272 JEFFERSON AVE - BUILDING INSPECTION (3) �L ?VS-KIRiST- E f4L-E81N0 APPROVED BY T*IE
J,AI$,PXT-0jR ,PFWR T-0A.PERMIT BEWG GRANTED
CITY OF SALEM
9 7403
No. 3( �—Z OU C t ..� ,\ Date �
NEI
a
Is Property Located in Location of �p
the Historic District? Yes_No— Building o�7� Sf tiSc
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications: )
Owner's Name r1
Address & Phone a� 5P9t1�1 (�78) �5°S-S�33
Architect's Name
Address & Phone
Mechanics Name Eric- 7 10c4z,ta;l _ ,� f✓ri Z �ca5r ni z
Addfess & Phone 7 N-S4g3
What is the purpose of building? t CWI&C _ __-
i r/
Material of building? If a dwelling, for how many families? 7
Will building conform to law? Asbestos?
Estimated cost I )q(M City License # N/A State 'c se #
lO� t)o Home Improvement X Lic. 1 ? ► 1
G.t�- 12 7 Signature of Ap icant
SIGNED UN R THE PENALTY
OF PERJURY
DESCRIPTION OF WO K TO BE DONE
� 00
MAIL PERMIT TO: 10 Read Sf 96t1-en Guff omo
t
No.
APPLICATION FOR 1
PERMIT TO
LOCATION
PERMIT GRANTED
APP VFD
INSPECTO OF BUILDINGS
{
' 1
i
09/22/2003 MON 14:47 FAX 781 593 0776 WOOD & ASSOC INSURANCE _ R 001
p " ACORD TI
vnobuGER 9/22/03
THIS CERTIFICATE 16 1 bUIED AS A MATTER OF INFORMATION
f WOOD & ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
INSURANCE AGENCY INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
32 SOUTH COMMON STREET COMPANI COVERAGE
AFFORDING COVE
I ];YNN, MA 01902 " - ...
COMPANY
A INSURANCE INNOVATORS
INSURED .,.
COMPANY
URIC 2 DISPOSAL B
5 ROTCHINSON COURT COMPANY "—
LYNN, MA 01902 C
COMPANY -
@' D
a:2 &y o4hk`.' ` W 3'4.�,.,: ��?I>€i y 'A&L�
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED,E MAYNOTW BN ISSUED
ANY REQUIREMENT,TERM A CONDIT)ON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TI{IS
CERTIFICATE MAY BE I$$UED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
IXCL_USIOf15 AND CONDITIONS OF SUCH POLICIES.LIMITS$MOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LT2 TPEOFINSURANCE POLICY NUMBER POUCYEFFECTNE POUCVEXPIRATION
DATE(MMIDDNY) DATE(MAWDr'Y) LIMITS
OENERAL LIABILITY
GENERALAGGREGATE S 1,000,000
A X COMMERCULLGENERALUABILITV CLP-6227428
2/O5/O3 2/OS/04 PRODUCTS- $ 500',000
CLA1Ma MADE OCCUR PERSONAL B ADV INJURY a 5a0,000
OWNEF.'S B CONTRACTOR'S PRDT EACH OCCURRENCE $ 900,ppp
--' — FIRE DAMAGE(Atg bne rue) S 100,000
MEO PXF VAY enb PW ) E 5,000
AUTOMOIIIJ-UABIUTY
JEXCESS
TO COM91NED SINGLE LIMIT S ALL OWNED - "
ULED AUTOS BODILY INJURY $
(Par persgl)
Auros
MED AUTOS BODILY INJURY $
(Pw AdldPml
I
PROPERTYDAMA.GE $
IIILTTY Al1TO ONLY•EA ACCIDENT $
I'O THAN AUTO ONLY; 7—
OTHER .
-' -- EACH ACCIDENT 3
AGGREGATE a
1LTryEACH OCCURRENCE S
LLAFORMAGGREGATE1HAN UMBRELLA FORM
a
! WORKERS COMPENSATION AND STATU•
EMPLOYERS'LIABILITY T 1.ITS iFi
THE ELEACHACCIDENT $
PARTNE PRIETORI INCL -
RS/E)�CUTryE EL bISEASE-POLICY LIMR $
OIFFIC 9ARE E%Cl
OTHERTHER ElDISEASE-EAEMPLOYEE S
I
iI
DESCRIPTION OF OFERATIONS/LOCATIONSNEHICLESISPECIAL ITEMS
272 JEFFERSON AVENUE, SALEM , MA
ATTN: TOM; ST PETER, BUILDING INSPECTOR
E TIFICp' IE {oLDe *�` AMA r
SALEM BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
12-D WASBINGTON ST, 3RD FL EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
SA.LEM, MA 01970 . 10 .GAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LFJ-T,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KINO UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHOR12E0 REPRESENTATIVE
�E �,"r�..•,. P
(fOct—rny =niur:a9
ol Maf6each Batt
Ea �Jeparlaasaasl o/.J�d�ria(�eeiar<�i.
a 600 r &IjLm-31-d
Jatnet J.Catncoel - Uoalon, //!as>dc�„as.lb 02111
CO-M3sarxr
7 Workers' Compensation Insurance Affidavit
tti......e.•e•pe1
with.a principal place of business at:
do hereby'certify under the pains and penalties of perjmya that:
(�am an employer providing workers' compensation coverage for my cinploye-es working on
this job.
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor
Insurance Company/Policy Number
() 1 am a homeowner performing all the work myself.
I Ynot ,,C Mat a coot of[hc Whhh nt riA of for aroee to the Offct of lmeatgaoom of the DIA for co+ att eeeiRca"n am that LM to seensv re
coKrare L reo'hiez unatr Section I5A of MGL 152 on kao to the irnpotnion of cruriasm oerwties corststint of a ftae of ND W-S 1.500A0 motor one
Years' ir..ynonment v tr0 as ' ' "naitiv in the form o STOP W ORK ORDER a"a W of S iOO-oO a Om starrot tne.
t--O S t-D3
Signed this day of l rw�� / O�
ccnsee/Fcrrniuee Building Department
.actrsing board
Seiectmens Office
Hcalth Department
-c00 X50= 40� 4Qc, 40°, 77t
?' OF SALEM. IMASSAcnvan " i =
PUBLIC PROPERTY DEPARTMENT
• ' 120 WASHINGTgN STREET, 3RD FLOOR
• gp SALEM,MA 01970
TEL. (978)745-9595 EXT.380
' pp FAX (978) 740-9846 .
iTANLEY J. USOVICZ, JR. .
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
that as a condition
In accordance with the provisions of MGL c 40,S34,I acknowledge
's resulting from the construction activity
' Permit
all debris �8
of Building b sp properly licensed solid-waste
governed by this Building Permit shall be disposed of m a op Y off `
disposal facility,as defined by MGL c III, S150A. r 13-f Cf7 c 7 5
� The debris will be disposed of at: '—
Location of Facility
22
S gna ;e df ermit Applicant Ds3 e
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
' 19
S�DS((1
Name of Permit ApphC
Firm Name,if any
(_7d�5.53
Address, City &State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
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