1 LAFAYETTE ST - BUILDING INSPECTION (2) _ Thr (bnunonwralth of Massachusetts I
t, lioaid of Building Regulations and Standards F(W
NII NII'll'.\1 fl l
' I l �`-� , Massurhusrtts Sluts Building ('ode. 780 CMR. 7"' rJiihm
Building Permit Application To Construct. Repair. Renosate Or DemohNh a /t.
Ont- iw Tutt-l'imuh— Dtrrl/in,q
This Section For Official Use Only
Building Permit Num r - Date Applied: _ _ _-_—_ -_
Buddn!g COmmr..wned ispecior of Buddu!gs Date
SECTION I: SITE INFORMATION
1.1 Properh Address: 1.2 :%ssessors flap & Parcel N:rntbers
64�9•/E77-
- I ll, Nu:uorr
i.la Is ibis m a' cepied s(RCt_' vee !1t' L p
t. P! meed (. , _ __--- Lot \I — J 01 ._F�'r•_c' !�'
Setbacks (ft)
Frani Yan1
SJe Yards Rear Yard --a
RryuncJ Provided RcyuucJ PruciJrJ RryuueJ Pi•. :JrJ j
1.6 Water Supply: !A1.QL c. 10. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: —I—
ZOne: Outside I-Ilsoesd Zone? I ,Slumcipal C3 Oil r-:Jicsnul sy,!ccn ❑
Public ❑ Pricate ❑ ('heck itf vesC7_ _
SECTFON 2: PROPERTY OWNERSHIP'
?.l Ow rt, f :ecor
N:wn•i
Prim! Address lox Service:
47Y- 7Ya - o 3o�*7
�S12mrture relephune
IN CTION z DE'SCRIP'TION OF PROPOSED WORK'(check all that apply)
0Exis in. Building ❑ Owner Occupied 0 Reou!rsl�;) O l 4 is Jum(s/ � suJ!iion ❑
-I
❑) \ et !v Jldg ❑ Number of Units - Other 0 Cp u1y:
_r.0 ipri:tn , k p,r .x'nrk- Lc,_//n//Jo V�_q..�/J
J ori G.c%Ge/',— I C..ii Oow
i
SEC :':d1N 1. ESTIMATE) CONSTRI,r'rION COSTS
Item I Official Use Only
Labor and Matenakl __
I. Building — Building Permit Fee: $ Indicate how fee is JeterinincJ:
-� ❑ Standard City/Town Application Fee.
? -
Electrical S ❑Tt
- -. otal Project Cost (Item 6) x multiplier x
3. Plumbing S ?. Other Fees: Sl..L—
.._ -- — 1 List:
4. Nlechanicai (HVAC) .5 i
5. Mechanical Tre Y -- ------
S ulprraspm) Total All Fees: S_
-� Cheek No, Check Amount: ('.t.h \mount:_.
a Total Project Cost 5 ZL/ 77o 0 Paid in Full 0 Ou(atanJimt Balance Dur:____
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Su ervisor IC•SL1
p y-:7--/0
Ll.rn,c Numhir 0,110
N.nnc Li(,Sl-. nitwe i
23U /54(t_-iA7✓'4 if s' r Li.l CSI_ T.pe t.ec hrlue1_
\JJres. ry Ue.cri +lion
L nKAlri ricJ u t to 15.o00( u FI 1
R Re.inrlyd L@_' F.umll Dtt:llhne
Sn� uurc Q \1 \lanonrn Onls
RC Ra.iJ:nUal Ruolinc (o\:une
J
rclephone \1} K.•sid.nlijl Nlndutt .Ind SiJu�_
S1: Rc,IJauu,J Solid 14,1 liol__ \lydi.ul.; lu.i.illan�m
D R:.idenli.11 Dcntohuon
5.2 Rr tsterrd Ilome Im rocr tent Contractor (IIIC)fi• �/la i �A ?�o
IiIC Com my N me ur tIIC Rc¢atranl Name Rcglstrauon\'anther
)moo Y —
AJJres.
ci-Zr ZrY-�r� y F,\pll aiutll Dalc
signattrre relephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)1
Workers Compensation Insurance affidavit must be completed and submitted with this application. F:ulure ht pioside
this affidavit will result in the denial of the Issuance of the building permit.
Signed Attidavit Attached? Yes .......... No ........_. ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 —_ /1, // G,/int /C% as Owner of the subject property hereby
authorize to act on my behalf, in all m:utel:s
relative to wol k authorized by this building permit application.
Signature til Owner Date _
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
1• ___/tom` sixon_� <<%—. as Owner or Authorized Agent hereby declare
that the statements an Intiamation on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name -U
/.— Y
CEJ �
Signatureor. ut nt Date —�
(Sign d u ' I le pains and penalties of e(u '1
NOTES:
I. An Owner who obtains a building permit to do his/her own \cork,or an olvner who hires an unre_imel ed urn0a,III]
(nut registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 112A. Other important infilrmanon on the til(' Program and
Construction Supervisor Licensing (CSL) can be found In 790 CMR Regulations I I O.R6 and I IO.RS, resperosrly
' When substantial work is planned, provide the information below:
Total floors area (5;1. A.) (Including garage, finished basemen Uamcs, decks I,r porch,
Gross living area ISq. Fr.) Habitable room count _
Number of tueplaces Number of hedro(mis -------_--
Nuniber of hathiooms Number of h.11f/hath. .,___ _ _
I\pe of heaWle syslem _. _—_— Number of Jerk./ pore hes
Type of rotlhnesystem Iin.InseJ --- open
J. 'Toed Project Syuare footage" may br .ubanufeJ circ "TnI:II Pro(er[ Co.t -
CITY OF SALEM
PUBLIC PROPRERTY
r DEPART-NiENT
..:•.;dP Rl i •i !eft fi, �`I: -
\I.\ [2- \X A,1 i1N-;i,,�i:IZI r f • 5.v: xt. 1!1
I'I.I: 778.?4;.');•1; • I:\\: 9,S -4_-'t84h
\Furkers' Compensation Insuriince Af idin'it: 13uilders/Contractors/Electricians/Plumbers
Al)[ lirtnt Information Please Print Legibly
N:itiic !nn;inc ,'))Il!'y.tnl[al!,m.l ,42
{n1 �
,fiNidduell:,��/,� /�� r' /' ' ' / i7 C�
City:State!Zip: 0Z -5.77 Phone :
Are You an employer? Check the appropriate box: Type of project (required):
I.-PCInr3 eon lu er with d, ❑ 1 :mt if �encral contractor and I -
on
P y � * have [fired the sub-contractors o' ❑ New construction
and/or part-time).
_. employees (toll
❑ I ;mr a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have nu employees these sub-contractors have 8. ❑ Dernoli ion
working for me in any capacity. workers' comp. insurance. y. ❑ Building addition
[No workers' comp. insurance _5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
>.❑ I :un a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers' comp: c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] r employees..[No workers'
13.❑ Other
comp. insurance required.]
'Any.applicant that cheeks box nl must also lilt out the section below showing their workers'compensation policy information.
' H...neu,ners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�Coutracmn that check this hox must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am un employer that is providing workers'cntnpensatiun insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:_-- (l_(�/.�l-�l
Policy k or Self-ins. Lie. 0: /+0 j UdV f''/ Expiration Date: ��� _� U
Job Site Address: ��C'`tJ'T� ,/��-�1Gf� City/State/Z.ip: 5YV�1t1,,1--
:\ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
line up it) S 1.500.00 amUor one-year imprisonment. as well as civil penalties in the harm of a STOP WORK ORDER and a fine
tel up to S'_50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Irr.eaie;uion.i of the DIA IiN insurance coverage verilicaiion.
I du hereby cerci/i' under the and Per rw t infbrrrrwiun provided above is true and correct
�i�llam rd; Date:
0f/iciul use,only. Do not write in this area, to he completed by city or town official.
Cinor I ow n: _. _--------___---_-_-- Permit/License rt-__-_-_--_---'_- ---.--__----
Icsuim, .kinhority (circle one):
1. Board of health 2. Building Department J. Cityf fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
b. Other
Contact Phone Person:----------_---------_---- Phone
230 Ballardvale Street Suite B />,,�r/Cc-'at•••e/
FACTORY olREcr $INCE 1953 Wilmington,I.N. 8-24 -
O O O HIC 127172/T. .58-244-2642
® 978-284-6108•877.846-3699•978-284-6115
WIND S SIDING T ROOM /p�
io / Date I D" E-mail �l �J
�Aq� Home Phone �� 7�-0362 � q'7a' 7Y r
City State/� Zip 0/9 Business Phone(Mr./Mrs.)2:/X:c2�i �" E--y
Replacement Windows•Storm Windows&Doors•Vinyl Siding,Trim&Shutters-Glass&Screen Patio Rooms-Entry&Patio Doors
WHOLESALE & RETAIL WINDOW CONTRACT �Z
CHAMPION MANUFACTURING AGREES TO MEASURE,MANUFACTURE OR FURNISH AND
INSTALL THE FOLLOWING C STOM MADE WINDOWS FOR THE AMOUNT STIPULATED BELOW:
ALL CHAMPION WINDOWS FEATURE FIT 3659 GIASSWRH ARGON,FOAM ENHANCED SASH AND FRAME WITH FUSION-WELDED CORNERS,
INTERIOR/EXTERIOR WINDOW COLOR White O Tan if cngosin ColarMOO option for exterior ou must Still select an interior color
COLORBOND®OPTION:(ezlerior only)D Adobe D Brick Red O Bronze O Cotontal Blue O Conage Gray O Emerald Green 011811
O While q1 C
ounxrm OBSCURE GLASS O YES NO QUANTITY PVC COIL TRIM
vntxouT GRIQ LOCATION: cRITMOosUT GROSS, COLOR:
GRIQS
DOUBLE HUNG {)STYLE CASEMENT
_I (FULL SCREEN)
�JJJJKJJJ 61 f• C/!`! —(/✓/114_ t::t
2 LITE SLIDER i DOUBLE CASEMENT
M
(HALF-SCREENI f^' (TVIO FULL SCREENS)
PDOUBLE CASEMENT
PICTURE WINDOW
WITH FIXED CENTER
(NO SCREEN) + Leas Canequal lima
en
TTm 90' d re�erB 18.1 wWM1
OV O -eM verb are 42"n
'
(TWFULL
widM
QWO NLL SCREENS)
CU/i. oiI 3 LITE SLIDER AWNING
Ioi=. PICTU
ITWRE WINDOW j ' IFuu SCREEN)
OSCREENS)
1 H #1 �
TWO DOUBLE HUNGS CASEMENT BAY WITH
T
PICTURE WINDOW
WITH PICTURE WINDOW �A 1 i x. Imedorwoodk rol Dwmed or aalred.
t'+a (TWO MI-F-sCREENS) y, Tne elder xil cent¢p[t�re labw Mll vary
Bash On
New Wei. WN
( (nY0 FULL SCREENS)
DOUBLE-HUNG BAY WITH
_ GARDEN WINDOW WITH yt H PICTURE WINDOW
XA
CASEMENT END-VENTS Inlamr woad is na panlml or aelnal me mwOWbMaymedd amNed TMw mrbrppshire M.
Mil ry
(rvlO FULL SCREENS) basal W ovomll wam 1dv My Mrxbw
,{ (TWO HALF$GREENS)
7 BOW WINDOW
HOPPER TILT r ,? ImedO/wood 6nm as meds aainea.
snows In nw t ouch Ixm-number al 11 WM
3i. . Fit', BASEMENT WINDOW 1i :z armgn myu eon«,n.vy Beam an memo wam
(FULL SCREEN) of OFULL SCREENS
SLIDING PATIO DOOR-Nominal sizes @@[
❑5'-2.5'+2.5' ❑ 6'-3'+3' ❑ T 3'+4 dry
8'-4'+d' ❑ V-3'+3'+3' ❑ 12'-3 +3'+3'+3 r rT1Ula ' Y eh Lt
Cr4*+ V+4
X=ACTIVE O=FIXED
InterAlyftod is Not Painted Or Stained
TOTAL NUMBER OF AINDOWS ON THIS ORDER: TOTNUMBER OFF PATIO DOORS ON THIS ORDER:
OTHER:
4
✓� fF
❑ Customer agrees to allow Champion to display a yard sign.until 30 days atter completion
TWO YEARS FREE IN HOME SERVICE ?l� �p�
BUYER'S RIGHTTO CANCEL Total price for above S
BUYER MAY CANCEL THIS CONTRACT BY DELIVERING WRITTEN
NOTICE TO THE SELLER AT ANY TIME PRIOR TO MIDNIGHT OF THE Down payment $ S D6 Q
THIRD BUSINESS DAY.AFTER THE DATE OF THIS TRANSACTION.
BUYER MAY USE THIS CONTRACT AS THAT NOTICE BY WRITING "I Mance Payable on �y
HEREBY CANCEL"AT THE BOTTOM AND ADDING BUYER'S NAME AND InstallatioruDelivery $ 1
ADDRESS.THE NOTICE MUST BE DELIVERED TO THE SELLER AT THE D Bank Financing E(Cash on Completion
ADDRESS SHOWN ABOVE.
AI marine*guaronvedmoeas slsedieo,At exit,s er M conlplaetl in a x onnimi mannera¢atlilgm W^n_tl-m.tl precliasa.TNs Wnaacl6vaBtl onN�hDmper BYgna ural.Cnampian BhAI ro1bnam
rB5par151Ne farflmB end IIIdIBIG1d9L9Y8,SInk09.&60f GOdb 811Y OdBr maVBR 1aYa11C EB dnB0.al(Y6!dM M'w agreB811mgR aQetY In 1116 DrdDCrN 195BCUrIIY mllNa Nnaa41.$m9 dl6 WIIVaat Cde
mrmede m oNargoods.it6 not 50BILti71 mcarcalWrn except as smell abve.S4ninstaaadonan w BIYIN��_waakae0m aBme date.Eskmamtltlambaubsmnllacompledon s�AA Cargea
Gatedabove.nnne6nm slime ei:n away aY e,reW"able AU samsaM"I dee eryarden neonse andrldxanaadom 'a bee uiimr00MNe deNoUBuildup Raff"eF Vantl Np`eois
almanY Bquv6s retalilgm reg6banonsMW b d4edetlmms apeay.Champion dWlabyalnerryantlaa nxasaery pemNa aft OMrer's agent unlessoNem6e diregBdby Bwer n Buyer secure lsmds,
Be or me may be e.mdetl Imm th guaramY Nn0 Pov6ixin of G.L.c.f a]A ttCM1elrmun must WIB+B Buyer fumllemon of amoml6 Dalt due,Buyer wJl b ISNa ter ClunQtbn'e reemraB6 fees erq msm,
hWutiW enanays ma3,AFINMICE CHARGE abJemd el tla r�eW l-12 perms(per mmM llS%ANNIIAI PBRCENfAGE MTEI MII be addBdm deliryrad saeums.All ilWalmgpn ant mlrylelixin
tlamsale alAmalor udsllgedmdalge aNrpO nobs.VmbalPmmlus®"tausa m6u11derslaMilpB.Nolebre nuemnnaclmrl fBt.elh wgersWMlnpaldb Dan)as.anduoNu u11de1staMcp.
collateral.veialwa rise.sh'dOly Nrd6g,un6w sipnm BY BDN nlvOBa.Thank ydr bryM order. Doretsignthis ha are are arty Weals spi
neq 1
uy is SignaW a Social city o. Champion Repre (alive -
X
Buyer's Signature ial Securly No. Champion Re sentative
.- '?/ 5 -70093Le-) -_�009-
? FACTORY DIRECT INCE 1453
1 1
(WINDOWS SIDING PATIO ROOMS _—
AFFIDAVIT
I, the undersigned;being the owner of the property at
hereby verify that I have authorized Champion Window, Siding and patio Rooms and its
agents to apply to the Building Department of the City of
to act as representatives in obtaining a building permit.
Signatu+ofwne-r:
pate:
Owner: /
AddresL �'
City & State: Cj p lZC Zip:
Tel. No. 9 284-6108
Champion Window, Siding and Patio Rooms Fax (9 8) 284-6115
/�,4Tlo �ooQ �1C7L12z= (,(�INDoW
a+ CRAM 40M WINDOW MFG. �.ot CHAMPION WINDOW ?AFG.
31 CO SERIES PATIO ODOR 700 SERIES PICTUREYANDOW
CPD�&A-1
NFAC 01 NFRC CPGi1358-A-004
a
RIGID VINYL.FRAME I SASH •�y
RIGID VINYL FOAM ENHANCED FRAME
W�(o'otd�:.�'--ems I- 3 DOl1BLE GLAZE ARGON F0.1{aW E . I DGUBIE GL'AL•AAGON FB'110.W E a
��YC.OQC-<w � .:-..0 d_ .v..w4.. s'. ,.a,4tie- En,��,- .m«.. ww:»~ -ars...:+..a�°•.i^aek
F
� w Reg G0u1a7. �
a � � �. E All .. .
' .. taMIPt!TIdm/7ainvdgo�dn_.ratioew a �.'arr `� 'f ` 6rta9fl*Wlpwtdtp.eAm7F?!v�vAe e�br'd,paw aad lM M , ''s
nrp�.e�aa>+eo-a?ser��r,l.sr�I+c ..sde:x' .�
•Fyimora hprsio*aili l=1ppa7sas7ea MaR'IffRCaniO iRia
Lahr
�• eyeaaCr ,b2 ,.,�aaa�rato .b9 �-•» _. �..�._
.. asrae enraea aa. vs,uwr
-90 .32 .52 .50
1MeAd�sQid A!7anntrp aaaam b a[PtradY HFRC>�m b^�wnfbfp
�=_.`s v-.,,r^..-ss:r_=.-i^r ..'.v:_ = .. ._ -"-�.� Iry�-i-ti'wr'.`a nR•'�arm f�e`�!':md.•�:7 bsnY
.,:=_�_er.._s-.-. ... ." _ _qc.•.rrrc Ca.a aianrarnrra
SLIll DCIE' 131N c7aW /7a 013 LF >LIVNel,
a CHAMPION WINDOW MFG. CHAMPION WINDOW MFG.
800 SERIES SLIDER 800 SERIES COUBL_HUNG
—RC CP4dC58-A110'_ VFRC CP9il3!s-A-C6
R1GlO VINYL FOAM ENHANCED FRAME RICO VINYL FCM SNHPNCED F:V"JE
rleyQy ems OCUBLE GLA<'E+17GCN F"LL-LOW E Fm asbatlnt CCUBLE GLAZ=- aRGCN FILLIOW E
Padng Caacl Fagg Comtd
Eefetpy aari,ya n111 dap.nd m your rgadlk dlm:ee,Muw and Ircs.M• • Every-y+avinya MII faPr2-s.year apaCite<Inuta bam ane"lesty4
• For mm.9t(amutk,e all 1d0Yd7;3175 a Mait MFRCa'•ab aR•al y Far men W mud.,oil i4mr mn m vide NFRC's—b alb x 4
nma.Mre.orp a .om
�e ....._34 a .. �n .55 I� " '" 4a a ,55
a m^.
. ............
.33 .49 .571 .331 .50 =3
.Wr.Bpns aysip MOry ea'Ye aakamSil�-+tM NF.•1C 7mQ�aar.b'vmr.�v'S uamudas abinm lulls. �.:ain�soc'ae F.+CFwOasb3®rm�a9
adtdb and raec4 �'P•°a iva.e lv a.tatl aed mtim:wy 'fid 90 =wF JwtFna+r WRC-,r+p r Erev-,rad::s ak i rr.i.a+rwrJ
Paan ara .ar'sry aN aprSe aom+G axe
CQSEMEi�(T W f k[DO uJ
a CHAMPION WINDOW MFG.
700 SERIES CASEMENT WINDOW
NFRC CPCil356-A-002
RIGID VINYL Fv'A.M ENHANCED FRAME
Naomal DOUBLE GL,V.=-ARGCN--LL-LOIN-z
Ra&y Caar7
® ' p
•
"My mv*n adl drPnd an your rped&dV.W,Mur and Ilhatlfr -
• Fer man Slkrr_»1en,d 140 4MSM a H34 NFRCa.wb yb at
anancrihnor+ .�.
.32 .47 .55
lWaAmty*miY C haw,11a. I IareL rVfAC pax.erbyb�iy ��p(
^r'dapooC maGy:•envv.NFW-llhpan ae•a:vdba.6sd darhaur r I t
mMToe andv-A.- }u:pw o
••� s 0M. U/IN)Y//)NY➢i.[l.P.6��� O�.//�2Udrzl.'�UfJG�
board of Building Regulations and Standards
"-4Construction Supervisor License
. rvy� License: CS 72772
-
Expirati on::.4/7/2010 Tr# 24354
Restriction 010
JEFF C STEELE
ERWOOD AVE
24 SH _-----
DANVERS,
MA 01923
Col
nmissioner
c—
�1zs�oo/�mn/eu:na�/�. r�✓7�/unu-.�•eavllo -
_ •:
Rim,dol'Building Regulationtmd Standards
YtU
_�.
HOME IMPROVEMENT CONTRACTOR
� ,p'� I
4;"�11Registration: -127172
Expiration: 9115/2008
Type: Supplement Card
CHAMPION WINDOW;&;PATIO'R
230 BALLARDVALE ST SUITE B
WILMINGTON, MA 01887 Adminislratur
R_IFpp C {� O7L�YBILI / INSURANCE
{ SRTpGE . OPSPI-1TiIDATMAlIUD15 YY'tf
CFI 12/04/07
THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Ttoe_di c,q imiurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
7�'4 Ci:.anr_•n 1.7.n;- Dr ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
IC.rec.i:.view Hills KY 41017 —
+ •: 859-341-0202 r o_ L
Piax B� -341 370J
I _ _ I INSURERS AFFORDING COVERAGE NAIC:!
INSURER
ER/e
ua uI rx[+: INDIANA INSUR7aNCF COMPANY 22659
h 3t+ rl N r h LL Co. of _ __... ....___.
. 0
i t osi 3a North 1r, m u;[N r, rHUBB INSURANCE; GROUP 20303
- �G ,daa.].ardMA. 0 Dir Ste Q _-...._
r Tmi nrJ Loll 1�fA 01887 Ilsur Lr+.n'. -. .-Sentry Insurance
_ _-
r Ira .ala hcftov)HAv ❑IINIi II.O ODlrll'a HIP J N •IAID )Orr DI TIF 'oLIL( Cr+IOI)I1irflRaOIG.1 EfJ.r O(VI rItS'IAWplldf
r LACW !Ml.l01 OlOfIIJP JI 1YIUNr 'd 1 OH UPI-H IJUt UrI rlT )im L Ir OY.IICII 1111 CI' III( ILr.fA"Or ISSUCTIO11
(IDH')_ 4IC11101 IRJHE U YOII STAII IlICIFULCi EXUAI.StON:AND Cr PIciT10'r,frSUCII
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In oI-I mnN� aucr mrAorn -
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teinrl nr on rr' ilACnau.wel P+LI - 1 000, 000
u•c-r,An:r., a,..T,T,.a Jir1I ILdnmNILO 07/07./0 0-,1 01/08
u:u nsl 'I c r 300, 000
I•.L.f9 r.t rlI d PUC Jr -.
j Ir-1Jt r (Ally ro. o o ) ` 5 000
PF FSONAI ruV IT,UIZY l 000 , 000
rmNn .-C, t n -. 2 000, 000
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COLT foil
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c.n:nUIN a I:vt iLP 1,14UI
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c�n+n c r r, llal L I.cu,I,t 907.623ZG].00fi 61 12/01/07 12/01/08 ID1: 1_000, 000 '
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[L_DI Lis er.frll .- 1 ,000,000
2IDL.DIr I IOtM JI(IT f. 1 , 000,Ofi0
c .,_aLilTi,, 19160828 07/01./07 j 04/01/081 C'xcess
5, 000, 000
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rn;.,.roLi?nv runorsurTerin a r(;A_rnuvlsl�ir+.,. _. ----- --�
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L-iability , OI)),000/c2,000 000 FlInnl.ovmr'n i. Practices Li
. .;GI: , OaJn w:i ich $:000,000 deductible per c1a1"nT
I
CERIIPICATE I OLDER --- --- -- _-J
_ CANCELI_A"NON.
i POR PRP suout.n nuv nr and.:aovr u[,crenTr:D noLrcnss of cnNceueD nerori TNr::aT=In.rlv,r�
IJATI!THEREOF,TIIG 6511ING INSNRI31t N'I!I_iNo[AOOn l'O FIAR. 30 U:.YS t;Y:ITTFI:
P01 PRESENTATION (JSli ONLY NOTICE To ME CCI TIPICn TIE HOLITI-k NAIAZO To THE J:rT,auT FnlLuniro n0 so S;cA_I_
'.,'iiiCnI.i;?;}::rriX:iniCn3::i4':{v{i:3;.i';Ct:{_/.fiCl✓:
{j..sifr:{]:kAr:F1CX:�C•C} '}�,)(�{j;]C}�{,�^. ,t ILIPOSF NO QBL IGATION OR LIn61L1TY OF ANY THD I1PON T r:ItJSNPGR,ITS ACFUTS Oi:
Tl'1�-{C{r{;�jC} }ty{7p{,�}1X}' nePrteSeuranm;5. ____
Mara T,o.Onoi
ACORD CORPORATION T-
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
'.I .r. L'C U.�;n1\i, IN S ra r.r r ♦ SAI rel. %I\,;u !� .I 1 ,
l71:
978-74i-9;95 ♦ 1:\X: 978.74:9846
Construction Debris Disposal Affidavit
(rcyuired litr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit tt is issued with the condition that the debris resulting from
di
this work shall be sposed of in a properly licensed waste disposal lacility as defined by MGL c
1 11. S 150A.
The debris will be transported by:
S'O/u
(name of hauler)
The debris will be disposed of in
c/—oC'g7e d'it cL azo i e� Citta n�_ui��
(name tit facility)
P`y~
(address A facility)
naturc of permit applicant
date