7 WILLIAMS ST - BUILDING INSPECTION (2) E
(..-amm-.or_w,:a�rh of I1izJJaCL12?�
. t3, -�� �e7c rLrr�nC7,�-Jr�iitria`1J7Cc:��r�
ati 600 g�U�qVeirzei�lar. �fraaC
Janes J.Canpcell 9�a n, //lmsccLsalls 02
Ccrr:ntssroner
Workers' Compensation insurance Affidavit
l, CheS�Fi �J? � (�ow51�,
(nQueuva*�)
with.a principal place of business at:
(e i�b Vy (`/l C�
ccrsrLsLwso>
do hereby certify under the pains and penalties of perjury, that:
(k�x I am an employer providing workers' compensation coverage for my employees working or
this lob.
WC2315321s1 3oc-7 -/ll�
Insurance Company Policy ?lumber
O 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 plumber
Contractor insurance Company/Policy plumber
Contractor Insurance Cnmpany/Policy plumber
O I am a homeowner performing all the work myself.
I vnderuand t'tat a easy cf thus=un c,t«ill b<forwarded m tb<Of(a:<of in.<s:itadons o f t1<DU for eov<rat<verification attd U*at Ln7.R<n seam
rovvai<u«auir<d under 5¢tian 25l.of ttG1 1 S2 can lead to o+<et>;ovsion of[Zimirlii a<na,ues eorsu5nt of a fm<of va m S I.S00-DO and/or
yeah' -rmnm<ne ..e11 civil ornalties in:1«loon of a STOP WORK ORDER ono a fine of s 1 DO.Oo a ay aLairat m<.
Signed this _day of I P. 7 Q e
Licensee/Ptimixtee Building Department
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375
LIIIT III Saij!ul.
�\'�*�i % �uniiL �ru�Lrig �znr�rrrm�;
- �''�� iSuii�inlz �L�rtzzlrni
-
�na=s=-s 75 iF :- 33n
DI5?05 L 07 D�-31-15 A=:IDAVIT
in accordance with The provisions oI MC-L L 40 • 554 , - aCkno::ledge that as a
pa all debris resulting from the
condition of Building ': pe m_L shall be disposed of --
construction activiry governed by this 3ui_din�
a properly licensed solid cast disposal facility, as deigned by ttGL c III ,
S 150A. ow ��I/7 -
w��
The debris vill be d!spOseO OI at : location oL iacl_1Ly
2 �o
derv_- Appl±canT Dare
Signature of -
?ugly complete the folio-ing inforaation:
. T (?lease print clearly)
C°10� 11P Vlo ik
Name of ,PEr=1L ,%P11I-cant
Firm Name. if any -
2. It' �1&I I)
Address . City d State
-=auir=< that debris irorl the demo_ltion. renovation. rena
The above statute -
or other alteration of building or structure be disposed of in a properly
licensed solid _asze disposal Izcility zs defined by t•.GL ClII . 51SOA and rha
building its
Or 11 Censes are LO indicate the lOCZL1Dn Di Lhe facility ZL
ACORD CERTIFICATE OF LIABILITY INSURANCE 07/23/2007'
07/23/zoo7
PFMVCLR (978)774-8040 FAX (978)774-3581 TH18 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Tarpey Insurance Group inc HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
491 Maple St (Rt 62)-Suite 304 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 183
Danvers, MA 01923-0393 INSURERS AFFORDING COVERAGE NAIC N
INSURED thet OWS 1 INSURERA: Penn- America
P.O. Box 41Z INSURERS: Safety Insurance Co 394S4
Danvers, MA 01923 INSUReRC: Liberty Mutual Ins.CO
INSURER D:
INSURER E.
COVERAGES '
'THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L R NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/ ,UG MM LIMITS
ff
GENERAL LIABILITY PAC6680296 07/01/2007 07/01/2008 EACH OCCURRENCE E 1,000 Goo
X COMMERCIAL GENERAL LIABILITY .PREMISES oxurenrc S SD 00
CLAIMS MADE FxJ OCCUR MED EXP(Any one pennon) $ 5,000
A PERSONAL SADVINJURY S 1,000,000
GENERAL AGGREGATE S 2,000,00
GENL AGGREGATE LIMIT APPLIES FOR: PRODUCTS,OOMF/OP AGG S 1,000,00
POLICY jEC'T LOC
AUTOMOBILE LIABILITY 1613082 01/29/2007 01/29/2008 COMBINED-SINGLE LIMIT S
ANY AUTO (Ea epddeni) 1,000,000
ALL OWNED AUTOS BODILY INJURY
(Per Pere.) E
X SCHEDULED AUTOS
B X HIRED AUTOS BODILY INJURY S
NON-OMEDAUTOS - (Per eobdem)
PROPERTY DAMAGE S
(Par emldanl)
GARAGE LIABLLITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC i
AUTO ONLY] AGG E
EXCESWUMBRELLA LIABILITY EACH OCCURRENCE t
OCCUR ❑CLAIMS MADE AGGREGATE E '
E
DEDUCTIBLE i
RETENTION
WORKERS COMPENSATION AND WC231S321513017-AR 06/10/2007 06/10/2008 1 TORYLIMITB I ER
EMPLOYEWUABRITY 100,000
C ANY PROPRIETORMARTNER/EXECUTNE E.l.EACH PCCUIENT 7
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE S 100,0
Mgo,oeetllbe Under E.L DISEASE-POLICY LIMITS 50Q 00
SPECIAL PROVISIONS bebw
R
RIPTION OFORATION&ILOCA I VEHICLE81 11(GL I BA[IDEO BY ORSEMENTI BPE IAL PROVISIONS
NERAL CONTRACTOR
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER RAM ED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON TKE INSURER,ITS AGENTS DR REPRESENTATIVES.
AUTHORED REPRESENTATIVE
James Tarpety, CIC V Pres
ACORD 26(2001108) FAX! (978)777-7397 CACORD CORPORATION 1988
TO 39d6 SN3ANfU SNI A3ddVi 1896VLLBLST S£:80 L00Z/£Z/L0
-�e eommowawq&X ���
Board of Building Regulations
= One Ashburton Place, 1 m 1301
Boston, Ma 02108-1618
License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 07/10/1953
Number: CS- 055465 Expires:07/10/2008 Restricted To: 1G
CHESTER J DEMBOWSKI
2 VALLEY RD
DANVERS, MA 01923
Tr.no: 26885
Keep top for receipt and change of address notification.
A 5OM-04/05-PC8698
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement.Contractor Registration
Registration: 100098
--= Type: DBA
Expiration: 6/9/2008
CHET'S CARPENTRY
Chester Dembowski
2 VALLEY ROAD
Danvers, MA 01923
Update Address and return card.Mark reason for change.
0 50M-0506-rC8490 Address Renewal Employment Lost Card
DATE: 0 O�
• Y
Citp ]of '"&attm' �RaE;E;arbU5Ptt5
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
//
Location of Building 7
Building Permit Application For: �
Circle whichever applies) Roof, Reroof, Install Sidra' Construct Deck, Shed, Pool
Addition, Alteratio epair/Rep ace, oundation Only, Wrecking
Other:
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:Owners Name:��/T�-\.s1�� ` \-\,J-60'N Contractor: L C� � 'Z,p,^�W6L
Street'lWt �\,&,\A '� City ' 7q\QYA Street'L\Jc'N", -1�1) Cityi�:nQQ, 7
State,L1Y F Phone (�7�)7 t{J- l�(o �� State M°t, Phone(Y1 )
Architect: City of Salem Lie#( [541
Street Cin State Lic# HIP# (bbol
State Phone ( ) Homeowners Exempt Form_yes_no
Structure: please circle) Single Farnily, Multi Family# Other 00 h
Estimated Cost of job $ 20, 000
Will building confirm to law?des no
Asbestos?_yes ✓no
Description of work to be done:
'Re �Icx,a t Ci C �\ T�I� ����Q� k lcqof �s A t
Drawia s Submitted:_yes no Mail Permit to:g l 'A S�
Signature of Application, SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
Permit fee$ /yr
col*fms:
No. d
APPLICATION FOR
' 'PPRmrr TO "pp
LOCATION
_ 71rel S/' '
PE MIT GRANTED
APPR VFzD
N• ECTOpi OF ILDINGS
CERTIFICATE OF OCCUPANCY
YES
NO � ' �