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3 CONNERS RD - BUILDING PERMIT APP �oxry OF SAL.EM. MASSACHUSETTS 3� PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR - SALEM,MA O1970 a ''��.f_✓`� 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 of Building Permit# all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal fac ility, as defined by MGL c III, S I50A. The debris will be disposed of at: D✓ �wa � ` Location of Facility Sl / Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) pele r_ 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 cHl, S 150A, and the building permits or licenses are to indicate the location of the facility. ,1 1&l_-A -M"ST-BE fiLfg-AN0 AfIPROVED 8Y T44E MMPfXTDR PWDR TD A..PEWT BEWG GRANTED CITY OF SALEM No. a` '� *\ Date Is Property Located in Location the Historic District? Yes_No Building Is Property Located in 1/ the Conservation Area? Yes_No_ BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Replace Other: 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: yyJJ n q Owner's Name yH Y/P-�1� t(J/G /���"Saz y . aye nrs Address & Phone n e�,o7®y ( '7 G/�{��77O Architect's Name - Address & Phone 01 ( 1 Mechanics Name 2 Address & Phone What is the purpose of building? Material of building? /rGdoc/. If a dwelling, for how many families? b�� _ Will building conform to law? Asbestos?Estimated cost �� B�" City License # N A stalwiTeprise # OonU Pt� 6f. Home Improvement c. f 30(a5' Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE / �C d �� ,ro MAIL PERMIT TO: 2 er A a a jo7 6, ck,d s� No. APPLICATION FOR PERMIT TO ic � ., l� h � LOCATION r�L 5 PERMIT GRANTED ' APP OVfD ECTOR OF B ILDINGS t >r Com.monwiAk of Masiaclzueeff3 g s �eParU,ss,t1 of..7.dustrinf,eleeiau.ta James J.Campo" q�oslon, )V&mndhswal 02111 Cor-mrssiona /JWorke s' Comperuation Insurance Affidavit I, 0r with•a principal place of business at: ��w r/ tcJ.ra..�.,va do hereby certify under the pains and penalties of perjury, that: () 1 am an employer providing workers' compensation coverage for my employees working on this job. Insurance Comp�r • � . Policy Number r�`vl�rs� 1 am a aor an nave no one working for me in any capacity. () 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compemssatioon�policies: big/ �birdr�>k>/4�°nl`�s ® 1GylUaS��/�o/d Contractor Insurance Comparry/,PoNty Number D t�cyr S° - y` Contras r Insu nce ompany/Policy Number Contractor Insurance Company/Poligf Number O I am a homeowner performing all the work myself. I unoerwne tnat a coon of the ttitement wig be ion+aroed to the Ofrce of lnva6seataotd of the D1I, la cos att teAkation 3"t"t laaurt to Secure <o.trait v «aged undtr section 25A of MGL 1 S 2 can kad to the:twotnion of erteninz, ot"ties eorsotint of a fter of me W41.S0000 anolet one . reari ir.Urwnmtn wjd u Tuts the 1 of a STOP WORK ORDER f•+e of s 100.00 a oar ataimt rat• Si isday of licensee/Fcnnittee building Department Licensing board Selectmens Office {iealth Department dERlr CC" tk1-.GE iNFGF�'.� ,-. 7 I01r CAL Client#: 12728 MOORE A�ORD -CERTIFICATE'OF LIABILI�'Y INSURANCE osiiiio°"vYY) PRODUCER - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION B.K. McCarthy Ins.Agcy. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 10 Centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Peabody , MA 01960 978 532-5445 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA. American States Insurance Company 33618 Paul T.Moore Inc. DBA Moore Plumbing INSURER B Safety Indemnity Insurance Co. 39 Clark Street INSURER c _ Danvers, MA 01923"--- wsURER O. 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. TRUR DO' POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MMIODIYY A GENERAL LIABILITY 01CG8741782 09/01/06 09/01/07 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY PREMI ES Ed occurrence) cc rr s2000OO CLAIMS MADE a OCCUR MED EXP(Any one person) A0,000 FD Ded:500 PERSONAL a ADV INJURY S11000.000 GENERAL AGGREGATE $2 000 000 GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2000000 POLICY ECT LOC B AUTOMOBILE LIABILITY 3116571 09/01/06 09/01/07 COMBINED SINGLE LIMIT s110001000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS _ - BODILY INJURY S - X NON-OWNED AUTOS (Peraccidenp - PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY. ASS S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE _ $ RETENTION $ S WC IIMIT OTM- A 'vroRKcrsco±s^EHSAncvtnFro- - —' 01 SNK^25'44fi10—` - -- " 09101/06 09/01107" 'X' r- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $100,000 ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED' EL.DISEASE-EA EMPLOYEE $100,000 If yes,describe under EL DISEASE-POLICY LIMIT $50Q000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS 978-744.4880 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Peter Michaud DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10_ DAYS WRITTEN 12 Bridge Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Salem, MA 01970 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108)1 of 2 #53785 RBU © ACORD CORPORATION 1988