26 HERSEY ST - BUILDING INSPECTION (2) i�L�lllssJUSfi-BEfiLtg4A9 APPROVED BY T44E
=PFCIDl3 pWOR TD P6W.A PE BEING GRANTED
CITY OF SALEM
Date
i"
Is Pmpwty Located in Location olZ
Vw Historic Meld? Yak__No
is Property Looted in
no Conwivadon Ama? Yat No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Ins, ding, onstruct Deck, Shed, Pool,
Repair/Replace the
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:
Owners Name 110/ ed1/off i—Zef
Address & Phone � �
Architect's Name
Address & Phone
Mechanics Name I 14 7 n o S
Address & Phone 8�a�/�5 611, ( 1
Who is Vo purpose of bWldW /I
Mal"of twlldlnp?/ C n a dw ",for how many families?
WN b kWQ confoen to law? N S_ Asbestos? N`D
Eonated coat r2000 , City ucarwa r N A State Llcairsa a C� ��O f
Rome Iuprava t
r'i`' #' Signaturi orApplidint
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:�C��/iN &— AoT Ax
No. - o�
APPLICATION FOR
P//ERWr TO
LOCATION
PERMIT GRANTED
2.0
A PROVfD
INSPECTOR OF BUILDINGS
The CommaoxweoltlY ojMyssachuserfs
Depardnert of InduiWd Accidents
Ofa*fhWeS*A*"
600 W inset
esirLlstow
Boston,MA dull
Wwntnua jowad
Workers'Compentadoa bsurana A8ldrAt:BWMemAContradorwYledrW&= lumbers
Aonitcmd bt►t,=xdm 7 j Plan Plist Les<lbly
Name /! f-��i2�ca6✓S�G�.
Address: `'I Cm-al�rS
City/State2ia_�5 Phone
,.:
Are you ss eta?Chtiet tbi ripproprhde boos:' 1YPe dP de9dred):
I. I am employer with e: Q I am a gtmal combaesor and I 6. ❑New oomttoetion
ployaa(1ha and/as paR.d=1* have hied ms mit�edslrateors
2 I am a sole popielor or pstmam listed a doAUKW obeet t 7. ❑ Remoddmg
ship and have no employs These snb-metraaot have L O Demotidos
vsoddtrt tm is sagl mpacigl. w R/'�mP .10110180009. C1 Building adOm
s. ❑ Wems
(No worhaa'gamy,iamrasw and its. MO Elm repairs or additions
legp�l,, offian ti ye dk*
3.❑ I am a bomeown r.doing ap wwk right of p 11cii' 11.0 PhmebbtB rcp*s or additions
mysdt:(No wodxW-castp m IS$�1(. aslji�iebave'no 12.Q Roofrepafir
fit` ME3 Other
iosstsmoeCOW r
;Imy gipUc Aa*oft bmal=0 rho 6.0 nit*[=Wm tebv Am*6e�.w�p'ooagm�o�ply
trinesomasrr[loahmttQlYo�drva��wd�artlwtdthehpja�ei/�aontloKmr�irtabmit�aw - vitodiatin��orh -
tCmtrrbathdAmIddrboa'tmtanwham@&MW drbrednwmanrambrttt ddWk%Vha'om¢poL7bdb m dm
I sas qf mplVYW am ISPWPIAWS> 9.emppememlon brswwwfirxwa ~ RdewkokpoNees'a djobift
b f..ar don.
Immanoe Compayxama �-- �JP�r-C�h / � J
Policy 0 or Self-ios.Lis.e: 1;3/ce 0 70/Z Patpi'atios Date �l/s /off
Job site Address.2 c City/SW/Dp; -5'z/e ` l
Ateseb s copy of d o workers'eompeuatloa po ft dedaradw pall(dowdg the poncy somber and esplratlon date)6
Fathue b aecare avetaPt at regtmed soda Section 25A of MGL a 152 can lead b the
6ae up b t1,500.00 asd/ar onayar hWieonmeA as well a civil ofa STOP
W RK O penal an of a
ofup b$250.00 a day against the vioWne. Be advised that a in the no of a STOP WORK ORDER and s fine
Invet�tions of the DIA for fimu m coverage veri$mtios.SPY ofthis sortemat may be forwarded b�a OtBce of
I do Aarbp womdar&apWW ardpeneWer fpedkm that for brfwmados p vvl*d oboes b amr and ce"W"
'00-
i
O,BIeld mar mbL De ed wr&/w Ift one,ri tit cons ldd b cAyarsom ealrld
City or Towns Pamkll.lemse it
Issuing Authority(drde one):
1.Board of Haiti 2.Building Department I City/Town Clerk 1.Eleetried Isupedor S.Plumbing inspector
6.Other
Contact Persons Phone M:
Information and Instructions
remerd Laws ehspla 152 minima all emPICOM p PRmr O 00Q y Conuact ofbit%
Maaaacha+du is deSned " !►DasDu in the auvice of another Under any
pnsauaat to thin Stone,an s.lt y�s
e:press Of imp"oral of wnttes
aaoch"otxpowaoa fir oda IW eatit s Of any two Or more
oAn wop&OYW[ h� ��t6a� a�a docendb emP� q�
receiver or trmte0 of aver Wdividgd,parmaship,afaOOMIS or other le fal emuY,employ off .
owner of a dwel tbouse bavhat not mot than*M apart Sod who raids therein,or an dwdit Lame
dwenmg bonne of Staot W who enPloys pesos to do mSmteaaatce.oonsauctioS or aepair we#
'err on the grounds Orbtn']diot appentenal gwee shati tot bourne of luck en ieymeotbe deemed In be an OVIOW
MGL chapter 152,125W)*0 surer dust"every AM err Wed USSI trt&VW"whiSbold the kaaaee or
wd Of a lleeaae or Pf mil a o�se a hadaeas or to ea osse haildlStla the oommoa
for xmy
reae
SPO& A whe here act Produced becepuble aideaee oc cony 1►e hnnraate eoverap te re
gtdrsd
Addltioealty,h!($.chaP/er 15Z.12S )stSta"Neuber the oommonwaHh nor SSW of in,Political ssbOiSk s aha9
eater into any ooutsw flu too pa6m�ofpAVC we*u�tl aaePtab>c evidence of camPlianca w�Ism inaafaaee
OftuiacbaPterbavebenpfamtedto*0Conkaedlmtao »
ApPBe>aim smmstion nerd.if
dffidsvit oplegely.by dwclmvt thebora that apply D Yom
pkat fll out due workers'cOSvpematmon wide rhea Via)
tueoassfy,sapplY cob-oo�S�s(a)Uame(ab SddraKa) phOSe mambasbi OI wi&no employees°�than Ile
insurance. Limited LiabOW (�or Lhz d Liabiht'It of
ingemem 1�f an 11.0 or LLp doer have
members or partners,at not regttued to OSry wow ° o[bmdtastrial
empkryen,s pobcy is fegoired Be attviud d0 dhir affidi►trit may be nbmitted tD the Dgwunmt
Allu to�and date the iffidavlt. The affidavit should
Aocides>s for�rmatiea of imarana coverage 44 We . of
be returned tO the city a town that the application far the permit or license is being fe4SatOd.Sot the Dot
hadnstrid Aceidtatr, Should you bsve any gitations r the utw of if you are mldred to obmina enter• their
paynys Pkau caII the Deptnlmem at rue tanaabef 11StOd bekaw. Self-ioared'eompaaaia
sei[insdusnce>i�tSUumber°U>be li0a
(2tY or Tower t)ttddS
e we that the affidavit is complete and printed leOly. ne Dcpartmem bas provided a space at the bottom
pleat b
of the affidavit tar You to fill out in the event the Office of Westigatious has to contact you fegarding the appllcaat.number which wa71 be need err a rcfereace tmmber. In addition,SIR aPPticut
please be sae to in the paumt/lieense ea Dead o submit one affidavit isdicatiag current
that must submit m kVle Pffmwl m applications in any given y only or
poky informat!on(if n anus)and Ender"Job Site Address"the appticam sbmld writ0"all hmatiOSs is (city
town)»A cOVY oilue sffidavit that has bean officialbr sWVW CL by the city a town may be provided 10 the
applicant as proof chat a valid affidavit it On file Got lhtm pamros of liceata A new aflSdatrit mnitbe 811ed ant each
s lieaue or paamt not rdaeed,t0 any business or commercial vesture
yew.
Whet a home owners m dtiaxa s obtSiaaiot
(is.a dog license of permit 10 burn leaves ere.)said pason is NOT required to complete Chia S�
The Offioe of Investigations would W to dLnk you in advaaa for your WOPeradul ad sbould you bave any questions,
pleat do not beam 0 gm us a uiL
ikpSrtmenYt address,tekpbone and fu nombe
The Commonwealth of Massachusetts
Department of Ind>strial Accidents
Office of Invt'stvtdow
600 Washington Street
Bost^MA 02111
TeL #617-7274900 art 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
r , MR. SHAW INSURANCE Fax:9787458584 Apr 13 '006 9:12 P. 01
ACORD CERTIFICATE OF LIABILITY INSURANCE �Il DATE
0 (MMDbi 6 MTODuc,E J THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
M.R. Shaw Insurance Agency Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OH
P.O. Box 4428 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Salem MA 01970 ---
Phone: 978-744-4540 Fax:978-745-8584 INSURERS AFFORDING COVERAGE
74SUa�;5I INSURER -Beacon Insurance Company
INSURER 8.
S
Michael dynkowski N;URERCI "---
9 Brooks tre t 'INSURER D: ---.—
Salem MA 019791
h IN9VFE"
COVI:RAGES — ---�
THE?O*JP I� C .9 OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A .ABOVE ICATAM MAY
ic.S ECC-R p,IJG
ANY REQUIREMENT,TERM OR CON01T1Qry OF ANY CONTRACTOR OTHER DOCUMENT WITH.RESPECT T WHICH a c 0 H Nj THIS C USIONCA N CO R1 IIONS O OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE PERMS,E%CLU$ION$AND CONDITION$OF SUCH
POLICES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIp CLAIMS.
fA
TR TYPE OF INSURANCE POLICY NUMBER DATE MM/OD/YYI DATE MMNI �� LIMITS
GENERAL LUIRI1IfYEACH OCCURRENCE 330Q 000
_X COMMERCIAL GENERAL LIABILITY FBIU07012 06/15/05 06/15/06 j PIRE DAMAGE(Any orr:firs) S 300000_
CLVLffi MADE EJ OCCUR
r-1 MED E)(P(Any orc pwr )) s 5000 _
L- PERSONAL d AUV INJURY S 300000
GENERALAGGREGATE 5600000 —
jCIEN'L AGGREGATE LIMIT APPLIES PER! � PRODUCTS.CUMPJCp AGG S 600D
POLICY —,PRO_ LOC - 0`' --
AUTOMOBILE LLAML i ---
COMBINED SINGLE LIMIT
A ANYAUTO CB1E53848 06/16/05 06/16/06
ALL OWNED AUTOS
I- SCHEDULED AUTOS I BODILY INJURY o000
(Pd(ppnon}
HIRED AUTO:
NO!J I BOOT L
-OWNED AUTOS V INJURY i 4
J_ (For:IcManq i 00000
PROPERTY DAMAGE ~`
PeromiAsnt) s 100000
GARAGE LIABILITY li AUTO ONLY-EAACCIDENT S
ANY AUTO —
OTHERThp
I� I AUTO ONLY: AGG S ---
EXCESS LIABILITY EACH OCCURRENCE S
I_J OCCUR CIAIMS MADE AGGPEGATE
^� DEDUCTIBLE ` ----
RETENTION Y j -�---
S
WORKER£COMPENSATION AND _ --�--
EMPLOYERV LIABILITY ---'LORY UMUS I -ER —_
EL EACH ACCIDENT $
ii E L.DISEASE-EA EMPLOYEE 5
OTHER
' FL 013EASE-POLICY LIMB S
_
A Commercial Applica FBlU07012 I 06/15/05 06/15/06 ! `
A Ero�art Section F'e1U07012 06/15/05 06/15/06 'I
De$CRF TION OF OPERATIONSILDCATTONSNEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECULL PROVISIONS
CERTIFICATE HOLDER N ADDITIONAL INSURED;INSURER LETTER: CANCELLATION
1111111 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL bAY9 WRITTEN
NOTICE TO THE GENTFICATE HOLDERNAMEDOE LEFT,
MPO n%SfiAUI -&— AGFNCT/vKAE;LTSAGENTS ,I
REPRESENTATIVE&
AUTHgiI r REP
M.R. Sha
ACORD 25-5 Inv) OACORD CORPORATION 1988
MR. SHAW INSURANCE Fax:9787458584 Apr 13 2006 9: C1 F. 02
IMPORTANT
If the certificate holder Is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed.A statement
on this certificate does not confer rights to the cenlficate holder in Ilau of such endorsement(s).
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain polices may
require an endorsement.A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not consiltute a contract between
the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does it
affirmatively or negatively amend,extend or after the coverage afforded by the policies listed thereon.
AGORD 25S(7/97)
CITY OF SALEMO MASSACHUSETTS
• PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3R0 FLOOR
SALEM. MASSACHUSETTS 01970 -
STANLEY J. USOVICE, JR. TELEPHONE: 978-745-9399 ExT. 380
MATOR FAX: 978-740-9646
Salem Building Dena_Mwnt
Dsbrla Dis __ 1 Arm
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
(Location of Facility)
Sign of Applicant
Date