31 WILLIAMS ST - BUILDING INSPECTION (3) �+���EwlrwNB �ovEo sY ;�
CITY OF SALEM
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PUIM ILL.OLfr LROWLY ik OOMPUEMY TO AVOW DBLAYS N PIIOClB1M1
TO THE INSPECTOR OF N AMNM
Mot hereby @pow for a pmk to balid a000rditto tha.onlowl
Owners NMG M I/I N _r
Address A Phorr 7 PH h o K,�4 cI a 31 Zs"�— ,p 7,7K,
Address A Phom ( 1
Maohania Nana L
Aditn A Pharr %L? &e (rot, 173 Z- 17; 3 l
1Mrr 1a ar ragioaa a10u�gr1 �n_fi'I G��ll'1!G 1
MIN Nl of k~ N a dam g for how aapy
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Elalllbd OOM c��clv LIo 0" Lb11M•
a/e?D yS SW&Wo of Applford
st1ENEf111goN1 TW PBNALTY'
OP PMRRNW
DESCMI Nm OF WO1M(TO BE DONE
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120 YAWHIMrM SrrraRT aRO FLOOR
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TaL(070)749-MM Err.300
FAX (Y741)7404MS
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. DISPOSAL OF DEBRIS AFFIDAVIT
Ia s000rdaooe wine dre provisims adltdCii,a 334r I aelmawledp that as a 000didoa
atBaiWioB Permit fi .A debris rmokb*ftm the omgmcdon and ft
!mimed by dda Baift Permit shalt be dbpomd of in a p gwfy ltoemed
duyosel hcWly,as defined by MM c 13L SIX&
The Male w M be disposed of st p
Locadm ofFwft 0l S
afP
FULLY complete the jbUwhrS bhmadomL
(BLRASS PRIM CLEARLY)
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Name offtink AppliOW 7-
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Addtee16 City A Shoe G
The above ahmte mpam drat debris Am the demchdoq n mvadm rdub or odrs
alteration of bm"l ft or Muceae be disposed in a popedy-Hcwu d solidAvasis ditpoaal
Sabty adefined by M(H,al>; SISOA.and thebru7dioS permi0r or Homes are to
iadieah 66 bcsdon of dm f m1ry.
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boo w.di.,�...Sw
�1 Ca mew 8-den. Xuaalaeda 021/1
Workers' Compenaam irmmana Affldawk
- • wkba peilldpl of badnsfs:a
do herebr'cerdy under palm and penildes of pw*y, dm
Imam
—' -- > s Workers' cos+ wmdm towage ter mY eiaple�eer wmkbo m .
• /'; as '. (� C S� .S�
insurance cemplgr Few irameber
I an a aois proprlem and have no ens wmkimp fir me in MW tapadW.
() I an a cols proprieser, general camm=er or homeowner (drde one) and haws liked do
contrae+on lined below who-have the fopowiag workers' eolnpenandow POW=
Coneraceor Inwranea Cotnpsq/*
Coalaactor Insurance Compaq/Fe N
Comuaew larwanee Can%pany/Folky Number
() I am a homeowner performing all the work myself.
• .w..nuM.ar a pe/.f M6.neeaa.n a. ler..r.a a rr Ofic.A M.ettn w.!ee M M: ce"Waae.waan.a.sae ea tioa aeero
".-rap a moved~I.dea ZIA.f WA 1 I r can kN ed ow•saa.ebe of ariel.s.Wass".roefwe.f a am des 041.fMM abler am
+ran•ieerw.seaw a%0 a dd moadw in *# ian of a STOP WORK ORDER a.e a Saw of 1100Ae a an apkK aa.
Signed th day of 200
.icersceiFermittee -U1,41anf Department
Jtensin; Ecarie
Selettmens Office
wealth Depanmer,
7 - -.ccCC ` 4 : = 904 e05• ape• 77e
ACdA - CERTIFICATE OF LIABILITY INSUF*ANCI�� ?s DA,(7nODM
�Q THIS RT1P T -1H BLED AS A MATTER FIN . RMAT)PN
RICO Agency, Inc. OMLYgNp GT91VF1H:N0 RIGHTS UPON THE CERTIFICATE P.O. Boat 220493 HAI C1Ett THNI ICERTIFICATE DOES NOT AMEND,EXT$ND OR
21 Grace Aveuup . Suite 304 ALTE TFIErOVEl3tSyEAFFORDEjDBYTHEPCLICIIS�'ELOW.
Great black XT 12022-06P3
VhOne:516-466-60D7 Fazz518P09.5857 MUMS AFFOFLDINGCOVERAGE
.INSURED
PIBUT�Ra AtIeViEIRD Nome Assurance Co.
INeu�ItDl
W _�13 $srum Hiding cbxp. IN6URERD:
1 INSIIRGRD:
OPVERAPE9 NSURERE:
THE POLICES QPV/bURBNOGLItiEQ BELOW HAVE tEEN R76UG,0T0 THE MSUP,Ep NAMED AHOUE FQR THE POLIOY PERIOD IHOICATED.NpTWITHBTANPMG ANY REQUIRBMEN,TERM OR CPNDIFlPN OF ANY OONPRAOT OR OTHER OOCIDAWIAITH RESPEGTTO WHICH THISCERTIPIOATE MAY BE MWEP.OR
MAY PERTAIN,THE INSVRANCSAFPOTSDED BYTHC FONCIEB DWRIBEO HEREIN I$WWEOTTO ALL THE TERMS,WMURION3 AND CONDITIONS OF OUCH
POLICIES.AGGREOATEUMrM @MOWN MAY HAVERESN RECUOFA DY PAID CLAIMS,
TYpp pP RituPI1NOE FIVOY NUMRSR
LIMO9i
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PRNERAI,I.M9RIrr EACH OCCURRCNCE 5
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PERSONAL!AWIWURY i
GEML AW CSNFRALAGOREQATE i
RETAATC LWII'TAPPUES PER PPCoucir . .
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POLICY LQC -
AUTOMOBILB UABRJrY -
ANYAITO (Eseenq INGLELBAIr ;
ALLOWNEDAVIOS -
SCMEOULOPAUTDB BODILY SLIURY t
(Ov ..V)
HIRED AUTOS
NOW)WNEDAUTDS BODILY ELIURY t
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GARgDE LIABILITY
AUTO ONLY-EAACOIDENT 5
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OTHER THAN EA ACC ;..
AUTO ONLY: AGG0mba 5
'� EACH OCCI1PRe4CE ;
OCCUR �CUIMS MAPS AGGREGATE....
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RETENTION ; S
WORMERS COMPENSATION AND . . ER -
A eMPLOYERs'LIAWLRY ply
WC7755151 09/24/Dk 09/24/06 E1.EACHACCIDENT ii00000
ELOEIEASE-EA EMPL 51DDDDD
OTHER ELDI96ASE•POUCYLIMB b 'OOOUO
BEBPRIPTIPN QP OMM--RON9S. ADDED BY RIDORSWWRIPCCIAL PROYIt10N9
MRTTFICATSHOLE N ADorrNINALNZiBoiMWP Lerm OANCgLLATION
SHOULD ANY OPTNE ABOVE OESCRTSBD POuCIES BE omcis.,DO BEFORE THE WIRATION
DATETHBREOF THE ISSUINQ INEURER WILL ENDEAVORTO MAIL +3.0 DAYS WRrMN
NOTICETO THE CEIRIRQATE HOLDER NAMED TO THE LRWr,BUT PAILURETO DO$O SHALL
IMPOSC NOOBLfGAT10N QR UARILTrY OPANYW=UPON YHE fNSUREi1 Try AOENTL OR
REPP WTATIVES.
AUTHORTCRE REPREBENTATIVS
CORD 25-5(7/M - ®AC RD CORPORATION logo
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"Equal Sight Line"
Vinyl Double Hung
Nafiorl�l'Eenestrahon ARGON FILL IOW E
Raft CDuncll
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Energy sayings wM depend on Your spedf0:dlmate,hum and lifestyle
For more Wannation,oa01-WO.782-6347 Dr visit NFRVS wab site.at
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.� Board of Bw'Iding Regulations and Standards .
HOMEIMPROVEMENT.CONTRACTOR '
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