267 JEFFERSON - BUILDING INSPECTION "P d M1At9ST11Ef&E94AD APPROVED BY 744E
ASPFCM PWR TD A.PERMIT BEING GRANTED
CITY OF SALEM
No. Dab
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Remof, Install Siding, Ponstruct Deck, Shed, Ppol,
Repair/Replace, Other. Lc 11 nci n uie 6-enleecemeof)
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accord4ig.to the following
specifications:
Owner's Name Pow l 91`S C k i Q
Address & Phone T-Cf -ers(5n PHR S4 (,?;16) 7U- 37/?
Archkoces Name
Address & Phone ( )
Mechanics Name
Address & Phone ( 1
wtw m On vwPoee a bumw f h o w s
mdww of buYaq? i 1 n a r' , 12" ,for how many tamaas?
WIN bukkv corAam to law? V�e S Ambso os?
Emanated oat l=J)-06 C) CRY Liam a Stall Dana • S t
S
Name Improvement 7
'Signature of Applicant
SKIINED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
rpPlccc� ex� 5�;na w; �c�s /�-� y�"�"1 >r �Ie�eeh+enl � nG{o6J1
MAIL PERMIT TO:
��� �,�t
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- ��-��
lr OetRSO/iL/� 0��64�IIC��Ld
' b •11.pa.1...at a,.�a4aLia[�aeiaaats•
600
no
Damn 1 cae �rhay ��aeeAmwd, 02111
ca+est.ai.r
Workers' Compensatfoil Inurance dftidavk
1, CSeo e vgcb C
- • wfdt-a Prindpal Plata of boamn ass
300 AM10yer ,54.' 3,yI PPc��O�c�, /�iR
do hereby-certify undo the pals and peniklm of pakye tsaas '
IZI
G/ ass thir n employer pnwfding workers' cornpemsdoe coverage for my a ss wy yg
on
S,rc�n it-e S fc to To S (aC �f3l 7 ,6a 9
Insurance Compaw MW Nutubw
I am a sole Proprietor and have no one fdr un ht cs
working �' Padq.
U 1 am a sok Proprksore Reneral comraesor or homeowner (drde own) and hatve bred do
contractors lined below who•hM the felkowiatR workers' cosnpensathso pogckas
Contractor Insurance Cosnpat ylpo N
w u"w
Contractor Insurance CompanyRo Nuv*
Contractor Insurance Company/policy Number '
0 1 am a homeowner performing all the work nsyself.
•1 reavurwe orr s aq of M+aw sm wa be forww"s r ow CMee a te.esrwwe e(dw tNs.Ier ce..rare...tka�„see an tin rot
ronrap r newn.esw Srcwn SfA s(MM 1 f S on wen err i7rea " st pibs_+1 e.eede.ermwM of s lea Gin sa•61, OLM elder om
yaaM drr e/s r WORK ORDER rMsbwof ttoo.0osanspbMew.
Signed this . day of j / G
_rccnseeiFermiiva 1 rw1 tng Depart nt
�ctnsinf Eoard
Selectmen Office
ritslth Gepsmmen:
a, ,7r
Lj =e.
rumus rworpRf psUIAMMM
120 MMN1 EwaIALM O f6sM RoeA
T96 C sao
sTANLrr .L uaoNe3L s. - -
rat .
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di0iai l�al�i,,�1�+'liaa i Didra a r bAp do ag t @won
by Db rant ii��Ifa 00alaelioa ae '
iiiati aii a poor Yory di aMa
d4oai 5aift n dWbatl4L�i a>R D'1� •
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/28/2004 10:04 FAX 19785322217 B K MCCARTHY 001/002
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Client#:25567 NEWTO
ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DDTYYYY)
10/28/04
=RoouGER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
B.K.McCarthy Ins.Agcy. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER_THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
10 Centennial Drive Peabody , MA 01960 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
978 532-5445 INSURERS AFFORDING COVERAGE NAIC 0
'INSURED INSURER Western World
c/o/o Olytonmpic
Property Services, INSURER8. The Travelers Insurance Company
lympic Painting 8 Roofing - INsuueac Granite State Insurance Co
300 Andover Street.Suite 391
Peabody MA 01960 INSURERO:
..SURER E
COVERAGES '
EPOUCIES OF wSL RANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
Y REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
Y PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATC OMITS SHOWN MAY HAVE DEEN REDUCED BY PAID CLAIMS. -
NUMBER POCbI EFFECTNE POLICY QPIRAT[ON
IT NImucy
TYPE
IN$URANCE POLICY O MN YT LIMITS
ATY NPP899939 - 06117/04 06/17105 EACH OCCURRENCE 51000000
LGENERALLUBILITY DAMAGE TO RENTED 5100 DOD
SMADE ❑X OCCU0. ,
MED EXP IMy.upemPH) S5000
ad:500 PER50NAL A AGO INJURY S1000000
GENERALAGGREGATE S2 QQQ 000
TE LIMIT APPLIES PER: - PROOVOTS-COMPIOP AGG '1000000
7189 LOC
B AUTOMOBILE LIABILITY 18104046A0371NDD4 1Q115/04 101161Q5 COMBINED SINGLE LIMIT
ANY AUTO (ER SUOmII S500,000
ALL OWNED AUTOS
X SCMEONFDAu106 FOD�')uRY S
X HIRED AUTOS
X MONOWNED AUTOS BODILY INJUHY S
(Pw arLUe,rtf
PROPERTY DAMAGE
(Pp AmArnl) S
GAR!REIENTION
RY AUIOONLY-EAACGDENY S
OTHER THAN EA ACC S
AUTOON.Y. AGG S
EXCELLA LIABILITY EACH OCCURRENCE 5 _
CLAMS MADE AGGREGATE $
S
LE
5
C WORKERS COMPENSATION AND WC4315629 041011 4d 04I01/US wcsrnru- oTH-
EMPLOYERS,LUBIUYY
ANY PHOMGTOR/PARTNERIXECUTAIE EL.ENCH ACCIDENT S500 000
REMBEREXCLUOEO'
11 . IM - EL.DISEASE-FAEMPLBYEe 5500,000
SPECIAL PROVI510NR -ITV EE DISEgBE-POLICYUMrt S$00 QQQ
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES,E CW5IONS ADDED BY ENDORSEMENT 15PECIALPROYISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD A"OF THE ABOVE GE5CRISW POUCIES BE CANCELLED BEFORE THE EXPIRATIDN
DATE THEREOFTHE ISSUING INSURER WILLENDEgvDR TO MAIL 911 BAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO5-ALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
i
ACORD 25(2001IBB) 1 Of 2 946256 DMN 0 ACORD CORPORATION 1988