13 LINDEN ST - BUILDING INSPECTION (3) 'PL�l161MWT-9E 44L{44AD APPROVED BY TiiE
MSPEC=PWR TD A:PERMIT BEING GRANTED
CITY OF_SALEM
Date , �2
rl`.-. �a Ward
\, Zoning DlsMq
Is PnOperfy Loq(b i1 / Location of _
Oro Flietorlc DWrW Yes No t/ BallAing Ll 1,1r�Pam/
Is PMP"Locded In
ft Ccoservayon Am? Yes No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Instaliq idin Cgnstruct Deck, Shed, Pool,
Repair/Replace, Other: 4a6f .�
e
PLEASE FILL OUT LEGIBLY 6 COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accorckriq to the following
specifications:
Owner's Name r-x—
Address & Phone
Architect's Name
Address & Phone
Mechanics Name / \C7 C>P✓( �. / <55'itlfdn7 7g(-7a(o-q jv
Address 6 Phone '3-��ss�mJ(
What Is ar v xpm of bw vt, w e G
mm"of b~ -cJ M s for how
LcJ u�J dw.wng, merry femaes9
WIN b Ad ig conform to low? 1 e Asbeskos4 i y
E*mM cost / S 1 7.S C� Cly U==N Sufi LOW=A
/ IL T—aews t
/Vin)
6 6 Ltc. /
2—
Signature of Applicant
Si�ED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
ve
�(�-- MAIL PERMIT
C4
No.
APPLICATION FOR
PERMT TO
LOCATION
e
PERMIT GRANTED
AP vFo
INSPECTOR OF BUILDINGS
` ' :DrivesLicense„ �'
04 25-60
k Date aleilh. 04Ex�5�-0$5x D S95709532:
Wffnb.F
Mum
@
ROBERT 0
230 WASHINOTOg ST
MARBLE AD MA
01"63366
r
°J,4e Pa,r w�xalNc o�� .aoa�/ua
SN
Board of Badtijo j Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
{ Registration! 140432
Expire tion-. 10/15/2005
Type:. DBA ,
R B REMODELING CO ,.
ROBERT BENSON
4 HARRIS ST
j� MARBLEHEAD,MA 01945 Administrator
nignthax Hartford , 6/4/2004 9:00 PAGE 003/003 Fax Server
FPRODUCER
RTIFICATE OF INSURANCE06-03-04
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
E ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
sT HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
ALTER THECOVERAGE AFFORDED BYTHE POLICIESL BELOW.
MA 01760 COMPANIES AFFORDING COVERAGE
COMPANY
A CONTINENTAL CASUALTY COMPANY
INSURED COMPANY
BENSON, ROBERT D
5 BESSOM STREET
MARBLEHEAD MA 01945 COMPANY
C
COMPANY
D
,COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURA
INDICATED, MAY NOTWITHSTANDING NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ONE FOR THE POLICY PERIOD
CERTIFICATE MAY NE ISSUED
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
EXCLUSIONS AND CONDITIONS
SSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
NDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POL
ICY CY NUMBER
TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION
DATE(Mi DATE(MIAIDDWY) LIMITS
GENERAL LIABILITY
g
COMMERCIAL GENERAL LIABILITYGENERAL AGGREGATE
PRODUCTS-COMP/OP AGG. $
CLAIMS MADE F7 OCCUR. PERSONAL S ADV.INJURY
OWNER'S S CONTRACTOR'S PROT. $
EACH OCCURRENCE $
FIRE DAMAGE(Any one fire) $
AUTOMOBILE LIABILITY
MED.EXPENSE(Any one person) $
ANY AUTO COMBINED SINGLE $
LIMB
ALL OWNED AUTOS
SCHEDULED AUTOS BODILY INJURY
(Per Person) $
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY $
(Per Accident)
PROPERTY DAMAGE $
GARAGE LIABILITY
AUTO ONLY EAACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
EXCESS LIABILITY AGGREGATE $
UMBRELLA FORM EACH OCCURRENCE $
OTHER THAN UMBRELLA FORM AGGREGATE $
A WORKER'S COMPENSATION AND
EMPLOYER'S UABILRY (UB-9068A57-9-03) 09-09-03 08-22-04 STATUTORY LIMITS
THE PROPRIETOR/ INCL EACH ACCIDENT $ 100 000
PARTNERS/EXECUTIVE
OFFICERS ARE: X EXCL DISEASE—POLICY LIMIT $ 500 000
OTHER DISEASE—EACH EMPLOYEE $ 100,000
DESCRIPTION OF OPERATIONSILOCATIONS'VEHICLES'RESTRICTIONS'SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE FOLDER AFFECTING WORKERS COMP CERTIFICATE HOLDER• - --�;CANCELLATION COVERAGE.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
GRAYSTONE MANOR EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
256-260 LAFAYETTE STREET 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
13 LINDEN STREET LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
SALEM MA 01947 LIABILITY O F ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES
AUTHORIZED REPRESENTATIVE /7
ACORD
AtAr f * PUBLIC PROPERTY DEPARTMENT
12o wASNINOTON STRUT,3RD FLooR
SALW4.MA o1570
TEL (575)745-D555 EXT.350
FAX (975) 740-5545
STANLEY J. USOVICZ, JIL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the proviaioas of MOL c 40,S34,I aclmowledge dw as a condidoa
of Bmldiag Pamit 0 .all debris reaaltiag ftm the cm*ucsioa W"
govam d by this Building Permit shall be disposed of in a properly licensed aotidrwaft
disposal facilityo as defined by MGL c III,S130A.
The debris will be disposed of at o Q m etv me
Locadou of Facilky N `
Sigoaum ofP Applicant Dde
FULLY complete the fol
lowing llowrng infom>ation:
(PLEASE PRINT CLEARLY)
-26 6 ,e t/-7 D,
Name ofPc mk AWlicaat
Firm Name,if any
Address,City&State
The above striate requires that debris from du demolition,renovation,rehab or other
alteration of banding or stractme be disposed in a propaly-licensed solid-waste&vow
facility as defined by Mtn,cnI; S 1 BOA,and the banding permits or licenses are to
indicate the location of the facility.
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, aRD FLODR
BAI.EM,MA 01 B70
TEL. (575)7454595 EXT.350
FAX (975) 740-9645
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBR3 AFFIDAVIT
In accordance with the pmvisiom of MGL c 40,S34,I acknowledge that sa a condidm
of Building Permit 0_ .all deluis resulting from the cmamcbm whyty
governed by, this Building Permit shall be disposed of in a properly licensed sogd waa
disposal filcifity. a defined by MGL c IQ 1112501A.
The debris wM be disposed of at 13 ;- l-
Location ofFacility
Signature OfPamut Applicant D
FULLY complete the following infamutiolL
(PLEASE PRINT CLEARLY)
wU b fir I: (-�)
Name ofPeamitjWhc—Dt
LfA�- /21 Q J e%e
Firm Name,if any
i��ss d/Yi J
Address,City&Stater
The above statute regains that debris 5om the demolition,renovation,rehab or other
alteradon of banding or structure be disposed in a properly-licensed solid-waste disposal
fid*as defined by MGL clll, S I BOA,and the building permits or iicensea are to
indicate the beadon of the Lcility.