6 FOSTER ST - BUILDING INSPECTION +;r
fLl1M61NbSf'sE II �t VED BY T+IE e
JdSAECIL�B W D YMUPT R INR GRANTED
CITY OF SALEM
N o. `�� Dft 3v o
Is PraP"Laortrd in roerrion of
fN H tado Dktdd7 Y No Dai]dina Q<
IN Property Lcamd in
Permit to: BUILDING PERMIT APPLICATION FOR:
'
(Circle whichever apply) Roof Reroof, Install Siding. Construct_Doolt. Shad, Pool
epaldReplaos. Other.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCEMM
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the tkwinp
speciHcatlons: / /
Owners Name t,,/ R.� �G 1 Z1
Addresa & Phone ios-/c ST ( 1
Architect's Name
Address & Phone ( 1
Mechanics Name /�1G/lam s�.s a ry '� -0
Address & Phone Sef Dr. L4-4ere4(
Whd bti Vo pirpow it W a W
Mwiw of twYdrg4 Lvo uc/ M a O&W ft.for how mmy bmarr4 ,
WE b ik"carom b kW ''
Edm@W cW. 6 5'0 0. ° Su Clly Uaiw r N P` umm to
eIso nat
ature of Apotl6ant
SIGNF,D UNDER THE '
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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{ + , MAIL PERMIT TO:
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boo W-1-11asSheaf
�ametlCamows &,L.,. Y1... J.Ib 02111
Coesnsaoaar
Workers' Compensation Insurance Mdayit
. . with.a principal place of business at:
�e
. . (tarNe.e.rir2 .
do hereby'ctnify under the pains and peniltim of perjury, this
() 1 am an employer providing workers' compensation coverage for my employees working an
this job.
Insurance Company Policy Humber
I am a sole proprietor and have no one working for me in any npaeky.
() I am a sole proprietor, general contnetor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation polieks:
,�J�N 1
ntractor Insurance Cornparry/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
i Ynoeescane we a cool or"au<emene"a be io,aroee m the Orke of Mwcrano+o of the DM for coversre •wfaown ane O n Ulu"m.eeere
comarr M reo"re sneer Section 25A er MGL 15 2 can kae w eAe inverlien of c'+o'na'ocnnda eormdnr d a rwe of we 041.500A0 WWOf ooe
nan"rrarwnn<nt>r ai ciei naiun � the lone o(a STOP WORK ORDER as l im of S 100.00 a ear OSARA we.
Signed rhis day of .. G
ccnsceiFcrrniuet iiuilcing Deparrrrrent
uccn-ing Ecar�
seieetmens Office
nc<Ith DtP2r*rr1cn•
ACORD CERTIFICATE OF LIABILITY INSURANCE
03/26/2005
mDDDceI THL4 CERTifIC1{TE M ISSUED AS A MATTER OF INFORBIA710N
Water Street Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
9 Y HOLDER THIS CERTD76ATE DOES NOT AMEND. EXTEND OR
27 Water St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Wakefield HA 01980
7912450898 INSURERS AFFOROMG COVERAGE
Helina Ryan IEI�M 9Yestern World
Ryan 6 Sons oasuac One Beacon
13 Sunset Dr EowRgTc Li bertY Hutua.l
Wakefield, HA 01880 a - -
MSuaFR e
COVERAGES
THE PCIAMS OF DISURANCE OSTED BROW MW BEEN ISSUED TO TM BISURFD NAMEDAROVE FOR THE FOLICYPERIOD NWCATEO.NOTWRHSTANOMG
ANY R90UMEMENT-TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCIBENT WITH RESPECT TO WMCN TM MnINCATE NAY BE ISSUED OR
MY rERTAM.THE SLSIRAHCE AFFORDED BY THE POLICIES 021CROM MISIN ff SUMOT TOALL Tiff TLRM.EXM UW*S AND CONORDNS OF SUCH
POLICE&AGGREGATE LIARS SHOWN MAY HAVE BEEN REDUCED BY PAD CIIVfS.
trni TYN or wR,oAEe i IDIILY ROIFER I WNIA
004AAL LYIDIVIY I fiAON OCEIApiNCF s500,000
X I COLMEA MdAftLWA— i mma swcEwm.&v lo100,0DO
i��UAAt9NN IX m "mote YbeDDDwwM i 5,000--
I NPP818810 12/02/03 12/02/04 v0a8DTwLSATArMAwY s500,U60
Ee,eAwt AaGALUTE i500,000
DpILATdJ69ATEMIDT AN+NEEALA: •TALOAIPAOG A$00,DDD I
_WIi0MD6AE LwMU1Y I GONBw®SIIIDLE LDET
IAw AUTO IEADNwTO E
ALL DNM®AVOS %Romy"A RT
X SC WUL DAVTDS I P'Rrws m i100,000
BI MMDAWOS ICBXB23137 02/11/04 02/11/05 eDDLrwIUTY
_ �HORawHEDAurxi i PRimw^° 300,000
i
100, 000
wAAu u.eA,n ; � � '�AlnD arLv,wAecGEHT ii _ _
._ 4NT LL1T0 I o/lIFA THw TyArc s
I AVID ONIY. A G I S
EECEnIYDDmT � I I fiIGIOCIVMDICF { I
OCQw C l:NM91wDE I AGGREWTE 9 --__...
I wetiNteA i I ••••• i ^,
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i WPR11EPf GpOEy,1110MA1p A�MLL OT14
AnLevGArLiLTMm WC531S349832013 12/09/03I12109/04 EA,mAcNA000PM 3100,000
CI F..aTeAai_DATA�D.EF s100 000
�mAml
FiyLOAoe-rOLCTLrarr s500 000
' I I
oTxArno.GA aEAATnEin°cAruALaFwnELA71ESAso4 AmEDAY L.mnea..4.miL FADD®NS
CERTIRCATE HOLDER AIiRgAAi D4DAED:DLDY Lo ! CANCELUTION
O r /T DIID"D Oi"a am"=Snam 10VEAE w EwE�;m DFAORL TEF m""TIDD I
[V••T c GATE TAEI�.TIIF I mmm N WRL ENDFAYq TO HNL 30 GYS YM°
MRRATOTWCMRRCAW 1pLPgl w TO TW UWt.w MXIWTO W 90 SML
Wn LIO ON16ATML OR LLGARI6 ANT IUD VON DR YNWEA RA AOIIITS OR
RPRESMARVI
' ADTA®ITIW
ACORD 2"pN7) BACORD CORPORATION T SSS
' PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, SRO FLOOR
SALEM,MA 01970
l TEL (978)745-9595 EUT. 360
FAX (976) 740-9646
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 constriction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III,S150A
The debris will be disposed of at: 6`0,f-k Gs Sefv( Le
Location of Facility
Xb d Z�1-11
—
Signature o emmt Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any
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.
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