14 HOLLY ST - BUILDING INSPECTION tF
'PL�11161AWIDE flt*54IND AP'PROVEO BY 774E
JMPZC=PWR TO A.PERMIT BEING GRAND
/ CITY OF_SALEM // —,✓/�
No. oats
Oats r C/
Jac Ward
ZWft olstrlcl
Is Property Located In Location of
U»HWAric Dbtdd? Yet No Building
Is Properly Located In
the C memaaon Ama? Yas No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof Install Siding, Construct Deck, Shed, Pool,
Repair eplace, or: w' Y
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accord4lo.to the following
specifications:
Owner's Name �Se. V' u i51c
Address & Rhone 144 oc sti L&�L ��MA,4 (q-IMl b-n kl
Architect's Name Address & Phone -� L�y���`
\` , q 5a1 QyM 0-6 )_ go-Z�I
Mechanics Name C"urt,6w&� ( G8V'A-& CO A F
Address & Phone?b2 0L�\L ,�I 1LAU-tI (°ll`d -n -ogzI
what Is trr prapm cI a u*W 1A T,W W%v)Dp W\S
6AdWW of Itulldkrp? N a dmo ft for how mmy famift?_LU
WIN buk kq c9ift A to law? Admdos?
Emnated orb `S�aty ucara r 15(A stay umm M O 5 a 4(o5
CW �� I MNb
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: 4C�-V'Ki
i
No.
APPLICATION FOR
PEFIIwT TO
0
LOCATION
1 `? m���
PERMIT GRANTED
AP POV�72-
, ,z
INSPECTOA OF BUILDINGS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STRaaT,3ND FLAOR
SAUU.MA O1 S70
TEL (976)745-MOO EXT.360
FAX (*7e)740-9/4a
STANLEY J. U9ovIcz, JR.,
MAYOR
DMIOMAI,OF DEBRb4 AFFIDAVIT
Ia acgordsnce With the provisions of MGL c 40,W I aclmowledge that®a a motion
of BmIding Permit 0 . A debris resulting from&a consbwdm.cdvity
governed by this Building Permit shaft be disposed of in a properly licensed soH&wasta
disposal facift,as defioad by MOL c a%SIX&
The debris will be disposed of at <111 uld`�, F-bo.) 1 Pi AVCA1011
Location of Facility
Sigaatrae of Permit Applieaat Date
0UASl3 PRW CLBARL meson.
qnp-
�
Name ofPezmk Applicant
Firm Name,if nay
Addceas.City dt State
The above astute requires that debris 5om the demolition,renovation,rehab or other
alteration of building or SaUc a be disposed in a properly-liceaaed soli waste dispoaal
facility as defined by MU cA S1SOA,and the building permit or liceroses are to
indicate the location of the facility.
6M WUL6#sbeel
seatw.aea &w "L. A..6 o.2111
Ceer..oer
Workers' Compensatiml Imoram Af ldwk
. . witk.a principal place of bushmm ac
10 Y, vyUCi � �G �
de he cerdfj� under:be pafas snd peaihiea of per}yy chm '
(`J 1 sun an employer peovk%g workars' compensation cowra#e for arty eiayloysea working m
this jsk
• 1..�.�j < � •' �1315' 3ZIS13a ��( .
inswance cbnww Few Humber
I an a sob proprietor and haw an ones working fd►was in any upader.
() 1 am a sob proprietor, general contractor or homeowner (circle one) and hour Mrad the
concianon lined below who•hava the following workers' conipenaufoe poGd1= "
Conwaaer irourancs Connpsrry/►o Nuaeber
Contractor Insurance Compaeq/Po Nt ndw
Contractor Insurance Company/Policy Number
() 1 am a homeowner performing all the work mystll.
• we.wat a..mat a eaq.f 06 wwwrw wa be forwareeg r dr 01req r b.a nwa of dk MA let tereraq.alandm aft AN taaan 0 rue
cawrap a I..Yer. 2SA N MGL 1 S 2 an lead w we baeeerie.ef obwu.eauds serueint el a aaa el.e M I.SOOAO reVer er
+rw/'" >r w bra.of aSTOPWORKORDEIt Peeafar.f5100A0aanaaiwme.
Signed chi day of ,
:iceraeeiFermiuce 6mlcrng Department
!jcensint Ecarc
SelecLmens Office
=mlth Gepat:mer,:
-_ - - - - _- - - .eeCC yt: _ spa epc ape 77c
06/09/2005 09:41 19787743581 TARPEY INS DANVERS PAGE 01
A RD CERTIFICATE OF LIABILITY INSURANCE 06/09/2005
06/09/loos
P (978)774-8040 (978)774-3S81 T I
Tarpey Insurance Group Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
491 Maple e St (Rt 62)-Suite 304 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 193
Danvers, MA 01923-0393 INSURERS AFFORDING COVERAGE NAIC/
INSURED Chet Dembows WSURERA Penn- America
P.O. Box 412 INSURERS: Safety Insurance Co 394S4
Danvers, MA 01923 INSURERC: Liberty Mutual Ins Co
INSURER D:
INSURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR NSR TYPE OF INSURANCE POLICY NUMBER DARE M M LIMITS
GENERAL UAWLRY PAC6303397 07/0l/ZOOS 07/01/2006 EACHOCCURRENCE t 11000,00
rX COMMERCIALGENERAL LIABILITY PREMISES AERT 9_ i SO 00CLAIMS MADE O R/oneOCCUR MED EXP(A PWW) t 5A PERSONAL SAOV INJURY $ 1,000 DO
GENERAL AGGREGATE t 2,000100
GEML AGGREGATE LIMIT APPLIES PER; PRODUCTS•COMP/OP AGG i 1,00O 00
POLICY PRO•
JEC7 LOC
AUTOMOBILE LIABILITY 1613092 01/29/2005 O1/29/2006 COMBINED SINGLE LIMIT
ANY AUTO (Ee ecci f) i
ALL OWNED AUTOS 1,000,00
X SCHEDULED AUTOS (BOeO1L�YI�)URY
B t
X HIRED AUTOS
BODILY INJURY
X NONAVMED AUT03 (P�r�r�iderlO) i
PROPERTY DAMAGE i
(Pe,ecddenU
GARAGE LIABILITY AUTO ONLY,EA ACCIDENT i
ANY AUTO
OTHER THAN EA ACC i
AUTO ONLY: AGG i
ECCESS/UMERELLA UABIUTY
EACH OCCURRENCE t
OCCUR a CLAIMS MADE AGGREGATE j
i
DEDUCTIBLE
f
RETENTION S i
WORKERS COMPENSATION AND WC131S321513014 06/10/2005 06/10/2006
EMPLOYERS'LIABILITY TORY LIMIi9 ER
C ANY PROPRIETORIPARTNERIEXECUTNE E.L,EACH ACCIDENT i TOO QO OFFICERMEMI ER EXCLUDED?
n yy�EF PEYIAYUMw E.L.DISEASE-EAEMPLOYE i 100,DD
6PEC`NL PROVISIONS WICK
OTHER E.L DISEASE-POLICY LIMR 7 SOO 00
TI
OEBCRIPTION OF OPERATIONS)LOCATIONS I VENT L 9/ X LU ADDED RY ENDORSEMENT/SPECIAL pROVISI N
neral Contracting & Carpentry
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE TNEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
In DAYS WRITTEN NOTICE TO THE CERYU9CATE MOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO ODUGATTON OR LIABILITY
OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Chet Dembowski AUTNG D P ENTATWE
Laur�
ACORD 26(2001108) - (DACORD CORPORATION isee
Board of Building Regqulations
One Ashburton Place, Ism 1301
Boston, M 2108-1618
License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 07/10/1953
Number. CS 055465 Expires:07/10/20 —_. Restricted To: I
CHESTER I DEMBOWSKI
2 VALLEY RD
DANVERS, MA 01923
Tr.no: 26308
Keep top for receipt and change of address notification.
DPSCAI O 5OM-04104GIO1216
� �>/ie
Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 100098
Type: DBA
Expiration: 6/9/2006
CHET'S CARPENTRY
Chester Dembowski
2 VALLEY ROAD
Danvers, MA 01923
Update Address and return card.Mark reason for change.
❑ Address C. Renewal ❑ Employment .7 Lost Card