1-3 LAURENT RD - BUILDING INSPECTION IN-AM Mill T-9E fH£ APPROVED BY T44E
.WSPP XTQR PRIOR TP A_PERMIT BEING GRANTED
CITY OF SALEM
N . # I Date
o
Ward II
Zoning District
Is Property Located in notation of
the Historic District? Yes_No_ Building
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) 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 'KboA eeAn I 'n�6 0 A&L4\
Address & Phone I`3 L gyef+s ( )
Architect's Name
Address & Phone ( )
Mechanics Name &4 -6�f✓e 4
Address & Phone 19'I6 pe-rst to
What is the purpose of building? COS OS
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost '3,-7W W City License # 3ignature
a
s/o #
Home Improvement
193 OIL
J (J Lic. /�� 17_7 �
of Applic t
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
�+ri
MAIL PERMIT TO:
No\\��
APPLICATION FOR
PERMIT TO
a
LOCATION
�i 31 in rrrtxz�
PERMIT GRANTED
,'13alo t l 19
AP OV�D
INSPECTOR OF BUILDINGS r
1�
PP..27.2004 1:52PM RIM MUTUAL -
s
CERTIFICATE OF INSURANCE ISS FDATE(,,MIDD,m
PRODUCER THIS CERTIBYCATE YS ISSUS:D AS A M1IA TP;R OF LNFORMATION NI.1'AND
Brewer&Lord LLC CONFERS NO RIGHTS UPON TID•;CEA12
TYPICATE HOLDER. THIS CERITFYCATE
DOES NOT ATIMND,EXTM OR ALTER TIME COVERAGE AFFORDED]BY THE
P 0 Box 9146 POLICIES BELOW.
Norwell, MA 02061 COMPANIES AFFORDING COVERAGE
INSURED
Bay Slale Roofers Inc COMPANY
P 0 Box 189 ILETTER A AI.M. Mutual Insurance Co
North Reading, MA 01864
COVERAGES
THIS YS TO C$ATII-YT$AY THE POLICIES OF INSURANCE LISTED BELOWII iii TiEENISSLIELI:O'PHE LVSUxED NA:rfED ABOVg FOR THE?oLICy PERIOD
INDiCA1Ts➢,NOTWIPHSTANDWGANY REQHIRE.LIE.\T,TEF3d OR CONDITION OF ANY CONTRACT OR OSIIERDOCUME\'T WITH RESPECTTO WHICH THIS
CERTIFICATE.M,MAY BE ISSL-�D OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB7ECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. Ln UTS SHOWN MAY HAVE SEEN REDUCED BY PAID CL:)HER
CO
LTR TYPE;or YNSLTUNCp PDLICY VUMBER POLICY F.YYT IYM POLICY r"MATIOtN
DATE(MM(DD/1'Y) DATE(NM/DDNY) I LIMITS
IGB,YETyL LLABILITY
IG6!yRP.AL nGGREGnTE � S
COMMERCIAL GENERAL LIABTLJTy
PROppCPSd OMP(OP AGC, S
�LAIhIS MADP.j bCCLV[
PERSONAL A.ADV.INIURV
OwNER`S 4CONITRACTOR'S PROT,
i EACH OC TARENCE ;
~— FIRE DAMAGE(ARy om file) S
MUD.EXPENSE(M)•one person) 5
AL�TDM1[o)aLE LIA&/LPPV
IANY AUTO I (COMBINED SINGLE
LIMIT 8
ALL OWNED AUTOS
I75CHEDULGp AUTOS BODILY INJURY
I:''� m•ison) S
I IHIAF.D AUTOS (N'
NON; o BODILY INJURY OW MM ALTOS
I(Fv lmidcm) S
Gr\RAGE LIABILITY
1 IPROPERTYDAMAGB ;
EYCFSS LIABILITY
it �_,WrIBRELLA FORM1I i LEACH OCCURRENCE $
AGGREGATE
!DTHER THAN U3iHR6[.LA FOR"I
WORKER'S COMPo e
_ILITY NAND N1'STA'1'W X DTH,
EMPLOYEPS'LIAB[I,iPY
A; 600s3lsoiaooa
i7'IR PROPRIF,•fOR( 04/63/.O�s 04/03/2005 S
PRS/EXECIlT1VE L\CL
AAT'F.
OFR ERSAR6' ( cgCl Dr q' SE- CYIIMIT S SOD OOO
O[HER I iF DISEASE-En MPLOYEE S 500,000
DESCRIPTION OF OPER,ITION5/LGC..ITI0N5/VFIDCLES(SFECIAL ITEI•IS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE MSUL\'G COMPANY WILL EM1bEAVOA TO
MAIL 15 DAYS WFI77E.N NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT.BUT FAILURE TO m.AM SUCFI NOTICE SHALL IMPOSE NO OBLIGATION OR
I-Lv ITY OF ANY KINA UPON THE COMpANY, ITS AGENTS OR
YIEPRESrN I ATIVES.
OOOOO AUTHORIZED 12EPri}�SEM1TATI�
e i
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL (976)745-9595 EXT. 380
FAX (976) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
III accordance with the provisions of MGL c 40,S34,I acknowledge tbat.as a condition
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III, S150A.
The debris will be disposed of at �I/f 1Y15 _ �IS CIb�-A C
Location of Facility
Signature of Permit mplicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any
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 cI[L S150A, and the building permits or licenses are to
indicate the location of the facili .
ty