37 INTERVALE - BUILDING INSPECTION 1
gPW%W4AlIST-9EfMA9 M APPROVED BY TW
JNSPECTOR PWR TAD A PERWT BEING GRANTED
CITY OF SALEM
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BINLDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding. Con0r Ct Deck, Shad P
RWaidReplace, Other
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSM
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build aocordw-1p.to the t kming
"Owners Name �d✓r ✓�/� S ,
Address a Phan
Architect's Name
Address a Phone f ,
Mechanics NameeY�
Address & Phon Uar( f q7A 990 7d� 5 JJ\\
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of Applicant
SIGNED UNDER THE PENALTY
DESCRIPTION OF WORK TO BE DONE of PEnwRY
MAIL PERMIT TO: 11Z/-e
e
1
APPLICATION FOR
PTO
LOCATION
PERMIT GRANTED
2a�Ll 19
AP,l�ROVFD
INSPECTOR OF BUILDINGS
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BOARD OF BUILDING REGULATIONS;.
s CONSTRUCTION
�Lkease: SUPERVISOR,
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N-u `CS 686492
i �Iithtlada.;0412211979. '
5 201
x�CPfr�sy 04/2210T Tr.no: 86492 1
-. Ree
sWot5dt00 gal . .�
ANDREL EBERSOLE
17 LAKESHORE AVE
BEVERLY, AAA 01915- °' AdministratorI
AIR WCIP Liberty \Wall
ISSYM OMCE 354 Mutual_
MORMATION PAGE Emp1e
ACCOUNT NO. SUB ACCT NO. Liheety M911181 Insurance Group/BoRoa
1-35I374 0000 LIBERTY MUMAL FIRE 94 SURANCP CO. 16586
POLICY NO. TD/CD SALES OFFICE CODE SALES CODE N/
WC2-31S-3SI375-015 7% WESTON 102 REPRESENTATIVE 3000 2
ASSIGNED
Item 1.Name of ANDRE EBERSOLE
Loured DRA EBERSOLE CONgMUCTION FEIN 204KM165
Address 17 LAMMORE AVE
BEVERLY,MA 01915 RIM M 124064
Sotto 91INDIVIDUAL
Other workplaces not shown above: SEE ITEM 4
Ira Dell Y" ?Na Dap Ym
Item 2.Policy Period:From 04-20.OS to 04.20-06
12-01 AM standard time at the address of the insured as gated heroin.
Item 3.Coverage
A. Work= Compensation Insurance: Part Oct of the policy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers Liability insurance: Pare Two of the policy applies to work in each Rate listed in item 3A The limits
of our liability under Part Two arc:
Bodily Injury by Accident 500,000 each accident
Bodily Injury by Disease S09A00 policy limit
Bodily injury by Disease S00,000 each employee
C. Other States Insurance.Part Three of the policy applies to the gates,if any,listed here:
SEE END WC 20 03 06A
D_ This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
hem 4.Premiumpremium for this policy will be da termiaed by our Manuals of Rubs Classifications Rates and Rating
Plans. All ii subj,=to verification and cba a by all&
PremiamHaw nun LINE 110
ryrlmmN Per flan P.ulmued
CheahtaliDns Code TOWAmmal or RE. Am"
SEE
coo Preeiamr
EXTENSION OF INFORMATION PAG£
Minimum Premium S 5W ( MA ) Total Estimated Annual Premium S 4705
Interim ad11ustment of premium shall be made: ANNUAL
TMs policy,mclodmg all endorsements Issued therewith,is hereby coontc pLd by SEE ATTACHED FORM 1710
roc eeoe I To Orv. Ao.aL aunt V&Mdk pgMt t ftfi It auk. 1Lr.KM Ilene swe D'nweer RENEWAL OK
04.25.0
5
NR I aura
IWCS-31S-3513754n4
OPU unto 1st Copyriala In?National Council on Cwnpemation Inwrar m WC m ao our A
LOCK Lac
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 146495
Type: Ltd Liability Corporation
EBERSOLE CONSTRUCTION LLC. Expiration: 4/27/2007
ANDRE EBERSOLE
10 KITTRIDGE ST.
BEVERLY, MA 01915
Update Address and return card.Mark reason for change.
'CAI o 60M-04104-o101218 Address Renewal Employment Lost Card `
_.... . _. ._.__-_-_ ---- - r
�u '�oono�eoau�ea�. o�✓�aaeac/taaeQ2
Board of Building Regulations and Standards License or registration valid for individul use only E
HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
Registration: 146495 Board of Building Regulations and Standards
Expiration: 4/27/2007 One Ashburton Place Rm 1301
Type: Ltd Liability Corporation Boffin,Mo.02108
EBERSOLE CONSTRUCTION LLC.
ANDRE EBERSOLE
10 KITTRIDGE ST. _-
BEVERLY.MA 01915 .�_._._.__.__ u.,...,,na...u�......t......«....
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