AUTOMOBILELIABILITY
COMBINED SINGLE LIMIT
A ANY AUTO CBIE53849 06/16/05 96/16/06 (Eaa«idaop $
ALL OWNED AUTOS BODI ---
SCHEDULED AUTOS (Pwpa pp.) $ 50000
HIRED AUTO$NOW-OWNED AUTOS BODILY INJURY $100000
(Per acclumt)
PROPERTY DAMAGE $ 100000
(Per accidenl)
ly
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 5
ANY AUTO FA ACC $
OTHER THAN
AUTO ONLY: AGG S
EXCESS LIABILITY EACH OCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE $
OEpU4TIBLE_
REt ErvnON S
WORKER$COMPENSATION AND EMPLOYERS' M'LR I TORY LIMITS BR
E.L.EACH ACCIDENT S
E.L.DISEASE-EA EMPLOYEE S
OTHER
El DISEASE POLICY LIMIT $
A Commercial Applica FBlU07012 06/15/05 06/15/06
A property Section FBlU07012 06/15/05 06/15/06
OrMC YRI'I JVN OF OPERATIQNSILOCAnONSNBHICLESIEI(CLUSIONS AID.BY ENDOR$Eh7EnnSPECUIL PROVWIOHg
CERTIFICATE HOLDER IN I ADDITIONAL INSURED;INSURER LETTER: CANCELLATION
1111111 BHOULD ANY OF THE ABOVE DESCRIBEO POLICIES BE CAN09LLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVORTO MAIL bAYSWRITTEN
NOTICE TO�THE C[[E��RITIIFIIJC��A�T/EI�HOL�OERR NAMED�TTO THE
'L�//EFF�T�.//BUT FAILURE TO DO SO SHALL
IMPOE$�LISHA 1pAINp Rh`AEN�UKfAUIT�IEVNEN B1 VS AGENTS OR
REPRESENTATIVES,
AUTHgfIR$O REP E
M.R. Shay �iTJIV
AGORD 25S(7/87) OACORD CORPORATION 198P
MR. SHAW INSURANCE Fax:9787458584 Apr 13 2006 9:12 R.02
IMPORTANT
lithe certificate holder Is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed.A Statement
on this certificate does not confer rights to the certlflcate holder in Ileu of such endorsement(s).
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,cenaln policies may
require an endorsement.A statement on this Certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
I
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does it
affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon.
I
- ACORD 25S(7f97)