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17 BUENA VISTA AVENUE - BUILDING JACKET I 4tna (-rJck �Sl� nkK9gP0 O° 2J cpm UPC 10330 No153L a �— `osr coa��ti nass�r��s, snrs ROBERT J. SWAJIAN & ASSOCIATES, INC. INSURANCE ADJUSTERS 161 SOUTH MAIN STREET MIDDLETON,MA 01949 TELEPHONE(508) 777-1400 FAX(508) 777-2255 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B TO: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman G i 5 7 o SAME ADDRESSES RE: Our File No: Insured: Loss Location: /'cl-e Date of Loss: Policy Number:�/�J3 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws. Chapter 143 Section 6 to be applicable. If any notice under Mass. Gen. Laws. Chapter 139. Section 3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, and claim or file number. ADJUSTERS TITLE: On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. 10�7Ewv f ADJUSTER DATE r Af1C(IAIp. MIY.Q II Ia 5 +t*NG1 HST-REfflz-E iJD APPROVED BY T+IE II PBCTOA ,PRQR TO A PERMIT B,EWG GRANTED CITY OF SALEM Null No. No. .`' y \ Date Is Property Located in � Location of the Historic District? Yes Not Building �� l�� eh�a ll•3fA Is Property Located in Q� 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- Owner's Name No ks-�) 79 Address & Phone �� y`S�` °�(cot) _71 Architect's Name Address & Phone ( 1 Mechanics Name ��`� Address & Phone cn ��5��\� rot) J What is the purpose of building? (o Material of building? �d If a dwelling, for how many families? Will building conform to law? S Asbestos? Estimated cos oCY:JO City License # N P State Inane Home Improvementhl 2g-2,ocot9 Lic. t Signature of Applicant $1256" SIGNED UNDER THE PENALTY OF PERJURY DESCRRI \IO�nN, F WORK TO BE DONE MAIL PERMIT TO: No. APPLICATION FOR PE/RMR TO LOCATION nf PERMIT GRANTED APP "D INSPECTOR OF BUILDINGS C0fnrrwnw,!aAk o/ mw ackwedi r g �epa,1.n.nla/9rrdir:,binf..?eaiaanLt yy��600 Woajs:rybh S1,481 .lames J.Camroe9 fJodlon, 9w�k of 02111 c orhmrsstoner Workers' Cc m ensation Insurance Affidavit wither principal place of business at: (Oq,wwaq, 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 Company Policy Number am a'sole proprietor and have no one working for me in any opacity. () 1 am a sole proprietor, general conzratzor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation policies: Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number O 1 am a homeowner performing all the work myself. I undenund that a coax of chit wte t wiN be iorwaroed to the Office of loxstitawrt of the DIA for coverage verification and MX failure a Secure (overate at reoarea unoer Section 2SA of MGL 152 an lead to the i noosttion of cr'irninat oennttes corststint of a fix of oo toi 1.5=00-anal«one VC 'imaruonmmt>r Kra cir3 ties in the loan of a STOP WORK ORDER ano fine of S Io0.00 a daY agiwt me. hh Sign thi �� day ofGL Licens a/Permittee Suil ing Depa ntent Licensing Board Seleamens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375 co r _. ; Y OF SALEM- MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT ®' 120 WASHINGTON STREET, 3RD FLOOR 1, P SALEM, MA 01970 TEL. (978)745-9595 EXT. 380 �Gnna 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 facility,as defined by MGL c III,S150A. The debris will be disposed of at: Location of Facih' Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant N 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. 4. a CITY OF S BEM ., Dab a.s rotation Of ._ \ w.w�aio dN�ct?� Y. No V -) :• is Po"my LowW In hs Cmmvo qn AIsa7 YMR_No BUILDING PERMIT APPLICATION FOR: Permit to: (ChW whWmW 41") Roof, ROW, n Siding, Deck, Shed, Pool, RepalNRsplace � 1�-t m0 C\ Xt'CI -� PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS W PROONOW TO THE INSPECTOR OF BUILDINGS: The ulod hereby applies for a panne to build according to the fob" speollicatlowe Ownses Name Address 6 Phone Archkmds Name Address tt, P MW ---- ---_-- 1 Modmi s Name 7S cc-r-,-- Address A Phone N c> 5c-\W\ momm d- A - g4_ �fyO Q s a dwa ft,for how wr bAdrq Donlon.a MW zS ,town i Essnwae coat. csy Uo s N P► WAb 6�\��o v: r Signature of A *ca t SIQNqD UNDER THE 111114", DESCRIPTION OF WORK TO BE DONE OF PERJURY 14 MAIL PERMIT TO• fill", v NO. V , 1 W APPLICATION FOR PERMIT TO LOCATION All PERMIT GRANTED A , . INSPECTOR OF BUILDINGS j 1 __ =r PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM,MA O1970 TEL (978)745-9595 EXT. 360 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 facility,as defined by MGL c III,S 150A The de ' will be disposed of at �U N�y� CW Location f Facility � v3oy S Date FULLY left,the following' nation: (PLEAS Name of Paimilt Applicant —'�V\Z— V��0 � L� Firm Name,if any Address,City &Stake 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 cIll, S 150A, and the building permits or licenses are to indicate the location of the facility. I M Coryrymmanmi alfhBOl Illoeeata 6 �Uep.elaat.af ./.7.Lislft�ee;4.� 600 W"Llim-Simal �attrsaaatooa �•i••. ?V.u.eluu•lit 02111 Ctxamasstousr Worker Compensation Insurance davit . . with.a principal place of business a \ "fib) do hereby•certify under the pains and penalties of perjury. than () 1 am an employer providing worker' compensation coverafe for my employees working an this job. Insurance Company Policy Number 1 am a sole proprietor and have no one working for me in any oWcicy () 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation poll tier oli m ber Contractor In Com !P surance Wiry ty Nn Contractor Insurance ComWfly/Pol'ury Number Contractor Insurance Company/Policy Number () I am a homeowner performing all the work myself. I unoeruand nut a tool of the wumem.i be 1e 3roed m the Once Sl InveatitaAt d of the DIA for coverage vetircadon and OX Haut m loco" toverart x[*Duren avow Section ISA of MGL 15 I can lead to Me i++Deution of pimmat oenalo"cvrsotint a1 a h"of w 04 I.S0D+0D ardor oft ream" Do[.n*nt W vi at ovi penalou the Iorm of a STOP WORK ORDER and a W of S 100.00 a .af ar+rtat cite. Signed is day of :ictnscei crtriutt ouilcing Geparcn+ent �censing Eearc Seiectmens Office r,t:Ith Depammer.' ..n 7 Gr1G G(tr G(1C T'/e