1 FORRESTER - BUILDING INSPECTION \ �
APPLICATION FOR
PEFOW TO
LOCATION
PERMIT GRANTED
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APItVfD
INSPECTOR OF BUILDINGS
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MPACMB PWR TD A.PERMIT AEM GRANTkD
CITY OF SALEM
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Permit to: St LDM PERMIT APPLICATION FOR:
Ode whkAowr apply) Roof. Rer . r otall SWk4 Camtruct Dock, Shed, Pool,
PLEASE RLL OUT LEOOLY i COMPLETELY TO AVOID DELAYS w PROCEMM
TO THE INSPECTOR OF BUILDING& '.
The um*so-od hereby applin for a permit to buaki accor&V to tha.tNowkrp
Owner's Name D d IA 4,G S {4 h o I
Address a Phone FoR Q.es 7-,.rz s`T
AmhllWs Name ✓U
Address a Phorm
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AddressaPh" sr�`� (97�17yo - �g3a
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No
she Of Applicant
SIGNED UNDER THE PENALTY
DESCRIPTION OF WORK TO BE DO//NE OP PE LRW
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MNL PERMIT TO:
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V 4 '. ,J� �✓�e >°Oonvneonu�ea�lJe o`./�aeaaa�u�ae!!a ' . .
rii Iw �\ Board of Building Regulations and Standards
kl HOME IMPROVEMENT CONTRACTOR +
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tc �y a rt'ate Corpora0on
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ASPEN ROOFING�f2VIFE$-IN,G
DAVID BENSON
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'r 4 FLORENCE ST �� � ���-amu✓
SALEM,MA 01970
Administrator
Him; ..
4 License or registration
before the a pivalid fora
r individul use only
Y fr V _ Board of Bul din Regulations tion date. If found return to:
`' One Ashburton 8 Re$Ulaand Standards
I Boston,MaX00 Place Rm 1301
.02108
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CITY OR SALZMj MASSACHUS&TTO
Pu4uC Pnormm DtFARTMaNT
120 V"NIWMN MUM. 340FLOM
sALi11.NA 01470
TEL (474)74848M 9W. 340
FAR (474) 7409444
STAML6V A L14OVIC2. JIL
MAYOR
DlSP0 L 0!DIt =AFMAVI?
Is accordmes wi&tba poVLtaoe Q(MM a 44 M41 aebwwledp that n a eaogdm
of Dal ft F4mdt h .Ot dabda 1eR11tiaF has tba amesucaoa activihr
ptramed by dds Bodft F+asdt dal be dkpn d Otis a poparly lieaoeed nlid-wraat4
Avosd heft,n daMoarl by)Atli,s 1q SIX&
lbdebdawill bedlgmWatme Wood Cisnsi , F 603�o t
LaeadoRaAFaeiNyr QS �o��o- ��u•
U J
Sismu m of Patmit AppHe t; Dde
FULLY compbft dw!i►ll mbS mhmsdo L
MIASB PRW C.BARLY)
Nme of Permit App east
AS Pew 0 oo Ici 60a
Fila Named if my
1 �LUh.2tic�. � �� 5/ale� Gf'1/•a U /�i7G
Addrak city er<etas
The above ata de mq nm that debris Em dw damObuck reaovadoq rahab or odw
&asdm Otba'&l or atr won be diapoaad is a popaly-ka m d soh&waat4 disposal
Soft at de66ad by MSB.ca 3130& and the bt i ft permits a li elm an to
iadicatr the loeat;OR Of h+a q.
ueparratenr of tnausTnas nectaenrs
Offla of InmWeadons
600 Washington Street
Boston,MA 02111
wwwasassgoddi'e
Workers'Compensation Imuranee Affidavit: Bugders/Contractors/Elecbiclans/Plnmbers
Applicant Information Pipx Print Legibly
Name
Address• cl S 7—
City/Stategip: S�)9 ew iV9 0 0 /X70 Phone
Are you as employer?Cheek the appropriate box*. Type of project(required):
1 I=a empbyyVVer��with�� 4. ❑ i am s jendal aonuacbr 2111111 6. ❑New construction
employe py pmt. )a have hued the sub-COUVacbrs
2.❑ I am a sole ru ng or parmc listed on the attached sheet i 7. ❑ Remodeling
ship and have no employees These sub-convactms have S. ❑ Demolition
working forme in any capacity. workers'comp.ill mace. 9. ❑ Building addition
[No workers'comp.insurance 5. ❑ Weare a corporation add its ]0.0 ElecRical or addition
requi ed.l otters have exercised their
3.❑ 1 am a homeowner doing all work tight of ezempticu per MGL 11.0 Phumbiag repairs or addidens
myself[No workers' comp, a 152,11(41 and we have no 12.0 Roofrgmim
insurance required.,t employees. [No worlm, 13.M Other QP_2 OD/=
camp.insurance required.]
•Any applicant that clemb loot#t mat also all art the notion Labe ahowiaa their ro>�
wmbW on pdioy iofontrtloa
t Homeownaa who aelmk rho s idavit=&cgft they an domes an wank end than Inn ootids contacton mud arson a naw at6dava mmca#ina tuck
tConveebn that cheek ata box most eftwhad an edddond ahat abowies ma me of do aabmntreoton and they wmkaa
•GonVL PolicYndo+nntien
ran or employer that b providing worker'eostpensalon lnawraneefo►say employees Below is the polky ead job sits
Information.
Insurance Company Name: PP-A)hi-Y9 n7•e2 i I n. �F
Policy#or Self-ins.Lie. #: 61 0- t 9 Q 4 7 0 Expiration Daae: L l- /- 0 S—
tub Site Address: f FV 2n�s r1 ST Ciry/State2ip: sin La
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date}
Failure to segue coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$230.Oo a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
I do Akreby cepo wader Lhe polar andPexzelwof pedury tkst the IN&asadon provliled sbow Ar ave sad comet
Sim_ a�� - /' U I Date
Phone#: 9 7 6-- 7 9V - K- 7 3 b
O&Ad use only. Do not write in Ah area,to be completed by ej&of low o ked
City or Town: Permil/ileense#
Issuing Authority(circle one):
1.Board of lieakh 2. Building Department 3.Cky/I'ows Clerk 4. Electrical Inspector S.Plumbing Inspector
6. Other
Contact Person: Phone#:
Laws chapter 152 requires all empbyen to provide workas' compensation for tbu tr d Of
h
pursuant to this PWYCCL
Massachusetts C
statute, an rarPloya is defined as"...every person in the savice of another under MY contract of in,
express or muphed,oral or wrbm* ,
An empto w is defined as"an mdrvdnd,parmasbip,associa"corporation err other legal entity,or any two or mon
m a pmt enterprise.and including the legal retmunnadves of a deceased employer,or the
of the foregoing i . DS or other legal entity.cnVbM employees. However the
receiva or tramp,of an mdivmdtuai,p�l"� who resides theteie,of the ootnpaet of the
owner of a dwelling house bsv'mt°Dt more�°In do on sack dwelling home
house of another who employs pasons to do maintenance,of oungtr
mpl or repay work
f
dwelling �er y� &aeb shall not became of such employment be deemed to be an empluya•
MGL cbaPW 152,12SC(6)a>do stats that"every nate or lonl fieeadag agency slay withioid the
issuance or
renewd of a Ileease en perms to oWe a budKn or n eosimuct buiidho is the eommoawed*for stay
applicant win lasnot produced acceptable evidew of eompHance wMi the inarence eo ant requi rye&
Additionaft,MGL chapter 15Z 125C(?)swm"Neither the commonwealth nor any of los poli>ial mbdivisiona insurancenoorant
enter into any 0011113d0011113dffor the perfcrma>mce ofpobfic woth until acceptable evidence of eanpti s ce Wilk the
e
requirements of this chapter have been presented a the contracting tsrthonty"
Appfieaab
please fill out the workers'compessaton affidavit completely,by checking the boxy that apply b Your situation and,if
necessary,SUP sub.coatracwt(s)nandsb address(es)and phone mrmba(s)along with their catificate(a)of
insurance.. Limited Liability Compania(LLC)or Limfted Lublity partnerships(I.l p)with no employed other than the
members or partes, are not bbd to tarry workers' compensation ins
unanoe If an LLC or LLP does have
employees,a policy is requaed. Be advised that this affidavit submitted to the Department of Industrial
Aecidenb ger confirmation of im mance coverap. Also be sore to dp and date the affldavL not the thould
of
be returned b the city or two that the application for the per
or license is being requested.
Industrial Accidents. Should you have any question regarding the law or if you are required to obtain a wortrers'
compensatimpoliey,pkm call the Depxtnent at tLE
number listed below. Self-insured companies should enter thea
self-insurance license umber oil the liner
City or Town Officials
Please dare that the affidavit ti'er comp tete ad printed legibly. The Department has provided a apace at the boom
oft
of the affidavit for YOU to fill out in the sen the office of Investigations lug to contact you regarding the applicant•
Please be sore W fill in the paw number which will be used as a refamw number. in addition,an applicant
that must submit multiple parowlicense applications in any given yea,need only submit one affidavit indicating current
policy IDfotmadon(if necessary)and under"Job Site Address"the applicant should write"all basions in (city or
�)"A ropy of the affidavit that has bees officially stamped or marked by the city or town may be provided t the
applicant as proof that s valid affidavit is on tyle for finis permits or ligases. A new affidavit most be frilled out each
year.Where a home owner W citizen is obtaining a license or permit not related to any business or commercial venture
(ie. a dog license or permit to bum leaves etc.)said person is NOT required o complete this affidavit
hire to thank you in advance for your cooperation and should you have any questions,
The Office of Investigations would
please do not hesitate tis give m a call.
The Department's address,telephone and far number
The Commonwealth of Massachusdb
Department of IndusUW Accidents
office of Invetliptions
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2605 www.mm.gov/dia
6�4FD. CERTIFICATE OF LIABILITY INSURANCE CSR �a °°TE"""°°"
9ASPROS
It•0o{ICaR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
John J Walsh Ina Agency, Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P 0 Box 4407 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Salem 1U 01970-6407
Phonas978-745-3300 Pax1978-745-9557 INSURERS AFFORDING COVERAGE jNAIC9
YgUIttD INSURER A: Peace-America Insurance Co.
._ INSURER B: Arrieu Inc•sucioul Occup
Asonon Roofingg Services Inc INSURER C: ++,•..l.c. I Lt, Cs ,
SalamrXA enc01970(13 �INSURER D:
INSURER E:
CEEB
7IIE►OL1=OF WSl1RMICE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANYREOUIRFIIEM,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAYF®RABL THE WSURAN'E AFFORDED BY THE POLICIES DESCRIBED HEREIN LS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
FOLML AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PND CLAIMS, i
TR mw rm OF INSURANCE POLICY NUMBER DA MWD DATE MWD LIMITS- -- - -1,
0104m LIABILITY EACH OCCURRENCE S 1000000
A Y COUMFACMLGENERALLIABILITY SUB1010055 12/31/04 12/31/05 PREWSES EAocal, ' s 100000
CLAWS MADE x❑OCCUR MED EXP(My.Fe ) S 5000
PERSONAL 6 ADVIHJURV f 1 0 0 0 O 0 0
GENERAL AGGREGATE 1 2 0 0 0 0 0 0
GEMLAGOREGATE LOUR APPLIES PER: PRODUCTS.COMP,OP AGO 5 2000000
►Ol1CY J LOC
AUTOMOWA LIABILITY
tMBINED SINGLE LIMIT 51000000
C ANY AUTO 81053563217 12/31/04 12/31/05 (Ea cctlo.An
ALL OWNED AUTOS ..
BODILY INJURY
X JiCHEDAEO AUTOS (PM Fm )
HIRED AUTOS '
BODIYIWURY IS
NON-OWNED AUTOS (PM•coawu)
PROPERTY DAMAGE
(Pr MpMAq
GASIAOE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC I S
AUTO ONLY: AGG I $
KKC91Sk)MBR1JJ.A LIABILITY EACH OCCURRENCE S
OCCUR ❑CLAIMS MADE AGGREGATE S
S I
DEDUCTIBLE s _
RETENTION S s
MgRIQRECOIVENSATION ANO T RY LIMITS ER
E m"D1r""'A""'Y WC6932479 12/31/04 12/31/05 E.L.EACH ACCIDENT s 1000000 I
AIIYFROFRKTOI E=UONEXECVTNE 6-.
OfFIC81BIFMBER FXCLUOEDT E.L.DISEASE EA EMPLOYEE f 10 0 0 0 0 0 _
rSw,
PROVISIONS Ula., 1I
VECMI.FROVLSIONS Meow E.L.DISEASE POLICv uMrt 5 1000000
OTNER
OOCpfgM OF OKRATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
I I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE T nE
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 0+ S nRl
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BVT FAILURE TOGO SC S,,
IMPOSE NO OBLIOATION OR LIABILITY OF ANY IND UPON THE INSURER ITS AGE+T S Ju j
REPRESENTATIVES.'
AUTHORLZ90 REPRESENTATIVE
John J. Wale 'Iae. rA 'c^Salt. �
ACORD 25(2001/08) m ACORD CORPORATION 1.988
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