45 FEDERAL ST - BUILDING INSPECTION (4) �j
'PI*NSVAT9E f1WS AND APPROVEfl BY 741E
ASPEMDR.PRIOR TD A PERW BEING GRANtkD
CITY OF SALEM
No
l j \ om
I "' f'�o Ward
Zwft Dlatrid
is Property Loomed k,
Rn Hdodc Dhtrtct? Yes No its of
gs F'SZ7"C- ST
Is Property Located In
Rw Camaysdon Ana? Yes No '
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) , .Install Siding, Construct Deck, Shed, Pool,
epaidRepla .Other: DZ7--o c-( 17,�
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 C��� —C
Address & PhoneC`�'� -
Architect's Name
Address & Phone n ( )
Mechanics Name
Address & Phone /� /`'c Eli 1 P764
Sv I
wnd Is sr purpose of txdldW C / C c._l h( G—
Maww of buNdnp? Qj-b of-) R a dwaflffg,for taw mmy amass?
Wa bAdnq conform to law? Aebedos? A O
Edm ted cod�, G a CRY ucon a shh ucwats a
Lie. I
Sigma lr:artt
S . D UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
;r'76'j-0 g /T��7li?YGL(�f l
MAIL PERMIT TO:
/ � � I
No.L - u
APPLICATION FOR
PERWr TO
r 1 LOA,D
LOCATION
PERMIT GRANTED
t5�/mil lei 9 19
OVfD
INSPECTOR'OF BUILDINGS
lroeen�,►moeuuuaftJr, o�rr �a``�aC��d .
booULd;yia Sfaej
+.1n.a 1 eaa.ad gadrj% Mum L A 0.2111
Workers' Conlpensadn la wraw n A idayk
. . whi.a principal • of bu dneo ac
do here"'cerdly under t)n palm and pesahiv of paf.m chm
I an n employer pnwWbsg workers' eompeasaden coverage for ray empleyeea weekbs M
Insurance Company romw Tlumber
1 an a sob preprksor and haw no one we.rki g fig►me In any opodq.
() 1 am a sok proprktor, =eneral concrec* w or homeowner (drde ease) and bow bind do
contractors listed btbw who-have the fclnowilp workers' compensation po9eha2
Conaacwr Insurani Company/Po Number
Contractor Insurance Company/Po Ntsu&w
Conersaw insurance Conspassy/policy Alumbw
() I am a homeowner performing all the work myself.
•I raasuaae cow a ew1 d 09 RMNA r.a Of ka+aroee a Ow Office i1 hwwogaear of On CIA 1w te.erap naukadw aae an labs w weere
ca.erara a rrawre war Seciw 2fA d WU 152 ran kae w of a tea elm wi I.NO mover w
rear•kwea nm a ye a&i amnia in am kme a1 a STOP WORK ORDER sae s iw of S 1foaxe a M atabee aae.
signed thla . airy of T
.ice i' ncee building Deparcna nc
E3censinf Eoard
Selectmen) Office
=calth Depsrnner,c
:, _ - _ . =.:: : . - - _-.ccC-r Yet _ ace epc ape 77e
PUBLIC PROPERTY DEPARTMENT
Er 12.0 WASHINGTON STRaaT. 3RDFLOOR '
BALKN.NA O t Y70
TLL (D78)745-9595 EXT.360
FAX (678) 740-8846
STANLEY J. UaOvICZ. JIL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MQ,c 40,S34,I aclmowledge that as s condition
ofBWdimg Permit 0 .all debris resulting f m the dam„l y
governed by this Building Permit shag be disposed of in a pmpaiy licensed Solid-waste
may,as deftW by M(X c jS150A.
The debris will be of al `F'OU�
Locstlaa offmcilkly2'
of Pamit Applicant Data
(PLEASE PRINT CLEARLY)
�Q (L-o Nl a
Name ofPamit Applicant
Fizm Name,If my
address,City dt State
The above statute regmra that debris from the demolition,renovation,rehab or other
alteration of building or structue be disposed in a properly-ficensed solid-waste disposal
5cility as defined by MQ,cIq S 150A,aid the building pamib or licenses are to
indicate the location of the facility.
FROM.: DUFFY INSURANCE AGENCY INC PHONE NO. : 781 593 7260 Aug. 13 2004 09:09AM P1
BENXI
/�M4 CERTIFICATE OF LIABILITY INSURANCE DAT6(MMDOpyyp
PRODUCER (787)593-7200 FAX (781)593-7260 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 4
Duffy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
317 Broadway HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR
Wyoma Square
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Lynn, MA 01904-2602 INSURERS AFFORDING COVERAGE NAIC B
AIROWe RCktaoh Inc - msURERa Western World Insurance Co
196 Haynes Road INEURER0: PII rle Insurance compan 0045
Sudbury, MA 01776 INSURERC: Travelers insurance CORI any 0056
INSURER 01
NSURER E
COVERA E
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.AQF
ING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND COH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN$R MILF1DD' YYPE OF INBURANCi POLICY NUMBER POLICY EF ECTNE POLICYEXPI THINGENEggL UA&CITY NPP865262 10/23/2003 10/23/2004 EACNOCCURRENCE ,000CDMMERCML GENERAL LIABILITY OAAMNAGGE TORCNYEO00CLAIMSMADE nOCCUR MED EXP(AM AIR PNSON 000APERSONAL E ADV INJURY 00
GENERALAGGREGATE S 2,000,00
GENT AGGREGATE UM R APPUEB PER: PRODUCTS•CONPADP AGO t 1,000,QQ
X POLICY JET LOC
AUTOMODILELIABRRY PM07194539 01/27/2DO4 01/27/2005 COMBINED SINGLE LIMB
ANY AUTO (Ea eeeiSem) S
ALL OWNED AVY09 2004VINJURY
8 X SCHEDULEDAUTOS (P0fp0mn) t 250,00
X MIRED AVTD5
BODILYINJVNY S
X NON-OWNED AUTOS (PWe two 500,00
PROPERTYOAMAGE S
(PWRCBRMQ 25D.000
GARAOe VABAJTY AUTO ON LY-EA ACCIDENT f
ANYAUTO OTHERYN EA ACC 6
AUTO ONLY AGO t
UC558NMBRfilLA LIABILITY EACH OCCURRENCE S
OCCUR u CLAIMS MADE AGGREGATE
• S
DEDUCTIBLE
6
RETENTION E S
WORRER5 COMPENSATION AND 6KUB7402A34-3-04 04/08/2004 04/08/2005 X WC SiATU: ois
EAPLDYERT LABILITY
C ANY PROPRIETOWPARINCIVEXECUTNE E.L.EACH ACCIDENT S 100,00
OFFICERIMEMBEH EXCLUDED? E.L.DISEASE-EA EMPLOYEE 6 100.00
If Vee,Eeecwe.wder
SPECIAL PNDVI$ION$babes I E.L.DISEASE•POLICY LIMIT S SQQ,DO
OTMIA
DESCRIPTION OF OPERATIONS I LOCATIONS I VENICL6S I EXCLUSIONS ADOED BY ENDORSEMENT SPECIAL PROV%IONS
Ont'raCtor
CrATIFICATE
SHOULD ANY OF THE ABOVE DEECREED POLICIE8 ME CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE IBSUINO INSURER WILL ENDEAVOR TO MAIL
City of Salem 10 OATS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
ATTN•. Building Department B TFAILURfi TO MAIL SUCH NOTICE LIMPO NO LIOATMINCRLIABRITY
Town Hall 0 IND ON THE INSV ,ITS G NTSO REP S NTAWVES.
Salem, MA 01970 A NY IN
IVAVTW AR.105LnT10a Teas
ACORO 2512001105►