292 LAFAYETTE ST - BUILDING INSPECTION 1�[ '131 .IC 1)R(WFR-1Y
` J
Ii I ')-M--li 9,1'15 0 I',A.'i-.4.-pi ah.11r
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
EMPORTANT: .%pplicants must complete all items un this page
SITE INFORtNl,�j1ON r' {{__
Loc:uio❑ Name { 1 CST �gl7l'\S� (il'lU l�-Vt�uilding
Pro to v ddress L= & �
Located in: Conservation Area Y -Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes 123 Ra_
Residential Q or more Units) R2_
Type of improvement Residential (hotel/motel) RI _
(check one) Assembly (Theaters) Al _
New Building- Assembly(restaurants & clubs) A2r_A2nc_
Addition Assembly(churches) Al 'X
Alteration Business B �C
Repaid Replacement—4Z Educational E_
Demolition_ Factory(moderate hazard) FI _
Move/Relorue Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11
Institutional (incapacitated) 12
Institutional (restrained) 13
Mercantile M_
Storage SI _Moderate I-lazard
_ Storage S2_Low I kward
O\\NI(ItSIII11 INFORMATION(IIIase type or Print Clearh) r
OWNER Named l �i(SY 1�,���s� eb.�nrcbN nr,� int vat l
Address—D-
Telephone
t�t� Signature t
uI:N URIC—ma UP uRh To�F71 VRF()w` I� rrn leJ C�
w I 1�
s l ee4-- rock -SIA I C C C7
ICSI'INIA['ED CONST RUC'T'ION COST � 7. 00a
CONTRACTOlt IN'FOR\IA'FION
Name
Address G U�
Telephone, 314 ?
Construction Supervisor's Lic #
Home Improvement Contractor #
ARCIIII 1?C'['/1>NGINEI-'R INFOMIATION
Name �—
Address
Telephone
.Mass. Reoistration
w
PERINUT FEE CALCULATION
Estimated Cost x $11/$1,000 + $5.00=
CODINIENTS
The undersigned applicant does hereby attest that all information stated above is trite to the best of my knoivledge
under the penalties of perjury
Signed (owner) (agent)
APPROVED BY :
DATE ,kPPItOVEU:
t
DATE(MM/DD/YY)
A C- :C.ER.T,IF,I,C.A.TE:::O�FL�!Agii ILITY I SuAANCIEl .,
03/25/09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
E A STEVENS CO INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
389 MAIN ST BOX 188 COMPANIES AFFORDING COVERAGE
MALDEN-- MA 02148-5076 COMPANY
A CENTRAL INSURANCE
INSURED
COMPANY
MICHAEL OSBORNE B
v _t' k37 COMPANY
!' 36 DHOFF AVE C
BEVERLY MA 01915 COMPANY
D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO ICY NUMBER L
TYPE OF INSURANCE POLICY POLICY EFFECTIVE POLICY EXPIRATION IMIT$
LTR DATE(MM/DDNY) DATE(MM/DD/YY))
GENERAL LIABILITY 13027986677 10/05/08 10/05/09 GENERAL AGGREGATE $2 , 000 , 000
X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG s2 , 000 , 000
CLAIMS MADE OCCUR PERSONAL&ADV INJURY $1, 000 , 000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $1 000, 000
FIRE DAMAGE(Any on.fire) $ 100 000
MED EXP(Any one person) $ 5 000
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SIN.GLE LIMIT $
ALLOWNEDAUfdS BODILY INJURY
SCHEDULED AUTOS. (Per person) $1
HIRED AUTOS I
BODILY INJURY $
NON-OWNED AUTOS (Peraccident)
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION gA T�I
OyLJMIER
EMPLOYERS'LIABILITY
EL EACH ACCIDENT $
THE PROPRIETOR
PARTNERS/EXECUTIVE INCL EL DISEASE-POLICY LIMIT $
OFFICERS ARE F1 EXCL EL DISEASE-EA EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONWLOCAnONSNEHiCLES/SPECIAL ITEMS
:CERMCAlt: OLDER ..........
ANMLLATION,
..... ...........
... .................. ...... ..........
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
THE FIRST BAPTIST CHURCH EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
N 10 DAYS WRITTEN TICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
292 LAFAYETTE STREET I I BUT FAILURE AIL U H NOTICE SHALL IMPOSE NO OBLIGATI?N OR LIABILITY
SALEM MA 01970 OF ANY KIN WRITTEN
COVI5`AN`/ IT
AUTHORIZED REPRE$��Vl e&Ahlfs�k RkESENTATIVES.
F.M. CL FFORD, JR. CPCU, TJ A
CITY OF SALEM
1 7� t♦�iA
`'A PUBLIC PROPRERTY
DEPARTMENT
. I 1 a I,nl•.,.."N:1>n r • ti.tu V. �t. „v rl _
Construction Debris Disposal affidavit
(required lifr all demolition and tvnovation work)
In accordance with the sixth edition of the State Building Code, 780 C NIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit K is issued with the condition that the debris resultin.v from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
18m 1�4 f (-) L's
(name of hauler
I he debris will be disposed of in
.. ctI
(name ul Facility)
Gnn
"`J (address ul lacllity)
♦IL'lIa IUI I' ofI 1.1'efllul J1 lllcallt
11109
elate
alai..,......
r
Te Building
gulatii 9e eA" a
(((ggg Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR '
Registration: 116312
Expiration! 6/6/2010 Tr# 269653
Type: Individual
I MICHAEL OS90RNE - -
MICHAEL OSBORNE._ .
1:EOVEAVE"� 3 —,
BEVERLY, MA 61915
F _.;µ:,.• Admrnrshator -
Up BOARD Oil BUILDING k6LIA-non
•' NuCONSTRUCTION SUP" VISONS .
Birth ber. CS , 092158 R s
- ate 0910811955'
a.„ Eatplies 09/pgrj008
y"1 MICHAEL ResfHCE¢d 00 rr'no: 92158
tj 30 DOLLOH OSBORNE is
BEVERLY, AVE
MA 01915... z
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