20 FEDERAL ST - BUILDING INSPECTION (5) No. -��' `' �`\. Date
Is Property Located in Location of �L
the Historic District? Yes_No V Building 20 660601RL5 7—
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, oof Install Sidin Construct Deck, Shed, Pool,
Repai eplace t er:
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 Namei� UL—
Address & Phone
Archit j4Vame
Address& hone
Mechanics Name Ale)
ys,Q ( Ort/ST/ZLICT/cl�it[ ��/Y/j1pE//nl� //V
Address & Phone
What is the purpose of building?
Material of building? bl 2-1jo If a dwelling, for how many families?
Will building conform to law? yEs Asbestos? 1J t7
Estimated cost City License n "It State License is L
!\ Home Improvement
(J/ Lie. 1116 5(0
Signature of Appl' ant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
r
Ayr,) /2 ZO/-PL 61z /, rr-
f�t=./r/rzh=
>DF_UClM,F—
MAIL PERMIT TO: t `e
r -
Ornmonwaaft
>ra. I!
�7 600
James J.Camooes Uoslon� y/7�.a�Grr,.tta 02111
Cormrssoner
Workers' Compensation Insurance Affidavit
I, arc, 0�llY,�INCI
-- (ir�erre.r�.ear)
with.a principal place of business at:
Lc1)21 N iJ E S �I , C
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
1 am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general contactor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor - IntYrailee Company/policy Number
Contractor Insurance Company/Policy Number
Contactor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I vnom:anc wr a Goer or[he n 25Ar f Dr i1 5 2arere , rw Oncr el lmesof crir of a 40IA,for <oeerarr a fmisae*ana orx laa re scarce
co.eratr v rea�rra enaer Section ISA of FILL 1 52 can 1eaC to n+e:noesdien or crrrinx oa+xr+rs corseunr el a lei of roe to-[1.500.00.eels ear
rrars'"..eruor.i+.rer>,v_ u ar c:.s�orgloa:+m< Iona of a STOP WO RK ORDER anti1r/6"of 5100.00 a a.av 290ko"m--
da y of (�('7 _ zoo
Signed this , -
�Iccrse % rmlLcee
Building Depar'tr-+ nt
tjcenSing Board
seieamens Office
i=,calth Deparzmenc
< c�c _pc 77c
'f OF SALEM, trtA5!�A� nw+
• _ �z"{o PUBLIC PROPERTY DEPARTMENT
• ' 120 WASMINGTON STREET, 3RD FLOOR
�. SALEM,M A O t 970
'". TEL. (978)745-9595 EXT.380
J
�pry� FAX (978) 740-9846
>TANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
all debris resulting from the construction activity
of Building Permit#
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 Faciht(y
G
Signature of Permit Applicant Date
FULLY complete the following information.
(PLEASE PRINT CLEARLY)
Name of Pemut Applicant
Nf,) J LM Luc r ( 4 C MMJJ*- .' r4C+
Firm Name,if any
ft �CJe�►��G Mrs oi �o
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 cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.
AG-OW. CERTIFICATE OF LIABILITY INSURANCE 9DATr)5/2 /2007
115/21/2007
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF WORIVIAINM
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
TtoS® Insuraaca HOLDER. THIS CERTIFICATE DOES NOT AMENC, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLK;I E'5 BELOW.
P.O. Box 958 -
881em NA 01970- -INSURERS AFFORDING COVERAGE NAK:,I_!_
INSURED INSURER A;ESSEX ZM90RANCA COM@AT1Tt
TCoySa Tipm 7A1)proVEOTIBn7= INSURER&9dG9P -
68 Loring Avenue INSURER C: _
INSURER W.
Salem ba 01970- USURER R
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN LSSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOT%I 'HSTANDOJG ANY
REC IAREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NRTN RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUER]OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN LS SUBJECT TO ALL THE TERMS, EXCUJSIONS AND CONDITIONS CC SUCH POLICIES.
AGGREGATE LIMITS SHOM MAY HAVE BEEN REDUCED BY PAID CLAW.
INSR DO'L 'POLICY EFFECRVE FoLJCY EEPIRATbN I -
LTR mSRD TYPE OF INSURANCE POLJCY NUMBER DATE JMMIDDTYY) DATE IMMMMUM I LOOTS
GENERAL LWBILIIY / / / / EACH OCCURRENCE ., 1,000,000
X CONNERCIALGENERALLWBILRV INT�G `O RENTED �; 50 000
PREMIREY; E ALC.. _ /
CLJUYS MADE ❑OCCUR.,9CV6137 11/14/2006 11/14/200.7 WED EXP! o _ 5,000
PERSONAL B AM NJURY 11. 1,000,000
GENERAL AGGREGATE 2,000,000
GENL AGGREGATE ppLgqLMITAPPLESPER: PRODUCTS-COMP/OPAGG I,_- 2,000,000
� wy POLICY LOC
AUTOINO6LLE UABILRY / / / / CONBINH)SWGLE LINK ANY AUTO (E9 BttMe�
ALL OWNED AUTOS / / / / S=LYIWURY
SCHEDULED AUTOS (Par p, ')
HIREb AUTOS / / / / BODILYINJURY ,
NQN-OWNED AUTOS (PMa¢Bellq 1
PROPHTTY DAMAGE --
IFA.accMenO 1
GANAOE LIABILITY AUTO ONLY-FA ACCIDENT --
AN AUTO ! / / / OTKm TFAN EA ADC I•
AJTOONLY: AGO ( --
EACESEIUM IRELLA LIAZWTY / I / / EACH OCCURRENCE I••
OCCUR CLAIMS MADE AGGREGATE (__
I
DEDUCTIBLE1--
RETENTION S I -
8 rlpDZil(EI±S coEv"aaSA.t ,`.". -u /' 08/10/2006 CE4 ''C.R2o4. .- TD Y urT ..
raAN nv�A%raano . -
ANY PROPRIETORIPARTNER�UTT E E<_EACH ACCIDENT I 100,000
OFFTCEIUMEMSER FJLCLUDEW / / / / MIL DISEASE-EA EMPLOYEE 1 _--100,000
Ir yes,deearme mdm
SPECIAL PROVIEbN'mb EL,0=ASE-DOUCYLIMTT I 500,000
„
DESCRIPTION OF OPERAT)ONSLOCATNINSN0IICtEe1QCLU410NG ADDED BT ISNOORSENENTASFECULL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
( ► — ( ) — SHOULD ANY OF THE ABOVE 06WAIBm POLICIES DA CANCi JDD RIWORE THE
EXPIRATION DATE THEREOF. THE JSSUUIG INSURER WILL EI CRAVOR TO MAL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMI=I TO THE LEFT,BUT
p'Or 1O.Sured 13, records FNLORE TO DO SO SMALL IMPOSE NO OOLISATRN OR LIASSJTY OU V fY NOW UPON THE
INSURER.ITS AGENTS OR REPRESENTA'IIVFS,
AUTI/O SENTATRIE
ACORD 25(Z001108) I ®ACORD O:IWORATION IM
*,,;DLSB25(oim),I% ELECTRONIC LASER FORMS,INC.-(ADD}T27-0Stl5 Page 1 W 2
7aiTR 3910H ON39V 3ONVWISNI 3SO8 98£L50L8L6T 9b:TT )AA7/TZ/90
� r i
✓fee 1°ioonnxa�uirea.�f� a�✓�aoaac�umelYa
Board of Building Regulations and Standards License or registration valid for individul use only
I
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration: 18568 One Ashburton Place Ren 1301
Expuation *7J2009 Trill 129332
Boston,Ma.02108 ,
'; xTypo _.Rrivate Corporation .
NOYSA HOME IMPROVEMENT SERVICES,INC
MARC RIGGILLO
68 LORING AVE
SALEM,MA 01970 Administrator �i t valid without signature
Fa �i ,
� uax
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