26 FOREST AVE - BUILDING INSPECTION (5) i
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1�9kidS�dllfST-BE f L f{�- +ffiIM APPROVED BY T44E
p J(j ,Pt R 7-0 T i3EWG GRANTED
I CITY OF SALEM
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No. t �w D� �vt .N� F Date /U ' oZ'7`0`�>
f
Ward
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\""cirnnPc� : Zoning District
Is Property Located in Location of
the Historic District? Yes_No Building 06 �'D SIf lew4f
Is Property Located in
the Conservation Area? Yes_No XL_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct eck 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 /2 fC k- \)10A-/
Address & Phone 66 Gol2,r ,,& AuE, (978) Gy'Gy
Architect's Name
Address & Phone ( )
Mechanics Name S AEI?
Address & Phone 50 b0,t/CAI> 5� R& - 9 3 99
What Is the purpose of building?
Material of building? P/r f a dwelling, for how many families?_1
Will building conform to law? YES Asbestos?
Estimated cost CO,t9& City License # State License # /F Is 95-G
Home Improvement ✓ ^
�! Lie. 1
/p��I� Signat of Applicant
SIGNED UNDER THE PENAL
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
t�A/L, �ywn� � 2Ef3yrGt) 12FA2 ()EcJeS
MAIL PERMIT TO: SO DuvGa1'*� 5i9660�7
97
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�o' OF SALEM.
PUBLIC PROPERTY DEPARTMENT
• ^ 120 WASHINGTON STREET, 3RD FLOOR
e SALEM,MA 01970
TEL. 380
FAX (976) 740-9B46
iTANLEY 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 1 L S150A.
The debris will be disposed of at: Location o f F ci ity
/o
S' tore of Permit Applicant Date
FULLY complete the following information.
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
ri0 t) � Sr
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.
NOTICE OF ASSIGNMENT
EMPLOYER: STEPHEN CUMMINGS DBA CUMMINGS CONSTRUCTION \lv000458742
MBO I.D. STATUS OF EMPLOYER
50 DUNLAP ST \\\ Individual
SALEM, MA 01970 \Ay'
\\� V`COVERAGE GROUP
V\ 0460414
The Waiver of Our Right to Coverage under this assignment
Recover from Others Endorsement applies to Massachusetts
is available on Pool policies. operations only. For coverage
Contact your agent for details. outside of Massachusetts, contact
the appropriate Pool or Plan for
that state.
INSURANCE COMPANY:
AGENT ROSE INSURANCE AGENCY
OR 66 LORING AVE GRANITE STATE INS CO
PRODUCER: SALEM, MA 01970 RESIDUAL MARKET OPERATIONS
P 0 BOX 409
PARSIPPANY, NJ 07054-0409
(800) 645-2259
AGENCY FEIN:043157449
CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE- ESTIMATED
CODE TOTAL ANNUAL PREMIUM
.REMUNERATION
CARPENTRY-NOC 5403 $0 16.09 $0
CARPENTRY-DWELLINGS-3 STORIES OR LESS 5651 $2,350 9.93 $233
CARPENTRY-DETACHED PRIVATE RESIDENCES 5645 $0 9.93 $0
EMPLOYERS LIABILITY 100/100/500 9845
LOSS CONSTANT 0032 $50
STANDARD PREMIUM $283
EXPENSE CONSTANT 09¢0 $264
TERRORISM CHARGE 9 40 $1
ESTIMATED�'ANNUAL PREMIUM $548
DIA ASSESS. 3 .7% OF STANDARD PREM. $10
EST. ANNUAL PREM. PLUS ASSESSMENT $558
INSTALLMENT BASIS: Annual - REQUIRED DEPOSIT PREMIUM $558
COMMENTS
Coverage effective 12:01 AM on 09/23/03
DATE OF NOTICE: 09/23/03 PREPAREDBY: Maryellen Nee
EXT 532
* * VOLUNTARY DIRECT ASSIGNMENT
LETTER ID: -. 467924 COPY: AGENCY
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street• Boston, MA 02110
(617)439-9030 • FAX(617)439-6055 • www.wcribma.org
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�tpa.Gaunc a/.Judu,lrial �cciatnL
n7 b0O �yW"Lllon �t...l
iamesJ.Camm" I>oalon, //lassac�uwlL 0111 f
Carrmrsswaa
Workers' Compensation Insurance Affidavit
with.a principal place of business at:
�/�G[r-i yj'Jff p / 970
. . Itaa,astewa4)
do licreby'certify under the pairs and penalties of periM, that:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Dumber
I am a sole proprietor and have no one working for me in any opacity.
Q I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor 1nsYran4t Company/Policy Num;
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unOerWnC wr a eoor of thu ivrzrercn[wa1 be ioMaroeo m the oflKt el Imrtstitawnt of the DIA for co.arart verWicadon seo OW(aaatt 10 Nwrt
cosrarr m rcosrrto unoer Section ISA of MCL 1 52 can kao to rhr TLP*Pwn of croninm otr fws corso.unr of a rat of ae=4 i.sMoo wwor am
rtan'inoruommrnr v ws0 u cit3 oenaltier in�loan of a STOP WORK ORDER anc a h"of S 100.00 a Oat Mira'ant•
Signed this ;ems day of /( -;0 0-N
L l tc r,5 t t/Ftnr ittee building Departrment
Licensing board
Seleetmens Office
}ieaith Department
-_4°00 y - C_ 4Ce, 405, 40c -roc