57 LORING AVE - BUILDING INSPECTION (2) fb%"S*WT19EffL£� APPROVE{) By T44E
W.SPECJPA PF A TP A.PEAMIT I3EMO GRANTED
(\\ CITY OF SALEM
NV v � v` L\� � Date / D�
Is Property Located In Location of 77
the Historic District? Yes No Building 5 7'
Is Property Located in
the Conservation Area? Yak—
BUILDINGNo
PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof Raroof, Install Siding, Construct Deck, Shed, Pool,
epair/Replac , Other: /A!S)71-�C- P41L77 Tt 01J 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: -
Owner's Name Mt 51;3-- !'U 0 /Z 17}C
Address & Phone
L� o1)a,-Lo0-01C rZLn1AAgv 4
> Architect's Name
Address & Phone I
Mechanics Name
Address & Phone f 9 6 /aA:7YAIL'-S
�IJi7/3 vfGY, ,•K$ p I�'�'
What is the purpose of building? IP45T S-Rmlec
Material of building?�' 7zAr�L If a dwelling, for how many families?
Will building conform to law? _T r� Asbestos? Att
Estimated cost V�city License 0 N �''' state ucense s 05 0 f3 6 S
Bonn lWroveeient
Lie. / /¢-
Si re f Ap '
S NDER THE PENALTY
F PERJURY
DESCRIPTION OF WORK TO BE DONE
7LCr 5-74 Le A-nDA-Ir ®T' /��?! T(o w-r � ,Gt& 4 L
MAIL PERMIT TO-
No.� y�
APPLICATION FOR
PERMIT TO
LOCATION
P RMIT GRANTED
k
APP OVFD
i t
ECTOR OF. gUILDINGS -- .
ROM .? DUFFY INSURANCE AGENCY INC PHONE NO. : 761 593 7260 Feb. 03 2005 02:55PN PI
rBroadway
RD,,, CERTIFICATE OF LIABILITY INSURANCE 02/03/20o
781)593-1200 FAX (761)593-7260 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
9 Y' HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
dway ALTER HE COVERAGE AFFORDED BY THE POLICIES BELOW.
uare 01 90 4-2602 INSURERS AFFORDING COVERAGE NAIC C
teCh Inc INSURER A Haynes Road N uREae: Pilgrim Insurance Company 0045
bury, MA 01776 INSURERC: Travelers Insurance C mpany 0056
irisURER o:
IN6URFR 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.
NER 400-L TYPEOPINSURAHDE FOLICYNUMBER PDLM.Y EPIECTFB ICY FXPIpATON LIMITS
Im am GENERAL LIABRUTY EACH OCCVRRENCE E
COMMERCIAL GENERAL LIABILITY
fBILITY .EMI
CLAIMS MADE n OCCUR MED EXP(AAY oIIP PA'�A) S _
PERSONAL f ADV INJURY S
GENERALAOGAEGATE 9
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS;COMPA7P AGG 7
POLICY PER
LOG
AUTOMOBILE LIABILITY PMC7194539 01/27/2005 01/27/2006 (COMBDISINGLE LIMIT E
ANY AUTO
ALL OWNED AUTOS BODILY INJURY S
X SCHEDULEDAVTOS (PBIDSMOR) 2SO,O
B X NIREDAUTOS BODILY INJURY
0'a A''�BAB S 500,00
X NON.OYJNEDAUTOS --
PROPERTY DAMAGE I
;WCUITS
eml 250,0
OARAOEUABWTY LY-EA ACCIDENT S
ANY AUTO HAN ZTH-
WORKERS fLY: S
QCEBSMMBRELLA LIABILITY CURRENCS
OCCUR CLAIMS MADE ATEOEWCYIBLE
i
RETENTION f
COMPENSATION AND 6KUB7402A34-3-04 04/08/2004 04/08/200STATIC'EMPLOYERS'LIABILTTf H ACCIDENT S 100,C ANY PROPRIETORIPAR7NEPAXECUTIVE
OFFICEWMEMSER EXCLUDED? ASE•RAEMPLOYE E1Do,DOSiE411AL1'ISIONS BeImYEASE-POLICY LIMA S 500,0
OTMSR
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENOORSEMENTI SPECIAL PROVISIONS
ontractor
CERTIFICATE DER ANCELLATIQN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES EE CANCELLW BEFORE THE
EKRRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 CATS W MrMN NOTICE TO THE CERTSRCATE HOLDER NAMED TO THE LEFT,
C I ty of Sa i em ;FAILURE TO MALL AUCH NOTICE LLffLIGR IJASILITY
ATTN: Electrical DepartmentCity Ha l I _ T, DFR U THE INS R,
Salem, MA 01970 "
ACORD 25(2001J08) FAX: (978)745-3018 ORO ORPORATION 1998
4
The Commonwealth of Massachusetts
Department of Industrial Accidents
�� - OOIgN/Ine►>�yltlpt
_ 600 Washington Street, 11#Floor
Boston,Mass. 01111
qti Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractor
INSTITUTE
/y��
city �� /may—,�,� y r n �. #
work site location(full address),
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ i am a sole proprietor and have no one working in any capacity. Buildin Addition
am of*emPloYer-Previ9ittg orkars rkm trthts --
^'z{ Nm t`7V` arm v a v w
oxi ,;k IN,1�; "KZ.
fYr�ge 'yFF fr ,� r�'TM`'�" 'ik; ray�,
ti s i- tlrL{)x3 )�f ?ix - r
dd 5 .n5 .Elrl4ti {• "a5 ua
U 174kc q•,
ti
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
1,7
citv:
.: -
+
J 4 M
n r x F R
`6� ;;,
e. "'� _ u!' zg•"�.t� f z.'�,�i �j,4tu k.,a'`k5s{' r¢""�y:it£rcompact
_..
I � l+,m7wLrf1> ✓1 3.v.S\tiY A "'ly..�'
Failure to secure coverage m required under Section 25A of MGL 152 can lead to the Imposition of criminal penamn of a floe up to S1,500.00 and/or
one yesn'Imprisonment ns well as civil penalties In the form of a STOP WORK ORDER and aline of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to I6 mtt of investigations of the DIA for coverage verification.
1 do hereby cerltf0 under the pains an nalder ojperjury that the injormadon provided above is true and corre
Signature Datez. / 3 7 a.S
Print name Phone# --#q 7
omeinI use only do not write in this area to be completed by city or town omcial
city or town: permil/Ikesn# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Bnith Department
contact person: phone#; ❑Other
111,e Sepi.UNIn
CITY OF SALEM� MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
1ZO WASH INGTON STREET, 3RD FLOOR
j. SALEM, MA 01 970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acknowledge that 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, S 150A.
The debris will be disposed of at: r1 ^ 7� L
Location of Facility
G
S' t Applicant Date
LY complete the following information:
(PLEASE PRINT CLEARLY)
'--�-Z;w )
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.