45 FORRESTER - BUILDING INSPECTION f11MrS~*Ef KA154AD APPROVED BY TW
JdSPEOIOB.Pg=TOAf9BW B WOGRANTkD
CITY OF SALEM
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Permit to: WG BIALD PMIT APPUCATM FOR:
(Circle whichever apply) Roof, Reroof, InsWI Siding, Constnect Deck, Shred, Pool,
Repair/Replsoe, Other
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSMIG
TO THE INSPECTOR OF BUILDINGS: '•
The urtdwsood hereby applies for a permit to build accorcLig.to the.folkewktg-
Owmes Nme F':J kL Pe dk ( c ni e/ F)- I
Address A Phone // o ! Py� ) -F (I7f) POP -.Fz)� (/
Architect's Name _1�_i ��ar! / ,I-C cy �7n
Address & Phone '1�6 ,Ple<fc-, 6P— 3,U3
Mechania Name NLfLt? Cr,4 zdu14c
Address 6 Phone -TO &Aro 1U r41?&-0101 (61) 1 633-ff f
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ate, S of Applicant
SIGNED UIt M THE PENALTY
OP PERJURY
DESCRIP110N OF WORK TO BE DONE
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MAIL PERMIT TO: //
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APPLICATION FOR
PERI/T TO �ib�
LOCATION
PERMIT GRANTED
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INSPECTOR 16F BUILDINGS
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`PHIL GOUZOULEI _
PP PHILLIP GOUZO t
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N1{1RBLEHEAO,MA 01945 -Adminlamtor
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CERTIFICATE OF ,INSURANCE osroaroa
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PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Tuttle&Traina Ins Agcy Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Po Box 489 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Sterling, MA 01564
COMPANIES AFFORDING INSURANCE
COMPANY A GRANITE STATE INSURANCE COMPANY
INSURED
McIver Construction Co Inc
5
35 Norfolk Dr
Littleton,MA 01460-0000
I
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR !
THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER
DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE +
POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN
MAY HAVE BEEN REDUCED BY PAID CLAIMS.
co
TR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE
q NORKERS COMPENSATION
ND EMPLOYERS'LIABILITY LIMITS
ME PROPRIETOR/
PARTNERS/EXECUTIVE 6
FFICERS ARE: C
NCL o EXCL❑ 8722262 12/20/2004 12/20/200$ STATUTORY LIMITS
THER E
ovmege Applies to MA Operenons Only.
CH ACCIDENT $ 100,000I
DISEASE POLICY LIMIT $ 500,00 0
ISEASE-EACH EMPLOYEE $ 100,00
DESCRIPTION OF OPERATIONSIVEHICLES/SPECIAL ITEMS I t
1.
CERTIFICATE HOLDER CANCELLATION
PHIL GOUZOULE CONSTRUCTION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY W ILL ENDEAVOR TO MAIL 1Q
50 EVANS ROAD DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
MARBLEHEAD, MA 01945 FAILURETO MAIL SUCH NOTICE SHALL IMPOSE NOOBLIGATION OR LVBILITYOF n
ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. �!
AUTHORIZED REPRESENTATIVE
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\= The Commonwealth of Massachusetts
Department of Industrial Accidents
i+t = -= OHJeee/IpYestl>aetlB�
600 Washington Street, fb Floor
Boston,Mass. 02111
Workers'Com ensation Insurance Affidavit: Buildie lumhin lectrical Contractors
name:
address: S-0 411 l 1U,
city I ✓A 21-t i7/e-" state, M/1— aox Dji q-J phone#
work sitc location(full address):
❑ I am a homeowner performing all work myself. Project Type: El New Construction❑Remodel
❑ Lam a sole Proprietor and have no.one working in any capacity. ❑Building Addition
❑ I am an employer providing workers compensation for my employees working on this job
,>
Mir
r } S' "� n 5h5C. ' 'a& $4 `k.�`✓,.t^ �s tom,. -.tt i- �°c ��+ -e:" •g �y
R
NO
insuraatE
.
I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name: / iL1y4e V� C-0 N57
address 3S iw0/lt GZG( ��i
city L 07 4 4 fll'i p7/9 Df U phony,F c x . .
x ;^r H 3� 7�, >�;5� � . � '#: is e. =,�- '+k k � r y *a"°�'g• *�` `� / '�"`r+,v
<
�r
-, r .S:mFtc +wc.s '.�, oiry'Y�'1;@S" a .rii t� S 1: "- vv' 'a` '''��
comnanv name: . t.. . yr»,� r-r' .,.,n s,.,yu v-'^.,'&r,'-w"4v .:,41
.a " �yd a d
xe��i< die s x€ "�
address: �kA
i R
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up m$1,500.00 and/or
one years'imprisonment well as civil penalties in the form of s STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that s
copy of this slatem nt ma be forwarded to the Office or Investigations of the DIA for coverage verification.
I do hereby cer n r the pains and penalties of perjury that the information provided above is true andc rrect.
Signature Date 3( �� _Qq(y
Print name u �� Phone# 9 1 7-0 j) O [ I I
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
❑ ❑Sete check if immediate response is required ❑ tine Board
elenmeo4 Office
Department
officialoomct person: phone#;