20 FEDERAL ST - BUILDING INSPECTION 53
IMAM IMST-DEfIL{Q-AflD Af"OVED BY T44E
-WS,PECTOR .PWR TED A PERMIT BEMG GRANTED
No \\ ��/\ � J1 CITY OF SALEM
\ d� A Date
s: �I
ward
� nNeo°' Zoning District
Is Property Located In Location of �-11
the Historic District? Yes_No_ Building Aar-e ( x
Is Property Located in
the Conservation Area? Yes No 1
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Ro f Install Siding, Construct Deck, Shed, Pool,
Repair/ eplace 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 (J r l j(' a, S L2f-�n (—
Address & Phone ( u" �( (Q78 I - yY- y97C
Architect's Name
Address & Phone
Mechanics Name
s
Address & Phone
What Is the purpose of building?
Material of building? if a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost IZIZT=City License N State License a Q&t/t Y3
Bone r"rovement
Lic, e I Z977
Si nature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: Hlwr e �� P
APPLICATION FOR
PERMIT TO
LOCATION ft/ ^ � y
o)D oll, � Ao
PER/MIT GRANTED
oy 19
r
A V�D '
INSPECT .O T—OF BUILDING
f
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 9RD FLOOR
SALEM. MA O1970
• TEL (978)745-9595 EXT. 880
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 debris will be disposed of at: 4'
Location of Facility
c 2-k-c)
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY) /2
✓I `-N✓`�'L �7 �'t k 1 a"` / I L.�l/4 � t� �U W
Name 6f Permit Applicant
Firm Name,if say
t�S �vti tfwver-&L 0 li'1�9 aca33 Z
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.
O
MIS
S:D:^^.veaL�ar 8 Shecey ONLY AND CQJFERS NoI TH pIGHTS UFCTI 1�}IE3CER71Fi�OFJNFOR nC�
.'O Ec;K HOLOER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR
Prov:ae.^.c.:. PI CcV01LK.,45 AL7ERTHECOVEAAGEAFFOROEDEIYTHEPWC:SEEDW.
INSUREASAFFORDINGCOVERAGE INAIC
B_
'Ne':J Encsa YJincL-N Ana Coor inc Dba
_ -- INSURER A
Horo Insurance Co
OEA Pe:.a 1iincc.Ys INSURER
S Fcna;Foa❑ INSURER C.
HaremlJ 'AA 0183Z INSUR E=0
NSURE= ar I
2C:rIS::::i:CZ-: _Tc: 4ISSJED-C TriE"ISUr'�NAY1
.v:Ali —'.IC'CM:O(Ti:J.^„'GNV C,"tJ1RA07".,.1' CI H DO:.U.;.g'Q..JTMED��FCR THE PCUCYPE=J00:tJDICATED.Nar-yrn-ISTAND:NG
r-iCFCED 5Y TriE=OUC:ZS OESC iS=- H ��ECTTOlhiK}I THIS(,.'ii7FiG:TE!:AY BEiSSIJED OR sHa"N!:AY HAW.BEEN REDUCED BY PAID CLAMS.SUBJECT TO ALL THE TZVOS•EXCL::5CJS AN CCNDMCNS OF SUCH
v_-
' CCF'4SURANCE POLICYNUNBER PO LICI•EFECT:YE PO L CYEX RATipNI I C
A aE.-:E;AL_Ae:L.m i81NDEA14 OITE MM52E2 /C I DATE MMICOl - LIMITS
07 01 03
X cc 4_P._:ALG 07/01/04 EAc::OCCOF=eNCE IS1.000.000
a4=AL _.A2 L..,�
DAMA7- R�NjEp IS100000
,.:.4S 4AG=! X� O......FI ___umc e �•ev
— I 14E_EYP!Aty me Oenml Is5.000
---D`AL&ADVIN_LFIY ISI.6O6•00O
l. a-_�'_A-==.415,:__5?-s. i I 3Ei=Ai_•,96ReGAiE IS10.QOD.�O
�-'�' -- - CCMP/OPAG351OAOO.000
6iNDEA 1452E? i07'01/03 i07i01104
C 42N cp E:NG_E LI MI�
IS1,000r000
LY'4j_-Y IS
I_Y'4�_RY
f
N EAACIS
AGG 1 S
l07101/03 loravoa f Ise.e00.e00
I IS
r f
07,01103 '07i01104 1X - _ _ p
-IC '-^:-ENT Is500.m0
n _2 AEEVEAFYP'OYBSS00.000
I ' S=I<z �UCYU.YJS500.000
- - .,'•5. ,__ �nSr TEY.CLS:IX0:::5:OXS AuCED 9YE400R9 EMENTI SPEL;AL PROVISIONS
-- 9MOULC ANYOF THEA 00YE06 CA BED POLICIES BECANCELLED BEFOFIETHEEXP.R.
DATETHEREOF,THE SSUIN G INSURER WILL ENDEAVOR TO MAIL 2Q OAYS WRITTEN
NOT CETO THECEATIFICATEHOLDER NAMEDTO THE LEFT,BUTFAILURETO DOSOSHA
IMPOSENO OBLIGATION OR UA BILiTYOF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIyE ,tom
Mee O ACORD CORPOFIATION is&
PAGE:002 R=96:-
Board of Building Regulatlons and Standards
c—E One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 129774
Type: DBA
PELLA WINDOWS AND DOORS Expiration: 11/2/2005
RAYMOND ADAMS
45 FONDI RD.
HAVERHILL, MA 01832
Update Address and return card.Mark reason for change.
Address J Renewal Employment Lost Card
+\ ✓/te �o�X,in4nuK,aG(� c` ,L(6�¢�,/�U,1e��d
_ Board of Building Regulations and Standards License or registration valid for individul use oniv
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 129774 Board of Building Regulations and Standards
Expiration: 11/2/2005 One Ashburton Place Rim 1301
Type: DBA Boston,Ma.02108
PELLA WINDOWS AND DOORS
RAYMOND ADAMS
45 FONDI RD.
HAVERHILL, MA 01832
Administrator
✓/re fo'amnaa�t+.ieal!!c o��.�aaoaf/uiee/�
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 081843
Birthdate: 02/06/1966
Expires:02106/2006 Tr.no: 81843
`' Restricted: 00 -
STEPHEN T DICKINSON
17 BURNSIDE LANE
MERRIMAC, MA 01860 Administrator
j � COmmOILWal6YJL Of�alanthwatft4 .
games 1 ummw &d., N/... A..h 02111
C
Workers' Compensation lasorame Afrldapit
. . wiib.a principal place of butiam ac
do hereby'certify under the pains and penihha of petjesy, doe;
1 am an employer providing workers' compensation coverage for MYetnplopees workingoc1
tbb job.
Insurance Compatry Policy Number
1 am a sole proprietor and have no one working fdr me in any cap cky.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the followings workers' compensatiou poQeh=
Contractor insurance Company/Polley Number
Contractor insurance Comparry/Policy Humber
Contractor insurance Company/Policy Number
(} I am a homeowner performing all the work myself.
• I rnOASHa.mat a cast Of tle JUMMM.A M is r woes o dw O(rss et I1r.esCr... of ew DIA gar ce.er.ee.wrocas a am Mat(aa.n r News
cowraar a raw....n.a S.cden 2SA el MGL 152 can kid Now Wwalde.s(o4'iaa.s.aeia e.rveowg el a rek el w w4I.St1 M weler ew
,,.n•i wwmnrM a we a cf.i ,.as"in the bran o(a STO P WORK ORDER awe a Gw.1 s t OOAO�-4 a .at adst %
Signed this • /ZAS day of ��' y
c4cciFermittec Euiicing Dcp-3rzKbent
Ljccnsinf Eoare
Seieetmens Office
with Depsr:rier-.
- _ -- r . . . ___ :t:= - - _ . ten__ . - _ ' - car "e - - 9ne t(+c• _fie ��c