15 WILLOW AVE - BUILDING INSPECTION (3) No. ., \. Date
�fcrnrneW� }
e
Is Property Located in Location of
the Historic District? Yes Na Building
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof,(ZO—i—,ob Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
t The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name A6WLe,1 &I alT�
A,2
Address & Phone /S J,tII&441 -rv— OWL) 36//• 80'✓O
Architect's Name
Address & Phone
Mechanics Name /UUYSs1 l'�ntfrufeN 1 arm. /yt�
Address & Phone �� L ui2.Ybk Rl�e j9 ) 7yp .OSSL�
What is the purpose of building? rz6ov�
Material of building?f}$ Q,�/�y� It a dwelling,for how many families?
Will building conform to law? VtC�S Asbestos? �—
Estimated cost 9 K City License# N/"- State License#
Home Improvement
Lic. i
Sig afore of Applicant
SI NED UNDER TH PENALTY
DESCRIPTION OF WORK TO BE DONE OF PERJURY
Z/ i .t GJ,—�
�GCIJ�✓rit' J �o ����
MAIL PERMIT TO: WeYCA & OOYy14G✓I
oxnT a =' OF SALEM!
.,� PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON S7REE7, 3RO FLOOR
SALEM,MA 01970
j.
TEL. 380
FAX (976) 740-9846
;TANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
1n accordance with the provisions of MGL c 40,S34,1 acknowledge that as a condition
of Building Permit# all debris resulting from the constriction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c 111,S150A.
S�7j C�<J�Y1�
The debris will be disposed of at: ,III D n G
Location of Facility
G - 2o -off
Signature of Permit Appliq0ft Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
F' ame,if any
La�iilr a,�� �� /ter'► tN1ra
Address,City&State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.
CO/nmoawlAk 0 I l a-66acktda UL
n600 eW"Llim.3L..I
James J.Camooet Uoaloa /!/as+ac�+++,.W 021 it
Cw-mrsnona
Workers' Compensation Insurance Affidavit
I, _giw A �� 4�0„/�DG /VUNCA L'rnaS�rd�iD�1_
wirh.a principal place of business at:
. . tGnnoadatp
do hereby certify under the pairs and penalties of perjury, that:
�[ I 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 capadcy.
() 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
() I am a homeowner performing all the work myself.
I OnOen:a nO Wt a CM Of the W, n WW be fOM1+ ,"g M the OrrK.of Inveactavorq of the DIA for <oeerate leeiRcaeion ano Yaat la]aRe b a.tur.
co.eratt n rewreo unoee Section 25A of MCL 15 2 an too to the inocvrion of crvr+woi oe"em coousunt of a tee of w R-'S 1.500.00 anoler one
yean''r.-.oruenmenl W"E a[l.e cenaluet N the loan of, STOP WORK ORDER ant of S 100.00 a or ata+nt M.
Signed this ,�(a—Z— 0 day of
ict ec/Ferm it t ee building Depa ent
Licensing Board
Seleamens Office
cafth DeparTment
-1CT; .ALL _ _.
10/17/2005 10: 40 197874573BG ROSE INSURANCE AGENC PAGE 01/01
7EXTEND
YYYY)
A4, (JRD CERTIFICATE OF LIABILITY INSURANCE 0 ►,
pRODV(IdR (978) 795-6464 THIS CERTIFICATE IS ISSUED AS A MATTEION
ONLY AND CONFERS NO RIGHTS UPONATE
Rnsa Insurance ALTER THE EPL IOVERAGEIAFFORDED BY THE P 13OFS NOT OLICIES .OR66 t17ring Avenue
p.0. Hox 958MA 01970- INSURERS AFFORDING COVERAGE
INSURE? INsuRER A:PENN-AMERICA INSURANCE
NoyS.tY Home Improvement INSURER B;Hartford Insurance
68 boring Avenue INSURER C:
INhU ER DI
Sd1E110 MA 01970— INSURER E:
COVE I7IAGES
THE P17LICIES 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 MAYBE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EPFEcnYE POLICY ETMRANON
INSA A:DMJECT
POLICY NUMBER DATE MMIODr(Y DATE MMA➢Dn' LIMITS
LTA N IIR INSUPANCE 1,000,000
A ITY - / / EACH OCCURRENCE P
DAMAGE TO RENTED 50,000
LGENERALLIADIUTY PREMISES Eawxr mnw
06/27/2005 06/27/2006 MED E%P(AM,am roan a 5,OD0
CLAIMS MADE OCCUR PAC6500573 1 000,000
PERSONALS ACV INJURY I
GFNERALAGGREGATE F Z,000,OOO
AGGREGATE LIMIT APPLES PER:
PRODUCTC-COMP/OP AGO 9 2,000,000
PRO-
JECT LOC
AUTOMOBILE UARILITY / / / / COMBINEDSMOLELIMR
(E9 SccBeMJ
ANY AUTO
ALL OWNED AUTOS / / / / BODILY INJURY 9
(Pnr pen0n)
SCHEOULEDAUTOS UODILY INJURY
HIRED AUTOS (Pern=dont)
(PCI iCCNPA!)
INON`OWNEO AUTOS
PROPERTY DAMAGE 9
(Per neMertD
GARAGE WABILITY AUTO ONLY-EA ACCIDENT P
OTHER THAN EA ACC a
AUTO ONLY. ASS F
EXCESSUMBRELLA�LIABILITY / EACH OCCURRENCE 9
OCCUR E I CLAIMS MADE AGGREOATE e
P
DEDUCIBLE
F
RETENTION 8
10/09/2005 10/09/2006 x we BLIMT- OTFI-
H 'NO RKERS COMPENSATION AND 379IS999904 TOR ATU ER
EMPLOYERS'LIABILITY E,L,EACH ACCIDENT 9 100,00
.ANY PROPRIETOWPARTNEAIEXECUTIVE ZOO 000
OPFICER,M EMBER EXCLUDED? / / / / El.DISEASE-EA EMPLOYEEF I
N y M,denrlbe unM.r 500,000
SPECIAL PROVISIONS belay.'OTHER
DISEASE•POLICY LIMIT P
'OTHER
DES:RIPTION OF OPERATIONSR.00ATIONSMEHICLESMXCLUSnNS ADDED BY EXPORSEMENTISPECIAL PROVISIONS
CE:ITIFICATE HOLDER CANCELLATION
I ) _ SHOULD ANY OF THE ABOVE DESCWBEO POLICIES BE cauCELLfiD BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
GQ Lie l�yL� 30 DAYSMReITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT
FAILURE TO DO SO.WALL NAP035 NO OBLIGATION OR LIABILITYYIF ANY KIND UPON THE
INSURER ITS AGENTS OR REPRESENTATIVES,
AUTO" REPRESENTATIVE
ACGIRD 26(2001109) rD ACORD CORPORATION 1981
ftm•INS025(0100).05 ELECTRONIC LASER FORMS,INC.-(BD0)377-06A5 Pyp T M: