22 WILLSON ST - BUILDING INSPECTION 3 �Li4NISiNIiST�Ef Ef)- )D APPROVE0 BY CIE
.IJ,5 ECTDB ,PatOR TP.A PERMIT SEWG GRANTED
a7 CITY OF SALE
Date 314 05
No ' \
Is Property Located in Location of
the Historic District? Yes No Building o�a C�I��D�
Is Property Located in v�
the Conservation Area? Yak—No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Si ' Constru Deck, Shed, Pool,
Repair/Replace, Other: Al h,
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: (n�
Owner's Name �eNn�s C4-y)c%g 0 ocisSu1x
Address & Phone (7'6) y Ll - 96
Architect's Name
Address & Phone L )
Mechanics Name
Address & Phone ^ ( )
What Is the purpose of building? I id�Yl
Material of building? t')O Dd If a dwelling,for how many fam8les?
WHI building contonn to law? ye S Asbestos? Qb
Estimated cost f2 50 a o a CRY License t N P' state License# CS o tf 3 53 1,'
Barre Fuprover ent &gnatdre!7ojf
I
Lic. ti 09 t�1 App is nt
IGNED UNDER THE PENALTY
OF PERJURY
IDESCRIPTION OF WORK TO BE DONEE p
�jC'Ivl�ow. 1 �� LT3uw.
MAIL PERMIT TO: -
--54eN YVA o1S"l�
NOL
APPLICATION FOR
PERMIT TO
LOCATION s
PERMIT GRANTED
20 _
3
AP V�D #
2�,,�
INSPECTOA OF BUILDINGS
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
1'. SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition
--- -- — oLBuilding 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: .QL)A e}- Q-afiCe
Location of Facility
/Signature of Per mf t Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
p
Name of Permit Applicant
Firm Name, if any
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
�' �Garanapawlat� ����t�
43.4arai t.�ea�.fa
boo w.A&O.Sliest
Ewa a f'Mo" &Aw Mu .ei.rh o?f f f
workers' Compenu&n tnwrsnm ABidavic
ryloonavl� �' c
. • + prkm*W *ve of beailtaas ea
a Mo.YS�,. �'� tee. ����y YEA • Ol`�� •
de llereby'certly amdar t�as pahaz and peeihdee e!per�tga tilasl
() 1 ain an anplerw pmvWb+s workas' coeapepatioe covepis ter my einplopm wmkbg es
lurwaatp P i!Itwaber
1 am a ask proprleaer and hew no one workbg sir was In a W opadq-
1 am a " propriete enaul co cuw or (drde owe) sod how Iced the
coaeracmn Bated below who•hwe the followLsviforkets' cimpemntiou I 11,41 si
o4�U�� �
' Comraeax Interam:a Cotapaq/Po q u er
Cosuraaw Inwnnce CompW r/ a eniw
Cenaracter IMwance cAmwasy/poft iienubw
() I am a homeowner performing all the work myself.
•I wwnww am a aq of ei rnaeru will sa km.arar n ow Olin A Im aidtnaw der OIA 4 aa-arap w011kad a ar on 6iat k man
c.wrap a resnn aria 4 , I I IA of WA 15 2 Ca1 kae Is sr b.saba of a1 1 loudu serwdM 018 ar 01 ra w4 UCCIA asarar w
rean•:.rummim a naa a del a+rds in er Ian d a STOP WORK ORDER air a hu of 1100A0 a am aaiw sa
Signed chh; • day of
.ictracci Ferrrliuee bullaang Department
Lictntinf Ecare.
Selectmen: Office
:;ulch Deprmer?
' - eeCr ;e _ _ (1 et epr spe r7c
Mar-09-05 11 :49A Dan Huv-lay Insurance (976) 777-3306 p.01
� DAre ryMlwnmT
A(R RD. CERTIFICATE OF LIA131LITY INSURANCE G6R
DACSR 03 09 Ds
PRODUCER - i THIS CERTFICATE IS ISSUED AS A MATTER OF INFORMATION
Dan Hurley In$urenCe.Agonay_ _ _ _. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Chestnut Greets, suite 24 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Seven Federal Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers HIL 01923-3620
Phone: 9713-777-9394 fas:910-777-3306 INSURERS AFFORDING COVERAGE NAICB
INSURED N611RFF A_—L1ENirt HYLURl I
NSURFH R 1
Dari a T4an er�mE'eanqt Co. , Ina. Nsunenc .- `.. ...._... ._
� r 1DNA'019al
INSURER t:
COVERAGES
THE MUCIES Or INSU JUMF I IRTFD WOW GAVE SEEN 13SUED TO THE INMRI I NAMFO ABOVE FOR INt POLICY PERIOD NDICATED.NOTWITHSTANDING,
ANY Rk01AREMETTT.TERM M CONDITION MAW CON TRACT OR OTHER 00CU/!NT NATH RESPECT TO VNIr.M TMIS CFR I"CAI t MAY St 13SUtO UR
MAY rERrA I,TIN IN URAMCG UI,000tu SY THE rOLICIES DESCRIBED I9REN b 6URJFCI'10 ALL IHt TERMS,EXCLUSIONS AND CONDITIONS Or SV011
FOI A:IFS ArGREGA1t UMITS SMENM MAY❑AW OC6N RFHICED BV PAID CLAN I. _ . .........-_....
" YEFfECTIIIE:.FpLCY FypM
LIP ME TYPE OF INSURANCE FOLKY NVMBER OA'f! W(ODttY D.LTI IILLIR7D1W1 uMR6
OENEMI IIABWTY EACHUCCURRENCE 6 +1
UMIAUk 10 NtNItV
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PCRROMI 6AOV INJURY IS
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Gt NY ADEAMeGAIC LpN(fR APPLIES rtH — '—
POLH:Y JEC 1 I LOC
AUTOMOWLS LIABILITY 1 C.OMBINM SINOIE IIWI 6
ANY AUTO Ic..rATw>..
ALLONNCDAIMIA WDLY NJURY 6 ..I
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tACH OCCURRENCE 6
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NORRERSCOMFBNMTMFNAMO 1E JURY„LIMITS
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A AHYPROPRSTOREPARTM6Fc VCcunot KC1329318611012 11/30/04 11/23/05 tI.EACH Acuothr :s1000DO
OrrICER1%AFMHIaERCLUDED1 SEE ATTACKED NO I IMIY
ALvOOIM6AL MSNS Ore. ICIORFA6t-MLCUNIET 6160000000000_
OTHER
DESCRIPTION Of OPEMTIDU I L OCAnONS I VENICLIS I E6CLUMMS ADDED�T E IDORSEMMT/tWI L FHONSNIN!
Carpentry. <
CERTIFICATE HOLDER CANCELLATION
NEI D001 IMULDANYOF INE ABOVE DESCRIBED POLICIES BECANCELLED BEFORE TNEU1IRA110H
DATE THEREOF.THE Is6UMIKWRERYr.LLENOEAvowTOMAIL 10 DAYSV ITTCN
NOTICE TOT"GENTIFICATE HOLPER NAMEO TO THE LEFT,BUT FAILURE TO DO 0O SHALL
IMPOSE NO OBLIGATION OR LMMLITY OF ANY FIND UPON THE INW RER,ITS AGENTS ON
EMA7NRE. _ _
AU TMISMTNDRI teO Re►RED eNTAri46
Hurley
ACCRC 25 I2009l00) ®ACORO COR►DRATION 1908
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JOHN
HENRY
CIARCIA a
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