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267 JEFFERSON AVE - BUILDING INSPECTION (2) 1 "KIIN81AUSTIK fIL494SO Af"OVED BY TINE MSPFCXDB PWR TO A.PEAMTT BJisWG GRAN*D CITY OF_SALEM No. —U� Dab ward 3 zarng DlatAct ,8 Is y lActOtd In ✓ Location of Bn Hla6otlo Didrbl Ytt No Is Prowty Locftd in ✓ ;r tht.COrmmagon Am? Ym No 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 tt Whf Is a p zpoat or WNW (-e d hce f 00 mawm of bullk W V i V14 M a dwaattp,for row m Wy WON? WIN bLAdN ool".. to law? Atbnba? EWmM cod 6,0 00 csy ucw r soft ucww» C 0 8 O UC. 0 /77 ,357 (Signature of Applicant SIGNED UNDER THE PENALTY' OF PERJURY DESCRIPTION OF WORK TO BE DONE MAIL PERMIT T0: /� ✓ � C/ 90 Q�p • � C,.onsmonuftsa(!� o`r �- a`l�a/t-/�.l�d • n 6'oow..�L.,�.. utnn 1 casar Mass" 02111 Cetrreao�t. Workers' Compensating Insurance/lffidavfr i. 6eo V Cc 5" ah - "'101-41 Pr%chw place of bmbeo a>c 36o Andover- S4 Su1` Ie . do hembr'cer>:ihr under the palm and petajUN of pwj.wy# thm 0/ 1 am same n emploM providing workers' compeMam Cer"Fafs for nay sinployefs workieR o0 Po Number 1 am a sole proprietor and have ne one warkb1g fdr ms b m +� pedq►. 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. •1 nraraw.out•CM.f 06 Aatea•M M be ferwaroee r Ow Ofice A kAw4 aael of ON MA 1t .w.ra m'"W"faa Mtn an 1tM r Mva ce.w+tr M nwnn•caw Same•7fA M 1.1G1 152 cat Iew to Oy iryen•we d nodti+t eoaadr toreMti•an d a Eye/4 eei 1.1M,eg "e ca trap' Meraewe•M a va M w a! P WORK ORDER ace s 4y of 110040 a a"atohec Me. Sirned chit . diry of _tccrseei'Fcrmiun 6 g Gepartn,en ctnsing Eoarle Selectmens Office =eslch Deparrier: - - -_ee�r �e � _ eQe SQe, :pe Tic ruKic rworw"T cuppir .... 120 VAOIuwf m mar Ra . wa><w►o��e • *26 197 ��saa MAVM Dl�IOfAL Dr DRU APPMVlt �ooadaaoa wlr ma pao i�tor afI/(�, Iq!,�r '�,�to a*OWN a ds+i�lr■it� i�idr - by sh i. �aid•pgp•�,1,,...�.oii,,�r A""�,..e.d.tb�Ics.nj filo� ,Dr Liidr v/M Ckar(ts 6 eor5 e Tfvt�.i n9 �owlafa* 8ok IS-7 kon±0rlo -rrf Larr ail�o r Fumy omphft doMan mm 306 f}nhuer s-� c v e� Qy� itil 4frabow ama���did.has r d �,��i arms . -s b dipw iaa rt�'.eaaa y�1ci a%link r dwbwftpsmb r.ao�r�o�.air�►. /28/2004 10:04 FAX 19785322217 B K MCCARTHY �001/002 �l 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