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8 HOLLY ST - BUILDING INSPECTION { 4 h�J \ t��rh• s4Y1 r• t A �C,�C 4.. rP, s�..h r r it ' '•i (;$} �:V � :,! x'� 13{`�.p�' "{ e4 , I ?^lr��°i�'J^$h�y*:•.�W�d��') f�r'',4+��3,1 • .. . t,` ,Tr.r'in "'4' ,:^F$'�d d+`v-;;. : l • •':°dr1.{miA ati `P? t! `� Y�' +XSI. r. J t . .ri'i f r .., FT. :4'J(,)1 , • .jYrkltf '1."�' y1�t,,k: Nt....1:1 • .' U ad'.r...S 7ta aS lY:tK i,T a 9,.'.t {yrh n�:,.-.L +" .hi'✓ .'aY i�,�p :y<w i:ry Fy f�,.t:..na,.. '.A-t rf]`k�$}' xll.�ax%rlu'ytr a • _rt,a? .._ ' 'fs" .,:,,. r `3 r1=,k ,$be-. r "�= in Y'1'iti'4 P.9r i f;t,Si`: Y;t� i byy Ani ._.... .'.;ytm,xt i�„%6PAF r ,'ttY'r-'t•r<"M1M1I *'j'y��;. }t4 `i&k)Y'l�Ih;k,:'. 11;F.w., -`!'( 'M�a'tk3p,'11)'tV tip:QYk9 t}q,•9�:ei. >+;�Y3::Vf i} `1.�4r$: ilt t lt: r ra FA1:Y4i �3`4 evi�ir..�i+.. : i tµA e r „ Q= Z ✓1 0 : r °' o 1 Za w m o -a ort >Z — F- U 4 c o W a z. j n.- < z DATE: &e , o Citp of �R)A.YEmr 'fflaS5arbU!5ett5 PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED Building Permit.Applicatioo For: Location of Building a-LI '(Circle whichever applies) Roof, Reroof. Install Sidin Construct Deck, Shed,Pool Addition, Alteration epairgla ,Foundation Only, Wrecking Other. O ' 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: Contractor.__TfJt���, t G/ Street Gc ; City Street/4 eqi92'tj State Phone (970 71/S ,J 3.77 State 1' Phone Architect: City of Salem Licit Street City State Lic#O7Z?iti HIP# State Phone ( ) Homeowners Exempt Form_yes no Structure: (please circle) Single Family, Multi Famil # Other Estimated Cost of job$ Will building confirm to law? :fives no Asbestos?_yes o Description of work to be done: A1114&,t,/ C rc 1fj2.1A.10 A4/! L4/0 7-V eZiD E Drawings Submitted:_yes nqj Mail Permit to:g X Signature 6A rcation, _ DUN ER THE PENALTY OF PERJURY CONSTRUCTION TO B OMPLETE\D WITHIN SIX MONTHS OF PERMIT ISSUED DATE Department use only: Pernif'# —VZ�ing Map/i ot_r_ Permit fee `%x?% COMMENTS: a CITY OF SALEMv MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3Ro FLOOR SALEM, MA O1970 TEL. (978)745-9895 EXT. 360 40 FAX (978) 740-9846 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 construction activity governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility,as defined by MGL c III,S 150A. The debris will be disposed of at: Location of Facility i of P&inlfApplicant urge FULLY complete the following information: (PLEASE PRINT CLEARLY) Gam/Gk� /{ ;'�t' t /Cc i Name of Permit Applicant Firm Name,if any Z" Lt 9'�A 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 ca SI50A, and the building permits or licenses are to indicate the location of the facility. AC(�RDU CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/01/2005 PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 958 Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA.WORFOLK 6 DEDHAM JACK HINCH CARPENTRY INSURERS 19 Irving Street INSURERC. INSURER D. $ALEM MA 01970— INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCV PERIOD INDICATED.NOTIMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT MATH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRO TYPE OF INSURANCE POLICY NUMBER DATE(MMOMY) DATE(MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 300,000 X COMMERCIAL GENERAL LIABILITY PREMISES(RENTED ) $ 50,000 CLAIMS MADE D OCCUR R0003951 08/01/2004 08/01/2005 MED EXP(Any one pew) $ 5,000 PERSONAL S ADV INJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 600,000 POLICY JET LOD AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea a iderr* ALL OWNED AUTOS PODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILVINJURV (Per a¢ident) $ NON OWNEDAUTOS PROPERTY DAMAGE (Per axident) $ GARAGELIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—ICLAIMS MADE AGGREGATE $ S DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TOURV L MITS OER EMPLOYERS LIABILITY ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? EL.DISEASE-FA EMPLOYEES If yes,describe under SPECIAL PROVISIONS beb EL DISEASE-POLICY UMIT S OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. (AUTHOR REPR SENTATIVE A{�C, ORD 25(2001108) ©ACORD CORPORATION 1988 V6 INS025(0108).05 ELECTRONIC LASER FORMS,INC.-(800)327.0545 Page 1 of 2