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16 LEACH ST - BUILDING INSPECTION r 3 g -0 0 -vL s*Mr-BE FK*9 O ND APPROVED BY T44E IWZCM PFVDR TOA.PERW7 fiEWG GRANTED CITY OF_SALEM oa►o /0 Is Pmpwty Lou"d in ✓ location of//6 W ow Norte owda? Ya*No_ Is Pmpwly Looaled in a*CorranaYpn Am? Yaa�No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding,�truct Deck, Shed, Pool, Repau/Replace. Other: Z I 1 f}C L�9- S 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: q O mor's Name Address a Phone Architect's Name Address & Phone Mechanics Name Address a Phone 2l 1—t `-� tg21 1 7 YZ Wnu is do Puma"of buadrq? m"W a ta+l*Q? W 8 n a dwo&q,ar now many Wailwa? Ww to WV omlorm to law? 5 Arm? Etll WAd ooat 3,57 o f csy um"r N A Home Imprawmaant V Lie. i rA1 Stpnature of Applicant C 0`?Z/ dj SIGNED UNDER THE PENAL OF PERJURY DESCRIPTION OF WORK TO BE DONE MAIL PERMIT TO: PS L; 6 1,1 NO. APPLICATION FOR PERWT TO ono LOCATION Ao LNc . PERMIT GRANTED INSPECTOR OF BUILDINGS . M Connea waft 012rosao6nsom Dqotxew d1,FR&atlriaifA&Mm* _ BeOAb M! AUJ1 Workers'Comp="t[om�=mc*At dn& A pkant &dWM lNCmtradWWM bw@ Nm>u Ad km- 2- lP- l l djC6 C, t chyalwo iptAM 40 L ` � .. 1 r am a eeoployer.vid ' Q I am a tad eaa`,e�sea i (to marorpa I d=).* it.Meliea Ae rettioe.,y�o� � O?kw z I s a aob►peaprlstdr err pameti uaad as so Soub d ate= Z,®Remeaalst d *aad bees no employsee Tbae mfl.000trago4 bays s 0 as woAftlrmeimglapeeit . 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Board e(Nukk L Bulldfat Departmaet 3.C1t)/Powm Clerk 1. 6.Otier > ieal tarpedor i ttemblsp Inspector Coetsd remou Plane 0: Ons Information and Instructi sal Lows ems_ s�aII=PWM!Dmullumm � o�ac cca► oiDic.► �a�suall aa• . a arit0ea cc"ac aY tale air mm Fen ar odta'WI cc" a� b oleic _moocildimaradmki _ asshawdftbom as*6 va &arbtstldiet mows"to" 10cbecsoc•a[sse�asPieYs� � MOW c as tba loam . scats ar loot t stwe7'W���ur fw Ow w•aa ►�,chsPsttt iSZ.�ZSC(61 �•btd•on a to aoMcoet 1�m�pww roga4e&" re•ttwal d a KNOW w p� svidesp•t ab•1< appreart wfs h sot► "Neioc�e oo o[oamDgaoa de bwaramsce off"""D�0'mc°°°°t topkemcm of d&ehapah•vobaap >bebares fbaR apPb tiY°t atm��'d Mv�'a odoa aPdd•vit oastploieis►.bY ebee� iris weir oaaAesce(')� Phsee tha )assse(wl addseas(� �0°0 Ps•ssastaPs�w�as elllpwy a orhes than the neoasstY�> LbbftC�Q,l,t�aLimiled �9► i lrm U-C air u P don havo mosibW w hwwmwa auw% otregcBeeAA". � �grbe I apoNeyiaa4°� ,�ce AMIM/ ntedp SOm of AM fhc eaaBrma� 1 smsDec> i<b�Lat�ob"llw d • ihtdr b"city oc teas fat the cPP ., ft htw ac ifyas sbteymia� i•lA°ctla•1c.m °�ea09w � ao � B�ecosth• at the bolos Pleas be•ms�t dt°'i8dsvrt is the event d10 ocmpku and�oself- fk'�tiow has to� a of the affidavit for Yea to®oat samba which�be need s.a refcm ewOA mdicatini pke be s mm a fib is the Pam° is a ear trod oat sabmot one sfddorrt' at appNtada•s 1Rv Y wrbe"as loeadow is —(� ,hat>ma , ,mdar"7011 site Addred'the avPi d,a tow.em be to th. poft .A py offse af>ldak�hae bes ofeeid4► a -A ikw aif3davie mottbe f�ones& a vatic admit is as f0•fa flute pamds ar=uxw w vesmrs sVvCW w Pa0°f oc eidtow;s obtttidea•Near°a Dams mt rdaoedl to nay Y�Wbam a boma awat b boa levee ete.)said paces it NOT raNired Is wmpkw chi•ofsdsva (Le.a dos*cm oo Pa°0t a advatt A far yaw w4watim ad sboald Yon bows anY qucldO ' Oftloe of 1•va would Mw to thaot Yon pkaso do mt beskO Ill ld+m as•cA rw pRstimcnrs addtesc,uiNbO°e and fst mmtbm jU CMU=weg&of MLi3uhuwft ial Accident dIavttldpdoll 600 WasbkOM Strad Bo"MA 02111 TeL N 617-7V4900 or 1-8 7-MASSAFB 617-72 gevbad 5-2&05 www.mm.gov/dia CITY OR 9ALXMp MASSACNYltTT: P'JsUC PRCPRRTY CCPARTMCMT 120 WMM'MOMIS WN487, US Ams ULE"s MAGOM Muses Of f76 TtLth10N/t 67`740-9606 UT. aq /Au 67/.740-9W! 3a1lm Buildlue Dlde�+-�nf Debtla DlaooloL Forns 10 accordance with the provisions of M(X c40 3 549 a coadidon otyour Bm'ldin j piem*is that the debris reins from thin wmk shall be dbpowd Of la a p vpedy liceaaed solid waate`�ispoeal facility as deliaed by M(}L, Chapter IQ� 1J0 A. no debris will be dapoaed of ta: n ty 3ipature otAppHeant S Zz Q 6 mate ACORD CERTIFICATE OF LIABILITY INSURANCE 05/22/2006DAM(MMIDD�) PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rose Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Lorinq Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 958 Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Liberty Mutual Gansenberg Construction INSURER Br Penn America 21 Lincoln Road INSURER C. NSURER D: Salem MA 01970- INSURER E: 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. INSRADD-L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRO TYPE OF INSURANCE POLICY NUMBER DATE MMM OM/ DATE IMWDDIYYj LIMITS B GENERAL LIABILITY TBA 05/22/2006 05/22/2007 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 50,000 PREMISES Ee occurrence $ CLAIMS MADE OCCUR / / / / MED EXP(Any am person) $ 5,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 POLICY JECPROTT LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea a¢HeM) $ ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS / / / / BODILY INJURY NON-0WNED AUTOS (Per acciEem) $ PROPERTY DAMAGE (Perawderd) $ GAR AGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY. AGO $ EXCESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND / / / / X I TORV LA ITS I I OER EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER EMBER EXCLUDED? pgpOING 05/22/2006 05/22/2007 100,000 If yes,describe under E.l-DISEASE-EA EMPLOYEE r SPECIAL PROVISIONS We E.L.DISEASE-POLICY-LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATKINWLOCATIONSIVEHICLEWEXCLUSIONS ADDED BY ENDORSEMENTISPEC WL PROVISIONS CERTIFICATE HOLDER CANCELLATION — ) — SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City OP Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,IT ENTS OR REPRESENTATIVES. AUTHORIZE PRESENTATIVE — lCQcu r9 ��cry ACORD 25(2001108) ®ACORD CORPORATION 798E lkn�-INS025(010R).D ELECTRONIC LASER FORMS,INC.-(80 27-0545 Page 1 02