21 MARION ROAD - BUILDING INSPECTION ftAMIAUWOEfNAD#NO APPROVIED BY T4IE
MPM= PWR TD/I,'.PPAWT BEWR GRANTkD
CITY OF SALEM
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91MLDNG POW APPLICATION PM
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(Curds whicrwwr apply) Roof, Raoot, Instal Sklktp, CorwtrW Derfk, &W, Pool,
Rsp.ldRspLoe, Olher.
PLEASE R.L OUr LEONt.Y a COYPI.EMY TO AVOID DELAYS N PROCEt11B10
TO THE INSPECTOR OF BUILDINGS: '
The undersoied herby applin for a permit to budid acoorditto the.blimnp
speomoatlorrs:
Ownsrs Nam. T o k lV SIL A C K
Address a Phana �1 M A r E a Al RD (S ,) 2`/6— d�L S�
Amhkact's Nwne
Address a Phorm ( )
Mechanics Name A, D H A r ko J M AI%dw
Address a Phone 3 M /f n 1 Sa V /col Cr"vr=GAAIU(SW) 37 3 /a L/5
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\ SOIWI s. a IM PENALTY'
OF PWUURY
DESCRIPTION OF WORT(TO BE DONE nn
MAIL PERMIT TO:
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ACORDETiR IMATE L�AE �i T �NSYNE DATE(MM DD YY)
7/0
PRODUCbR' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
A S K Fowler Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
200 Park Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
North Reading, MA 01864 COMPANIES AFFORDING COVERAGE
COMPANY
A Hartford Insurance Company
INSURED
COMPANY
R J Construction B
3 Madison Ave. COMPANY
Groveland, MA 01834 C
COMPANY
D
,OVIERAGES
THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLTR LIMITS
DATE(MMIDD/YY) DATE(MMIDDI Y)
GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000
A X COMMERCIAL GENERAL LIABILITY 08SBANF7078 5/28/04 5/28/05 PRODUCTS-COMP/OP AGG $ 2,000,000
CLAIMS MADE OCCUR PERSONAL&ADV INJURY $ 1,000,000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000
FIRE DAMAGE(Any one fire) $ 300,000
MED EXP(Any one Person) $ 5,000
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE UMIT $
ALL OWNED AUTOS
BODILY INJURY $ 100 000
A X SCHEDULED AUTOS O4MCZ500008 6/28/04 8/28/05 (Per person) i..
HIRED AUTOS
BODILY amident) $ 300,000
NON-OWNED AUTOS (Per aaiden[)
PROPERTY DAMAGE $ 100,000
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY.
EACHACCIDENT $
11 AGGREGATE $
EXCESS LIABILITY _ EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND WC STATU OTH
EMPLOYERS'LIABILITY TORY LIMITS ER
EL EACH ACCIDENT $ 100,000
A THE PROPRIETOR/ INCL QBNECGQ0160 5/30/04 5/30/05 EL DISEASE-POLICY LIMIT $ SOO,000
PARTNERSIEXECUTIVE
OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE 8 100,000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSfVEHICLES/SPECIAL ITEMS
Insurance Verification
CERTfFICAT"E HQLOER _ .. CANCELLATION _
.SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
R J Construction EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO-MAIL
3 Madison Ave. 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Groveland, Ma 01834 '
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Kerri A. Boutin, CIC CISR
AG4t�U2S S�419.5) iDAC�7Rp GORL'�ORATIGN 19881
PUaUG PROPKM DKPARTMEff -
120 WASHINGTON VMKKT. 3ND FLOOR
qw fAUMI.NA O t 970
TmL. (078)745-0695 mlT.s!O
FAR (W7e)74040"
STANLLYJ. U210y(& .pt.
MAYCIIR
DUPOM OF DEBRIS AFFIDAVIT
In acmdaooa wi&the psoviaiom of MM c 4O M4.I aelmowledp dw as a cooditica
of Bml ft Permit/ .A debris resulting from the cmftocfiam„may
governed by this BuBft Permit dM be d gmud of in a propady lie4osed solid waase
disposal facrlitys ss ddbW by MOL c EL SIM&
The debris wM be diapoaed of at
Locadon of Facrlity
Srgoadne qq*nft AppHemot Daft
FULLY complete the followinS MhMSt o:
012ASE PRIM CLEARLY)
Name ofPemrit Appliom t
Fina Nam%if nay
3 ` J .
Address,City A sate
The above statute requires that debris from the demolitioq rumadoq rehab or other
alteradon of bmldiag or atr w me be diapered in a p mpaiy-licensed soH&waste disposal
fid ty as defined by MM cID. S150A.mad the building pamib or lkenam are to
indtieata the location of the LCafty.