15 LEE ST - BUILDING INSPECTION 443W SI"T:-BEf1L£9411 8 APPROVED BY T44E
,Ip p=10R PWR TO A.PERW.BEING GRANTED
CITY OF_SALEM
Date
No.
s:
is Property Located in Location of L J
Ow Hlatatc District? Yes No Building rr �
is Ptopwty Located In
to GwsamdW Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, r 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 3�4^ _ k/n
Address & Phone / L r r S1 sn/z/2 ( )
Architect's Name
Address & Phone
Mechanics Name
Address & Phone `�jj�
What Is the ptapose d buildirtp? /�al-7 r
Mob"of buk"? #a dwe m,for how many tams?
will buildlrty cattorm to law? Asbestos?
Esmmated cost 834v Gty user"r N A stave so s (J/f22 a/
Bete Lproveaent
Lit' 1— Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DON// /
MAIL PERMIT TO:
No.
APPLICATION FOR
PERNgT TO
LOCATION.
iS Alee
PERMIT GRANTED
/tad Z 9t. 2_
APP OV�D
I TOR OF SU INGS
Tire Commxweaft ofA4isechUS cis
Depwti wnt of InditiftidAmUmb
Boston,MA Gill
wwtnM"Asewad
Workers'Compenudon Insunmee A®ds tb Ulders/ContradorsM rldans/Plambers
Awdeant Informadm Please Print L miNv
Name '_��i r✓✓/a / Ao d /
Address: 0 a w-
a 6 Z
City5wellia � Xy� -�4�� Phan 17r
Are yy err a er!�tkEapproprlate Ears' Typeorp���ef
1. I am a employs with� E 0I am a smug ontraetor and I t. ❑New oomssnctios
e�bY'ea(fiB and/or pitFtime}• have hirdd tin mh�aoa�aaeton
2 ❑ I am a sole pmprielor or partaei` Iuted as me auaw:beet$ y ° Remode>ing
snip and I=no empk*va Tbew sub-aonaacom bm 3. ❑Demolitin
s. WeateaaopQ..P id
*«pdeedk� :
*� s 10-0 Mecitial upaas or additions
3.(] I am a homeowner doing all work rtpht MGL. 11.0 Pa e repairs err additions
myeK(No wa camp e. 132,11'.� 'a
12 Q'�oofrepa6f
iasarasce regni[emj t. employ.(I�(o rraaloai', . °13 omen
> r
•,1sy.ppue�teute3xLu.a�nm�sa.ofie.4e�l•egia.bebMawle��d,. ooao.o.au.ro>seymbim�acr
trtaeso.is�.Wp.ilnitMi!.t8&"bdoft ftymadn 4wat and an aaeddtaobl.oea.oaoRaLde.�.83daviti �
temr.ob.eLtdretad.baa'�mtauet.r..ddalandvwtstow ar.tastif�k emO�Ger.udemiswiortn•coup PC"taawantlae.
ld:wq+ewpkFetketbprvvf�i.a>bra'�awpeJ�*�brranateejn:gelr�tt aelotrhrtlkprdkyarsaTJolable
Inl 99
Insurance Compmyxame 7wi !� dJ/7>v�
Policy a or Self-ins Lid# 2 Expiration Dace: L///614,
Job site Addrw /9 `t Z f� may : 4
Attach a copy of the workers'eompexaatio■policy declaration page(skowing tke pal q number and espiratlon date}
Fae to same coverag ilur e n requ¢ed under Section 25A ofMGL c. 152 can lead io the bWosidon ofa®mal penalties of a
tfine ap to$1,500.00 and/or one-year item,»well err civil peoaldes in do form of a STOP WORK ORDER and a dire
of up In$250.00 a dry against tie violator. Be advised dial a copy oftifs smtemeot nay be forwarded In ms Office of
Iweodsations of the DIA for inaorunce coverage vaidodon.
I di Aiarby 'AN prbu Ar"N s 00R*7AM tht brferwadua provW above b trw err/mares
Date
d �
Op kid Tara M6L Do sat walla As Air any to k eowpfe&d by e4dibaw#Ikid
City or Tows: pavd lcem 0
Issalag Authority(circle ode):
I.Board of Health 2.Building Department 3.City/Towo Clerk 4.Electrical inspector S.Plumbing Inspector
6.Other
Contact Person: Phone 0:
Information and Instructions
MMSebnsMGmaat Law.chapter I52 an mtplgyatmow M of ir% . ;
Ptnsttaot m this:ra>�.ffi•�is aefined�"...every p _. �
CVM of mphed,teal of wntt ee
�Y,Wtmytwnof= M '
Aa e�aYp�►degnod ale"an individed.pa whip a�da��ad
of the foregoin e0prd is Siam coo S ise, atwciatioa a cubes]eg l eamy,m41oY�g emPiMY� llowavq the
receiver or 001 of as imdiviitai.pamash4, who asides&Cmi'6 of the oft
er
own of a dwelling bouse Saving trot more rhea twee spartmmusod aon:attctim > work on VVA dwell'mg borne
danIIing boase of snotha who m4lnYs patpm to do mamtmsooe, be Qamed io be as empbym»
err m the grom,ds orbs Uft ihaelo"notbeanse of stsah anph►ymeat
MGL c6apoa 152,12SC(6)abo ststea that"every rtate or l"d agar?"vkhboid the Musee or
reaewd of a license or permit to operate a butane or to westnet hvWW Is the atmmoawt� � »
avldem of eompgaaea wltY the hweraaa cavergp tM
nY MM dpyat rodoe"�states"Neither de eonunonweahh mr I"of'"POftd abdirisioas si
far the paftumance ofpublic wok d acceptable wMenee of eompliaace with the imar�ace
regn ca nay fdtbc pancaiwactmgau>botnly"
ngauemm>r of this dtapta have bes prammd
APPMeMN thebous mat apply>o Y�donation sad,if
Please fu71 out the wogs'congenn m affidavit c=Vkt ,by docking with their caddMe(s)of
ne Y,mVply tub-�elm(s)amc(s,W&es,(es)Sn4 pb0Od ems)along with no aoploYeea other than dw
immsaoei Limited Liabr'tby Cmp�OM or Limited Lbbr'ht'Y Parmersbipa(LZ P)
are not mquired to arry workew 0 If as ILC or LLP don have
pn"t is npircd. Be advised to dds affid=tvJtmy be nbmkW to to DqwtmW or brdosUW
Amy IN conomodm of bommee coverage totgpas+d date the affidavit. the affidavit shoold
be returned to the city or town that the application for the Permit let Yon sre n4ased b ab>am a wmkus'Ikense is being mPOMA not do DeparMIC01 of
Inda:u9d'Aoeidmts. Sh9tsld You love arty'4nado�ns ter .
compensytioapotiey;phmtM caII ie Deptgtmeat at the ttauttber psped below. Sel[mmtedd'oomptmies shoald eater
sa.0 arom lit CM tttombet m the �
CH,or Towa Offidsh
lea and printed IcAlY. The Department has provided a span at the botoom
please son that the at fin o is comp
Of the afBdavR far you to fill out in the event the Office of Immstigatiom has to contact you regarding die aPP&m•
please be sum a tin in the pern&jiceme Tim , wbich will be used as a reference number. In addition an aPpliewd
that most submit multiple p applications in aaY given Yea,nerd only submit one affidavit indicating aarent
>f necessary)and under"Job site Ad&cse the applicant gma wrb"all loeadons in (ciW or
wwnn}" ee afildn'rt drat has been of9cb*strtmpW t1l by 7!es town may be prwided to the
applicant s pmotthst a valid affidavit is m Me for&mm permits or licenses• A new a®davk molt uteach
year.wbete a borne owner or cithea is obtamiog a lionise s a is mit no fired to comP>coe sfBdavit
4 a dog license err permit m bras leaves ern.)said paron
The Ogee of Investigations would J&e to thaot you in advance for your cooperation and should you have arty VwdOms,
please do not beshM to give m a cWL
The Department',address,teleplane and fct tmmber.
The Commonwealth of Massachusetts
Dgmrtmettt of ludnsttial Accidents
Office of Investigations
600 Washington Stred
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mm.gov/dia
CITY OF SALEM9 MASSACHUSETTS
• PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, 3R0 FLOOR
SALEM. MASSACNUSETT9 01970
STAMLEI/ J. USOVICZ, Jot. TELErNONE: 978-745-9595 EXT. 380
MAYOR FAIL: 978-740.9046
Sales!BUII Ino Deosr�*+pnt
I
Debris Dimosd >? rm
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
Of in a properly licensed solid waste disposal facility as defined by MGL
Chapter M. S 150 A.
The debris will be disposed of in:
Q/a?,111ff 1 `' ///w c, (Location of Facility) L
Signature of Applicant
Date
ACM CERTIFICATE OF LIABILITY INSURANCE CSR
DaTEIMN'DnrcrrYt
PiKIDueEA 9PROM 04 19 06
THIS CERTIFICATE F$ISSUED AS A MATTER OF INFORMATION
Jehn J Walsh Ins Agency, Inc ONLY AN )CONFERS NO RIGHTS UPON THE CERTIFICATE;
P 0 Box 4407 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Salem ] 1.;r1g7p 67 -, - ALTER THE COVERAGE AFFORDEb MY THE POLICIES BELOW.
Hhdne`'978-745-33 0 Faa 97 ,.. . �I:: %%• t a : r,L, ",.;. , '`,t3:��7Y;, ,
8-745-9557 INSURERS AFFORDING COVERAGE
.. . . NAICg
.. .... .
e -. ..�. . INSUR,FA,A: --.
111,
Prp�.0S310I1A1 RCQf1AfJ. -INSURER B Amee1WA yvriab x,uuiyeve,co. .
Cohtragko= Inc., rysuRERc .. ,—
P'.. 0 Boa_ g2 . . �.
g
Salem .DAL ,01970 IN&URERD
INSURER E: ,,.. ._. . . ..
.OVERAGES
ThE POLICIES OF'INSUAANCE LISTED BELOW HAVE BEEN I36VED TO THE INSURER NAMED ABOVE FOR THE POLICY PERIOD INDICATED_NO'RMI .. .
ANY P.EOUIREMENT.'TERM OR CONDITION OF ANY CONTRACT :HSTANDING OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSLED OR
MAY PERTAIN,THE INSURANCE AFFORDEO BY THE POLICIES DESCRIBED HEREIN 16 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITION'3 OF SUCH
POLICIES:AGGREGATE LPRi3 SHOWN MAY HAVE BEEN REDUCED BY PAIR
ISA CLAIMS,
TR NSRD TYPEOFINS FE . . . . ..URANCE POLICY NUMBER DATE NMIO DATE MM/D
GENERAL LIA91LfIY LIMITS
1 EACH OCCURRENCE -§GCMMERCI.AL GENERAL LIABILITY I
CLAIMS MADE OCCUR PREMISES E; rgljLg $
NIED EXP IAAY up-pWwn) .$
PERSONAL S AOV INJURY $
GEN'LA6GREGATE LIMITAPPLIE$PER; GENERAL AGG EGATE $
ii POLICY PRO LOG PRODUCTS-COMPIDP AGO §
JECAUTONOBINE LUU31LffY '
ANY AIlTO COMBINEDSINGLE LMR $
IF.en,E)
ALL,:OWNED AUTOS
SCREDULEDAUTOS - BODILY INJURY a
HIREDAUTOS IPer pe ,)
NON-OWNED AUTOS soo&aiyINJURY i- $
PROPERTY DAMAGE
GARAOSI-ae ITY (PeYacdtle,Y) $
ANY,'AUTO .AUTOONLY-EAACCIOENf. $
. 'OTHERTHAN FAACC' E
AUTO,ONL - aGG S
10[CE99MMBRELLA LL49JUTY _
� EACH OOCUIiRE'CE, UCCUR CLAIMS MARE AGGREGATE
DE
DUCTEBLE
RETENTION
WORKERS CON.PEN$ATION AND
EMPLOYERS'LIABILITY TORY LIMITS' ER
s ANY PROPRIETORIPARTNERIEXECUTIVE 6ZZUB-9862A83—A-05 05/01/05 05/01/06 EL EACH ACCIDENT OFPICFRRAEMBER EXCLUDED? S-500000
IIy�_:AL PRb.imwrVSION E.L.DIft-3E-E4EMPL §500000
ELrUIL PROVISION$hvlaw - E-L DISEASE LIMIT°TMa? � ' � §500000
19CPJ9TON OF DPERATKINSI LOCA-QNS f YEHICLES)EW USIONS ADDED BY
- -- - F,IIPORSEMENTISPECW4PROVISIDNS
,
°RTIFICATE HOLDER - '
. CANCELLATION . ., ... .. ..
HA 0001003 SHOULD ANY OF THE ABOVE DESCRIBED POLICIF$BE CANCELLED BEFORE THE EXPIRATION
CITY H
CITY HALL 3ALEM DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR To MAIL 10 DAYS WRITTEN� '
ATTN: TOM ST. PIERRE NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHA_L
IMPOSE NO OBUGATEON OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR
SAXEN MA 01970 REPRESENNTATIVE&
UTHORI E➢REPAEMENTATWE
:01R1)2 (2001/08) Joha J. ➢7a1>ph IAB. Inc.
®ACORD CORPORATION 1988
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed:.A statement
on this certificate does not confer rights to the c6r ificate holder in lieu of such endorsement(s).
If SUBROGATION 15 WAIVED, subject to the terms and conditions of the policy, certain.policies may
require an endorsement.A statement on this cert)ficate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse.side of this form does not constitute a contract between
authorized re resentative or producer, and the certificate hglder,.nor does it
the issuing insurer(s), P
affirmatively or negatively amend, extend or alter the coverage afforded by the polioies.listed thereon.
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IMPORTANT
i
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed.A statement
on this certificate does,not confer rights to,the certificate holder in lieu of such endorsement($).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement.A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s),
i ,
I
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder,,nor does it
"affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
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