33 HANSON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CNlR, 7"edition OF SALEM
+ Rrvised Juttuan•
Building Permit Application'ro Construct, air, Renovate Or Dcmolish�a
One-or Two-Fur 'v Dn llitt
`( This Sectiu or Of7icia Use my
Building Permit Nu er. Date Ap lied
Signature:
Building Commissioner/Ins for of Buil ings Date
SECTI 1:SITEj;KFbRNIAAON
1.1 Pro a ddre'ss/ /� 1 lesson Ma & Parcel NumbersL l a Is this an accepted street?yes——no_ a Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
tuning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks III)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERS�H/IP'.
Name(Print) Address for Se ce:
&
Signature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description ot'Proposed Work': •�
d
O
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
y Check No. Check Amount: Cash Amount:
�;,1_ _
6.Total Project Cost: 1 071. 65f ❑paid in Full ❑Outstanding Balance Due:
1(? eot (( G,�l
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) P q 3 .j
/.�// 1Ael.4" /7 E Kg;, /b License Number I:sp' ution D to
�yyy�,,r{o •of CSl I It d•r ff�� r
/,/ l n/� � M)� O/A -0 i.ist CSL�I)pe(see below) �
j - /�/- w/n DU. n/I Y
\ddress t' Description
Ff ,
U l gvesx a W ieteJ to 35, 0 Cu.Ft. ,
It Restricted 1&2 Family IA%cllin
yti/'gngqat e U NJ Nlason Only
/t 7/ /777Z RC Residential Roofing Cuverin
fcle WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re tered om n provemgnt Contractor(HIC) registrat�i'o—n'Number
IiIC o pa N- r_xr IIC 1 ��islmn une Address7non D to
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the lssuan)76 of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. ,El;nr7Y G royhol as Owner of the subject property hereby
authorize 4:4'AA 4641_ t'-0-4a- to act on my behalf, in all matters
relative to work authorized by this building permit application.
Sit at of Owner Date
SECTION 7b:OWNEW ORAUTHO�R/IZEED AGENT DECLARATI N
1,1i1�1z, r02&,ZKR4b AM_ Id Al 6',?A caner Authorized Agent rebydeclare
that the statements and information on the foregoing application are true and accu es o my knowledge and
behalf.
Pr'
. i ure Owner or Auto ent Date
(Signed under the ptiins and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(FIIC)Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115. respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"
NSCAP
98 Main Street
Peabody,MA 01960
Tax Exem t#:042-385-280
Agency: NSCAP
PROGRAM: National Grid/2011
JOB NUMBER: 0 LNGRID Application#: 0
Work Order#! 0
Work Order Date: 07/08/11 Job Limit: ,
Primary Contractor. A&M General ContractingPer Unit $4500.00
Other Contractor:.Clifford Beckford
Client: Elinor Fouhey K+T Yes=1 Now
Street: 33 Hanson Street K&T: 0
City;State;Zip: Salem,Me y 01970 I
Telephone: 978-744-1337 Stand Alone: No
Fee Code: 0
t"Blower Door Test No a Stand Alone Yes=1 No=
Ins ect Knob&Tube: No Elec.Contractor. "
Attic Insulation'_ Est '':Act Cost- Est Cos Act Cost
Attic Flat R49open $L53
Attic.Flat R38open $1:40 v
Attic Flat R30 open
Attic Flat R20 open '$1.23
Attic Flat Rl0open
Attic Flat/Slope R30 restricted - $1.41
Attic Flat/Slope R20 restricted $1.35
Attic Flat/Slope RIO restricted $124
Attic/KW Floor Transition DP-tin.ft. 66 $2.40 $158.40
Attic Kneewall R 13 $1.25
Attic Kneewall Floor R30 restricted $1 41
Finished Attic Access $100.00
Temporary Attic Access $75.00
Crawl Space w/Poly Vaporp Barrier $2.53
Garage Ceiling/Floor R30(w/approval) $2.00
Vent Dryer/Bath ExhaustFan 3 $85.00 $255,00
Thermadome $175.00 . t�
Roof Vent small - $76.00
Turbine Vent $160.00
12"Stack Vent $145.00
Pro pa Vent 4 $3.75 $15.00
Gable Vent all sizes $88 00 €,:
Soffit Vent $26.00
Attic Air Sealing 2-part Foam(2 hrs max $75.00
0
L ti
i
*' ei Elinor Fouhe _'•_ Pa e 241 National Grid20l i
Est Act ost Est Cost Act Cost
Wall Insulation
Sin a Nailed Asbestos/Asphalt RIS DP '-
DoubleNeiledAebeeim/Aluminum RISDP Jp 50Q
Brick/Stucco RI5 DP;,-
Interior Wall Blow-Plaster RI S DP
Cia board/Wood Shingle./Vin I RIS DP $1 70
Test Drill 4 sides '
$60.00 � e
I
Air Scalia Limit:
Sin eFamil w/Blower Door=$400 _
All Others=$200 ....„`
Door Kit`. $43.00 -
$15.00
Automatic Door Swee �,."T •= '
Air Sealing 2- art Foam(3 hours max) r$75.00
Sash Lock $9.25
Glass Replacement $42.00
Blower Door Seto $45.00
Total Air Sealin Cost-" _
Heatin S stem Measures -
Duct Insulation&Seal Seams s it $2 95 ..
H dronic Pi a Insulation to 1"R5 $3 25
H dronic Pi a Insulation 1.25"+R5 $3.50
Steam Pipe Insulation to 1.25"RS $5.25
Steam Pipe Insulation 1.5"=2"R5 %$6.05 _
iBoiler/Furnace Re lacement $0.00
"Prograrn Repair
"*Action approval needed:Max$500.00
Actual Total does"not include$175.00 K&T chg. S1S28.40 11,jEstTotal
' 50.00 Act Total
AUDITOR: Brandon Dorrington
ACTION, INC
' 47 Washington Street
Gloucester, MA 01936
Agency: NSCAP NGRID Application#:
$PROGRAM: AARAWAP 0
JOB NUMBER: " 0
x DOE Work Order# 0 E.S.C.performed? No
Work Order Date: 07/08/11
C _ Primary Contractor: . A&M General Contracting
t " "_ #Bulbs installed $0.00
t k4 Other Contractor: Clifford Beckford.
Cost of Bulbs $0.00 '.
'-_- Client. Elinor Fouhey. ry ins $175.00 Max $0.00
m,
''> n Street: 33 Hanson Street Other In Kind $0.00
>- '
x41�City,State;-Zip: Salem,Mat �j 01970 Electrical Work $0.00
Telephone: 978-744-1337_ $Amount KeySpan $0.00
$Amount National Grid $0.00
* Blower Door,Test „t,4 No 4 Other Utility ' $0,00
Inspect Knob`&Tube ': No _ ; _
Date Job Completed Estimated Repair Total $557.00
.'; + si ,'s 41,,P-� 4 - - E'y�. Actual Repair Total t•. $0.00
Weatberization `=w1=" " " '.Est Act C
ost Est Cost ' Act Cost ...r
Door Kit= Ate p 7 $301.00Re lar DoorSwee � 5 $75.00
Automatic Door Swee """ "h!Air Sealing 2-part Foam( er hour) 4 $300.00Attic Air S41ina 2-part Fob(per hour)* 3 $225.00 -!'
Weatherstri Window( er side) 1. I'i t
Seat Ducts-Mastic 4 $62.00
W/S•&Insulate Attic Hatch R30 $30.00
$0.00
$0.00 1
$0.00
$0.00 q =
$0.00 ii•P°
$0.00 n
WeatherizationTotals: - $901.00
Insulation " ' _ Est Act Cost Est Cost Act Cost
Sub-Attic Roof Cavity DP R38 35 $1.40 $49.00
Attic Flat R30 open 396 $1.30 $514.80 c.
Slopes R30 restricted 90 $1.41 $126.90 '
KWF R20 restricted-. _ 477 $1.35 $643.95 �+
Attic Kneewal Blow Dense Pack. 396 $1.70 $673.20
Attic Kneewall R15 Cell w/Membrane $1.65
Attic Knawall Floor R30 restricted
$1.41
V
ttic Stars&Wails $130.00-Aluminum R15 DP 1766 $2.20 $3,885.20all-Plaster RlS DP $1.81BKwallSealedSeams 396 $1.85 $732.60ation R5&Seal Seams $2.95 ' 11' •`Pi a Insul to 1"R5 $3.25 All
3nsul to 1.25"R5 - $5.25
DHW Pipe Insuation R5 6 $2.50 $15.00
Insulate Door w/FB(1"min) 3 1 $44.00 1 $132.00
Sill 2-part Foam w/FIG Batt R19 "' 1 1 121 1 $2.00 1 1 $242.00
Insulation Totals: 1 ?. ' $7,014.65 $0.00
"Elinor.Fouhey Page 2 DOE 0
Other Measures Est Act Cost Est Cost,, Act Cost
Roof Vent-small '`+. #_ ,$76.00 4 i
Gable Vent-rectangular. $88.00
Recessed Can Cover _ $30.00
Cut/Finish Attic/Kneewall Access $100.00 mug=i+ +
Test Drill Sidewalls 4 sides $60.00 �r,..,.I;
Blower Door Test :,5:,:. + $45.00' •
z tic,. .,.fit.:.
Vinyl Replacement Wiiadow-101 ui 3 $350.00 it: c $1,050.00 t
Steel Pre-hung Door w/Lite $610.00 x, , a
Solid Core Door w/Hardware . $350.00 a:1•t -
Faucet Aerator $15.00
Low Flow Showerhead'* - $25.00
$0.00 ?, t'I
$100.00 •se: a+,
Other Totals: _ .„ $1,050.00
Energy Conservation ant ; X n s �Est Cost 'Act Cost
Totals: (Max$10,000.00) 1 1 1 1 $8,965.65 $0.00
I
Repairs Est Act Cost Est Cost Act Cost
Repair/Refit Door 1 $50.00 $50.00 ?
Adjust Door' fry;' 1 1 $20.00 $20.00�,;`
Clean Gutters(pr hr) 2 $60.00 $120.00
Sash Cord 6 $17.50 $105.00
Remove Old Fallen FG r hr) 1 $60.00 $60.00 Dispose of Old Fallen FG( r hr) 1 $60.00 $60.00
Glass Re.lacement to 64 ui 1 $42.00- $42.00
Site buia 1nt.Bulkhead Doorw/Jbs $415.00 "t
Building Permit Fee 1 $100.00 $100.00
$0.00
Health&Safety
Vent Clothes Dryer to Exterior :: $85.00 .k=, *. to,
Vent Bath Exhaust Fan to Exterior $85.00 -al 1:1 _
Replace Dryer Hose. $38.00 Nr 1.
Knob&Tube Inspection $175.00
Bathroom Exhaust Fan,. $500.00
�- $0.00 „r u :
Repairp Tot:(Max$2500.00 `_. ' " 'c $557.00`"'" $0.00 -
Work Order Sub Total: $9,522.65
Measures- Est Act Cost Est Cost Act Cost
Other ' $0.00
'.:.Other . ;. $0.00 €. .° •-,i, • .
**Heating S stem Repairp $0.00 $0.00
**Action approval only
Estimated Job Total: $9,522 65
?Job cannot exceed$10,000 00 ' ` .,
'Job minimum=$500.00 "Job Grand Total: $0.00 `
i
' AUDITOR: _Brandon Dorrington
a
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual):
Address:
City/State/Zip /fig,0y h?,4 0'i96(7 Phone 'r#: �>,Q ,�( r 7 77-
Are u an emplover? Check the appropriate box: Type of project(required):
1. I am a employer with- 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ oof repairs
insurance required.] t employees. [No workers' /,airs
comp, insurance required.) 13. Other ,V S_.d�
Any applicant that checks box,#] must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
Con tractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ,p
Policy#or Self-ins. Lic.#: ,// 7`� Expiration Date: L `n a /
_ /f
Job Site Address: .3 N iQ/�/ ��� �� City/Statemp`�' l�/7 7
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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 S250.00 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 hereby c the pgs d�pcnalties o eriury that the information provided above f true an correct.
Sign Date:
Phone#:
Official use only. Do not write in this area, to be completed by chy or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contact of hire,
express or implied, oral or written."
An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, &25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate'a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be, sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit,multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy informanon(if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. 4 617-727-4900 east 406 or 1-877-N ASSAFE
Revised 5-26-05 Fax 9 617-727-7749
www.mass.vov/dia
OP ID: SM
ACORL7" DATE(MMfOD/YYYY)
`.� CERTIFICATE OF LIABILITY INSURANCE 03/21/11
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
'IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,Certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsements.
PRODUCER 781-224-5700 CONTACT
NAME:
Mazonson LLC www.mazonson.com 781-224-5777 a"Co"N EA I, ac he
701 Edgewater Drive E-MAIL
Suite 230 ADDRESS:
Wakefield, MA 01880-6236 cucsioME"R ID M A&MGE-1
INSURERS AFFORDING COVERAGE NAIC p
INSURED A&M General Contracting, Inc. INSURER A:Peerless Insurance Co
Norman Dube INSURER B:ACE-USA
119R Foster Street
Peabody, MA 01960 INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING 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 BY 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.
INSR TYPE OF INSURANCE POLICY EFF POLICY EXP
LTR POLICY NUMBER MMlDOlYYYY MM/DD/YYYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,00
A X COMMERCIAL GENERAL LIABILITY CBP8762001 03/20/11 03/20/12 PREMISES Eeoccunence $ 100,00
CLAIMS-MADE Fx—]OCCUR MED EXP(Any one person) $ 5,00
PERSONAL B ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00
POLICY 17 PRO- LOC S
AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ 1,000,00
A ANY AUTO BA8762301 03/20/11 03/20/12 (Ea accident)
BODILY INJURY(Per person) $
ALL OWNED AUTOS
BODILY INJURY(Pera¢ident) S
X SCHEDULED AUTOS PROPERTY DAMAGE
X HIRED AUTOS (Peraccident) $
X NON-OWNED AUTOS $
X UMBRELLA LUIB X OCCUR EAC'OCCURRENCE $ 1,000,00
EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,00
11 03/20/12
DEDUCTIBLE $
X RETENTION $ 10,000 $
! WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LWBIUTY
B ANY PROPRIETOR/PARTNER/EXECUTIVE Y-- C46275251 03/20111 03/20/12 E.L.EACH ACCIDENT $ 500,00
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,00
If yes,describe under
DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT 1$ 500000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more apace is requlred)
CERTIFICATE HOLDER CANCELLATION
SALEM-2
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ty ACCORDANCE WITH THE POLICY PROVISIONS.
93 Washington St
Salem, MA 01970 AUTHORIZED REPRESENTATIVE
HO > y
0 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logoare registered marks of ACORD
1
� s, ✓�re F[.am rrurnueall�e- o��.'Glrzau�c%itiieCGi .
Office of Consumer Affairs&Bestness Regulation .
I r� l�HOME IMPROVEMENT CONTRACTOR
r Registration: 141124
9 ,Expiration: 1112/2012
«..�.%;,. Type: Supplement Card
€ A+M GENERAL CONTRACTING INC.
i
MICHAEL FITZGERALD
4 5 SOUTH RIDGE CIRCLE
LYNN,MA 01904 Undersecretary
.*=. \lit"a hu.cth - Drparnncnt d pubilc Nalri% -
Bnard ut Buildin_ Nc_ulatiun, mid 'IM"i;rrd1
.onstrucbon Sup,*wsor Specialty L!cer+.se
License. CS SL 99933
Restricted to: RF,WS,DM,IC
MICHAEL FITZGERALD
9 WINCHEST COURT
GLOUCESTER, MA 01930
Fzpiration. 6/19/2012
Tr' 99933
CITY OF SM EM, NWSACHUSETTS
• BUILDIING DEPsRT%l&NT
130 WASHLNGTON STREET, 3"FLOOR
sY TEL. (978) 745-9595
FAX(978) 740-9846
KI\BERL.BY DRISCOLL
1
MAYOR �to;vtAs ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUUMNG COMUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit# is issued witli the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(namof facility)'
(address of facility)
signature of permit applicant
JcbnsalLJn: