31 WILLSON ST - BUILDING INSPECTION AYl_
AC 9AP
CERTIFICATE OF LIABILITY INSURANCE
04/05/2007
PRODUCER (979) 745-6464 ONLY ERTWIAND CATE IS Mh JE WAS A nU�N TI1 E 'CE�AON
Rose YxLaursace HOLDER. THIS CERTIFICATE DOES NOT A1AV II, EX19NO OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED SY THE POLI:IE.B BELOW,
P.O. BOOM 95S
Salem T4A 01970- INSURMMFQMM RAGE NAI,a
INSURED INSURER A. T.BMltua .
Gang L'4 Construc:tion INSURER It _--
21 Llnaoln Road INSURER C:
IN O. r
Salem NA 01970- INSURER E: ••••`W
COVERAGES ..
THE POLICIES OF INSURANCE LISTED BELOW HAVE OWN ISSUED TO THE IHLSLJ E NAMEDASWE FOR THE POLICY PERIOD INDICATED,NOO RISTANDING ANY
RECUREMNT,TERM OR OOI IDITIOH OF ANY CONTRACTOR OTHER DOOUMENT WITH RESPECT TO IMHUGH THIS OERTIFICNTE MAY BE ISSU!t I OR 14AY PERTAIN,
THE INSURANCE AFFORDED BY THE POLIES DESCRIBED HEREIN IS SUBJECT TO ALL THE 79A NS, E%CLUSIOMB AND CONDITIONS :F SUCH POLICIES.
AGGREGATE LIMITS 13MOM MAY HAVE BEEN REDUCED BY PAID CLAW,
NAR ADMPOLICY EWECINE POLICY tDiP01A710N -••••�`
L TYPE OF Wb11RANCE POLICY NUMBER OAYE(MMMONY) DATECIAWDOAM I='.
OWERALLMLLITY / / / / EACH CE •E•••.•,•
COMMERCIAL OEIERAL LIABILITY PRW®NBi(EB llfMltal
CLAIMS MADE ❑aacuR / / / / ow ExP caw
PERSONAL A ADY INJ URY I
GENERAL APQREQATE A—
CPA MATE pLJRaIpD'APALIts PER:. PROOUGT8-COMPMPAGG I^�
Isom JECT Ll Lac
AUTOMOBILE LIABILITY / / J / CoNSINEDSINGLELIMIT
ANY AUTO 90 ) M
ALLOINNUDAUTOS I I / I BODILY INJURY SCHEDULED AUTOS (Par PPISM) 1
HIRED AUTOS / / / / •ODDILY INJURY
NOWOVINEDAUTOS fp-s H-o I
PRCPHRTYDAMAHE
(Fr=kmm
MARAGE LIABILITY AUTOONLY.EA ACCIDENT ,1
ANYALRO / / / / OTHER THAN _MACC 1
AUTO ONLY: ADO I
E%CES&VMBRELLA LIABILITY / / / / EACH
000UR ❑CLAWS MADE A00ALUATO9
9—
DEDUCTIBLE
RETENI'tON S S
A WORNE(PROVISIONS
COMPENSRTRm ANO TC 40 Y IY9 FJ2
EMPLOYRS'LIARLIYY -
ANYPRORIESORIPARTNERIMMCUTVE &L EACH ACCIDENT 1 _ 100,000
OFRCEREMBHIE LIDED? 5275C00706 06/22/2006 06/22/2007 EL.DISEASE,EA EMPLOYEE 1 100,000
R yes,Usa �r lm0r --
BIPED SL.DISEAM•PDucruMn 1 500.000
OTHER
DESCRIPTION OP 00'pRATIOU$LOGITIONSNEHIGL@SSERCLLL$NNE ADDED BY EMDOASEMENTISPECIAL PROVISIONS
CIERTWICATE HOLDER CANCELLATION ..__
(999) 744-6953 ( ) MOULD ANY OF THE ABOVE DEICRISED POLICIES BE CIMh 14,LLiO DEFORE THE
WIFIRATEM BATE THEREOF, THE OWING RMBUREI WILL -.10EAVLVM TO MAIL.
30 DAYS VMRma NOTLCB TO YHE DanomATB Nowam NA I It,To YHB LEFT.OUT
City Of Salem FULORE TO 00 SO SMALL IMPOSE NO OBUSATION OR UAMLUV : ANY KNO UPON THS
INSURER ITS AGENTS OR REPHIESENTATIVEL
AUTNOARINI ATNE ..B
ACORD 26 0681AATQ - V a ACORD I ORPORATION 1980
4"r wS028(01m}45 ELECTRONIC LASER FORME,INC.-(MPV-DW P/e/r of
10/10 39Vd ON39V 3ONVNnSNI 3SO8 98£L5hC8L6T Z£:0T L00Z/50/40
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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t2o W�'r'ot+s'ra"m•",serer,Alwssaatt�rtsor97o
Ton-VS-743A393 a Pex:Mono q K
Workers' Compensation Insurance Affidavit: Bolldere/Coutractorsmettsici&umomben
A
nt
Name
Address:
City/Stataimp: Phone
AN you AN emPhsyert Cheek the appropriate boss Type i
1.❑ 1 am a employer with 4. ❑ I am a general contractor and IFBWlding
eapalred):
ploYece( and/or part time).• have hired the wbcontrsctorstedou
Ypg
2.L7'1 am a role proprietor or partner. listed on the attuhed sheet,t
ship and have no employees These have
working for me is any capacity. worker'comp,insurance
(No workers'comp iaerrance 3. ❑ Wagree caparsdon and ita didau
required) o9leee have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption Par MGL 11.❑Phunbing mpeirs a addidona
myself (No workers'comp a 152.§101 and we have no 12.[3 Roof repairs
bet==required]t employes(No workers'
comp inamaooe re*IhV&l 13•❑Omer
ftimrow
ir om o dye arse tea e)onow ale ton out da a.rtio.Bela.dtawila oar rarkea'aropeedoa pouey learmeloa
wen rhs adonis die at!ldM1 dye we doing a weds ad an Mw anode 001ftciM moat ashen a ow iladwk
ICoaaloea err dradr din boa nitre ata;hed no sddltlaai dra[derby do ease of de saheaba em ad dsk waters,eoaR
Ifar an employer that to provfd/Bg workers eoapeasadoa
JBjoraadow, lnsarancejormy employees, Befow d the paltry and jod s14r
Insurance Company Name:
Policy N err Self-ins,Lie N
Expiration Date-
Job Site Address: City/Stamizip:
Attach a Copy of the workers'ComPaasadoe Policy declaration page(Skewingthe
Failure to secure covers u Po1kY number sad sxpdradon dads
iw required under Section 25A of MGL c. 152 can lead to the impoatne Of criminal Penalties of a
fine up to$1,500.00 and/or one-year impriaonmea4 as we"as civil Penalties in the form of a STOP WORK ORDER and a Hue
of up to$250.00 a de y a the violator. Be advised that a copy of this statement may be forwarded to the Oftk@ of
Investi o the D f Coverage verification
I do her c aB and Bald"ojperjary Char the IejormadoB provided d and comees
----------------
[Other
on/Je Do taw write In the area,to be completed br c/tp or town oQ7e/a(
n: Permit/Lkease 0
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 3.Plumbing Iuspeetor
son•
Phone*
��°.�\ CITY OF SALEM
PUBLIC PROPRERTY
�`oRq� DEPARTMENT
KINMEKI.F.1 DRISCOIT.
MAYOR 120 W;\SHINCTON SLREIT ♦ SALI M,NIASSACHUSIi'r1'S 0197C
Tct.:978-743-9595 ♦ F.ax:978-740.9846
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l It, S 150A.
The debris will be transported by:
(name of hauler)
1
The debris will be disposed of in
(name of facility)
(address of facility)
-signature of permit applicant
c ail
Jcbri;ait.doc -
� PUBLIC PROPERTY
DEPARTbIE,�1T
u�roEnsrouscwt
MAvoe 130 WAwtt+c tcx��[1FJrr
�Art�r,MAsu[Ht;se-rR 01970
Tr7:916-74i9m•FAr vs.740.9m6
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPwN['v_ FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property In located in a;Conservation Area Y Historic Distrlot Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land '
Name:
Address: /
�7
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN 1:YtATturs BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (st) Renovated
construction or renovation
of existing building New
arief Description of Proposed Work:
--
What is the current use of the Building? �—
U n It dwelling.how marry units?-----:—
Material of Building?
`I
W R the Building Conform to Law? � Asbestos?
Archited'sName
Address and Phone ( )
r
Mechanics Name
.
Address and Phone
Construction Supery isors Li
cense nse 06 5 0?21 D ? HIC Registration S
Estimated Cost of projed Z v° Permit Fee Calculation
��• � Estimated Cost X$7/$1000 Residential
Permit Fee$
Estimated CostX 5111:1000 Cornmer W----- -
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building P to bui to a above s ted
specifications. Signed under penalty of perjury
Date r 67
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