267 JEFFERSON AVE - BUILDING INSPECTION (2) 1
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MSPFCXDB PWR TO A.PEAMTT BJisWG GRAN*D
CITY OF_SALEM
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BUILDINZr ,
APPLICATION FOR:
Permit to:
(Circle whichever apply) R nsWI Siding, Construct Deck, Shed, Pool,
Reps Other: KuUxr ro6C
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accordwig.to the.folW4Mg
specifications:Owner's Name F401 6(,SCcacc,
Address & Phone a67 TeCGefson AV-e So lerj ( 97Y1 7� - 3 70
Architect's Name
Address & Phone ( 1
Mechanics Name
Address & Phone ( 1
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UC. 0 /77 ,357
(Signature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT T0: /� ✓ � C/ 90
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Cetrreao�t.
Workers' Compensating Insurance/lffidavfr
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0 1 am a sole proprksore renerai contractor or homeowner (drde ens) and hsys hired tIN
contractors ilned below who-be" the following workers' tompsyas3oq panel=
Cow Insunnu Compatry/Pogq Nuntisr
Comraaer Insurance Compasry/Po Nunslsr
Contractor Insurance Company/Policy Nombsr
0 1 am a homeowner performing all the work myself.
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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 1012814
olzeloa
-ROD°CER THIS CERTIFICATE 15 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 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Peabody ,MA 01960
978 532-5445 INSURERS AFFORDING COVERAGE NAIC R
INSURED INSUREka Western World
Newton Property Services,LLC IN
sURERB: The Travelers Insurance.Company
30 Olympic Painting Roofing - INSURER c: Granite State Insurance Co
0 Andover Street.Su
ite 39-I
INSURER D
Peabody , MA 01960
INSURER C.
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. -
POUC EEFFECTNE POLCY EXPIRAnON
LT0. NSftEF1,TeT
INSURANCE POLICY NUMBER D MM T LIMITS
A TY NPP899939 06/17/04 06/17/05 EACH OCCURRENCE 51000000
L GENERAL LUEILITY DAMAGC TO RENIED 5100 OOO
S MADE FX OCCUR MED EXP rMV one parse,-) s5000
ed:500 PER50NALAAOVINJURY S[ 000000
GENERA-AGGREGATE 52 000 000
TE LIMIT AUrLIES PER: PRODUCTS-COMPIOP AGG 51600000
PE 4 LOC
B AUTOMOBILE LIABILITY 1810404GA0371ND04 10115/04 10/15105 cOMeINEosINGLE OMIT
ANY AUTO (EA xW.D 5500,000
ALL OWNED AUTOS
BODILY INJURY 5
X SCHMU1FOAUIOS (F.pnronJ
X HIRED AUTOS -
BODILY INJURY
X NON-OWNED AUTOS (PIP A.dm)
PROPERTY DAMAGE S
(PI,acvdenl)
GARAGE LIABILILY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHERTHAN EAACC 5
AUTO OILY: AGG 5
EACESSIUMBRELLA LIABILITY EACH OCCURRENCE .5
OCCUR F-1CWMS MADE AGGREGATE S
S
DEDUCnBLE
S
REMWION
C WORKERS COMPENSAn)N AND WC4315629 Q4/01104 Q4101/05 We siarU- OTH- J
EMPLOYERS UABIU-YY
ANY PHO✓RIETORIPARTNER NECVTNE EL.EACH ACCIDENT $500 000
OFFICERIMEMBER EXCLUDED' - E.L.DISEASE_EA EMPjWEE 5500,000
If Y¢.dc:cnbc oMel
SPECIAL PROV1510NR DIIInw EL OISEg9E-POIIGY LIMIT ;$00 DQ0
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES.EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFOAe THE EMRATION
DATE THEREOF,THE ISSUING INSURER WILL EMDEAVOR TO MAR _20_ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DD 50 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OP ANY KIND UPON THE INSURER.ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
i
ACORD 25(20011081 1 Of 2 94625E DMN 0 ACORD CORPORATION 198E