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5 OLDE VILLAGE DR - BUILDING INSPECTION (� fbUr WMfM#�wPB A/PMVGD eY Tbw O-A11 SUPSCMM POM 7D A'VKMW BZM MANTID VJ CITY OF SALEM Vftd as-c�9 r...a oar r--�� : °`� �ld r.la.y Imre r Prtrn[to: DNO MILPool APPLrATION POR (Ckor rhkfrvK�PDIY) wow 81dit owwsw oswt 81wd. POOL Orly; PIAAU PLL OUT LAOWLY i OOW%ZMY TO AVOW ONLAYS N PPWaW W= TO THE INSPeCTOR OF allRDWM The wWwoVwd r tlY LOP/k1a br a po b WN awwd'Np b ow bk*Yq OvCe Naw accN Au�w6Rwr.'�Ofc��illo.a��C (97A1 7�-I!)-J-/fZ->n7 A N&. Addrw A Phew A (57R14�7��1,51 Mwrrrfa Nww Ad*w A Pfww 1 1 `Mr[r..n.P,�ueieo! Ry'Sir1 rr}i \ �,mm� Mwrdb~ P.ewrq,trw�wr�ry b.r.1 VIS hAdM m....b 41 e+..ra mr 171 oi1n cM ua.r. �rru . �5 u•. PISe_f9f .81prYw d Apps U M POUL7Y' OnCFWgM 1 OF WORK TO W 001! OFPWUUW I ate/ �RIYI:�\rCl :11 I r.-.4. !v-.�-< � c�/�!1r�lc (�-I-�n ��• .r1rS JIr-.c'. W crrw; �IIQ MAIL PSVAT TO; 57 ae 41, l PUBLIC PROPERTY DEPARTMENT 120 WA/XIMaTON 6Y11a:aT, SRDFLOOR 9ALKNO MA 01970 TEL(976)7454595 EXT.560 FAX (976) 740.9646 STANLEY J. (J6OyKZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT Ia acwrdanee with the Fvvidc=of M(3L c 40,S34,I ofEuild'mg Permit d all debars aclmowladge that as a condition governed by this Building Permit shaft debris S 8vm the comsbucti m y duposed of in a properly licensed solld-w=to disposal facility,as de$ned by M(1;,c UL S150A. The debris w171 be disposed st: Location of Facility Si oaf of P `5 a �- n9 heard l Daae FULLY complde the following informatm; (PLEASE PRINT CLEARLY) Z MMU ver—xi�Appffimm i chi li mi+tea EnF„- Tn riuu aramo, u any . 5 P Address,(�,�State O 19�p The above statute requua that debris from the demolition, renovation,rebab or other alteration of building or saucture be disposed in a grope rly_licensed solid-waste facility as defined by MQ,dff,S1S0A, and the building peamits lids am�sP°� indicate the location of the facility, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Minpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lef<ibiy Name(Business/Organization/tndividu 1): Tnr- Address:_ City/State/Zip:-P Phone#: 47R-�l7-31 i Are you an employer?Check the appropriate box: Type of project(required): L YJ I am a employer with._ 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).• have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [Remodeling ship and have no employees These sub-contractors have 8. E] Demolition working for me in any capacity. employees and have workers' comp. insurance.: 9. ❑ Building addition [No workers'comp.insurance P� required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.[1 Plumbing repairs or additions myself. (No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers'- 13.❑ Other comp. insurance required.] `Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: /0 5/t7i 7(i- 8070£S tJ- 0-1 Expiration Date:_)Q_Q-)_ 09 Job Site Address Jr (25 1 r1 V 1' I r (' City/State/Zip:�]'rn�a in (Yl A O I ci 70 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification do hereby certify u er he pains and ties ofpedury that the information provided above is true and correct — Signa tire Date 5-;)Q- Phone#: ')Phone#: 97F�- 977z�1�i I cia use on y. Do not write m t u area,to be comp e y city or town oJliciai City or Town: Permit(License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#• 11/04/2008 TUE 14: 17 FAX 781 581 7200 BENEVENTO INS AGENCY Z001/002 ACORD CERTIFICATE OF LIABILITY INSURANCE OF ID PM OATE(MMIODlYY YI CABIN-1 11 OS 08 -RODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Benevento Ins . Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 197 Humphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Swampscott, MA 01907- Phone: 781-599-3411 Fax:181-581-7200 INSURERS AFFORDING COVERAGE NAIL# NSURED INSURERK Ha focd Unccvci taco Ina. Cc. INSURER B: TRAVELERS INSURANCE CO. AIC Cabinetry Unlimited Enterpris® INSURER c: P ter Bagaralla President - 11�2 Rear Main 9t INSIIftER D: Peabody MA 01960 -- INSURER E: COVERAGES 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 4SR3DDL pgmm POLICY NUMBER DATPE�M D/YY DATE MM/�OOm LIMITS LTRINSRO TYPE OF INSURANCE GENERAL LIABILITY EACH OCCURRENCE $ 1,000, 000 ENTVU— B 1 X COMMERCIAL GENERAL LIABILITY I-680-4753B409-TCT-0810/21/08 10/21/09 PREMI6EJ ollw=tee S 300,000 F-17 CI-AIMSWDE I:X�] OCCUR MEO EXP(My ono pereonl $ 5,000 IL PERSONAL&ACV INJURY S1, 000 , 000 GENERAL AGGREGATE s2,000,000 LOIN AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO S 2,000, 000 POLICY ECT PRO- LOC AUTOMOBILELIABILITY COMBINED SINGLE LIMIT $ I� ANY AUTO (EB BCCldem) ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per Peraan) _J HIRED AUTOS BODILYINJURY $ NON-OWNED rAUTOS (Per ecJdent) PROPERTY OAMAGE $ — (Per amidenq GARAGE LIABILITY I AUTO ONLY-EA ACCIDENT E ANY AUTO OTHER THAN EA ACC E AUTO ONLY: AGO $ EXCESS/UMBRELLALIABILITY EACH OCCURRENCE S OCCUR [ CLAIM$MAGE AGGREGATE $ DEDUCTIBLE S RETENTION E E WORKERS COMPENSATION ANO X TORY LIMITS E0. 107KEMPLOYERS'LIABILITY B An'Y PROPRIETDFPARTNER/EAECUTIVE 6860UB-5807060-3-07 10/27/OB 10/27/09 E.L.EACHAcc1DENT 5100000 OFPICEPoMEMBER E%CLUDEOv E.L.DISCASE-EA EMPLOYEE $ 100000 Ir Y35 docrlu und9r SPECIAL PROVISIONS Ind— E.L.DISEASE-POLICY LIMIT ESDDDDD C OTHER OESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION CITYOFP SHOULDANYOF THE ABOVE DESCRIBED POLICIES BECANCELLED REFORETHE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00$0 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIN D UPON THE INSURER,ITS AO ENTS OR REPRESENTATIVES. AUTHOFED,KEPRE)SEN TIVE P ACORD 25(2001108) O ACORD CORPORATION 1986 y?-s 53a- � �v� �Iassachusctts - Depanntcnt of Puhlic Safeth Board of Building Regulations and standal-tls Construction Supervisor License License: CS 87554 Restricted to: 00 PETER BAGARELLA 28 MARLBOROUGH RD SALEM, MA 01970 {5 .dptiiM1.YF*.�. Expiration: 4/28/2011 ( nnni..imw' Tr#: 14975 9Xe & Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 156191 Type: Private Corporation Expiration: 6/12/2009 Tru 255742 CABINETRY UNLIMITED ENT, INC. PETER BAGARELLA 21 CALLER ST STE 2 — - — PEABODY, MA 01960 — — Update Address and return card. Mark reason for change. n Address n Renewal n Employment 1-1 Lost Card