4 MARION RD - BUILDING INSPECTION (3) No. Date �/
r
yr a�ms
Is Property Located in /' Location of
�/
- the Historic District? Yes_No Building (Jh
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, onstrucDDec 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 �IADIT7 f tmF}LG
Address & Phone �}Rl�ti[ 2n ( )
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone 19 blr
What is the purpose of building? i ,ESf lr;�, Yt A(-- T/U tr_/ / 1 f�
Material of building? KAX)f�> r9Qj j C-- if a dwelling, for how many families? I
Will building conform to law?_XEs Asbestos? A/6
I� Estima
ted!
cost , 3 City License# N A State License #
Bome Improvement �_,Lic. t // � r
ignaturl�Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE e�
�dYl t��YTT'1�JZt NT"
MAIL PERMITTO: IVIJ SA 119iC16rour i ioN $ r cfzlnitr 1qVr--_
/%A. C1171y5 _
I
I
� ee.. II o m monw,:altk ol May.iachl V el`�3
lil �J.par(ma,sr off//.J"a•,•r•iaf�cciwnU
boo W-J,,VLon.3L..I
James J.eamooea L�O,lon YYIGa,.w 021 r 1
tor.-.n,rssorxr
Workers' Compensation Insurance Affidavit
1, _ ,��r �i �.ii n /✓D YSA �n'ST,e�IGTtOA( � 24r7�L /NrC,
...•�•,l
with-a principal place of business at:
l
9 72K)
hereby c under the pains and penalties of Perjury, that:
do er by certify P
tom compensation coverage for my employees working on
O 1 am an employer providing workers' p
this job.
Policy Number
Insurance Company
1 am a sole proprietor and have no one working for me in any capacity.
() 1 am a sole Proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation polities:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
�! I rne,rsuno w[a coon of oX sx L„ t vs'i be ior.•a,oro o, o r One.of Inwdcas,o,u of o., DIA for <o'e,sic a fim uen ana wt laisrc w seorre
co.nar, w r,wrre under Secrion 25A of MGL 15 t can lean w o r.noosrs:on of cans— oersareses co—e"'t of a t.r of W w-S L500 CO anUa ear,
r,an"..xuonmrnt v vo x cir7 aNl[W in shh, loan o!a STOP WORK ORDER ant a fru ofS100.00 as .aI aTaat snt.
Signed this Gzf'l day of e5.�il'7� _ >
�iccrrm lttce building DePanr.+cnt
I�tensing board
Seieamens Office
Hulth Department
OF SALEM. [�tASSt n`
{� a PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, 3RD FLOOR
SALEM,MA 01970
a .3'
'9s'`tit�y TEL. (978)745-9595 EXT.380
FAX (978) 740-9846
iTANLEY J. USOVICZ, JR. - -
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,SA 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 in,S150A.
iThe debris will be disposed of at
Location of Facility
ate
Sr re of Permit Applicant
FULLY complete the following information:
(PLEASE PRwrrCL�EARLY)
rILLl�
Name of Permit Applicant
/-,,iSye,iLl l �5N rr�"►�
Firm Name if anyA,Lez
c M�r
i
Address, City ty &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.
AGORD_ CERTIFICATE OF LIABILITY INSURANCE "5/21/ 007
115/21/2007
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF NFORIINATION
Rose insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMENC. EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY SHE POLKI ES BELOW.
P.O. sox 958
Salem MR. 01970- INSURERS AFFORDING COVERAGE NAKA
INSURED IN.WRER A ESSEX INE IR8NC E COMMMY.. .
Noy$a Home Improvement INSURER e 1 69S,
68 Loring Avenue INSURER C:
IN61 MIR O' ,
Salem MA 01970- INSURED&
COVERAGES - ••�
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 711E INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOT I'NSTNNDING ANY
REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEP:nFRCATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS A,ND CONDITIONS CA' SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _
PIER ADVIL POLICY EFFECTIVE LACY EXPIRATION �—
LTn INSRDI TYPE OF INSURANCE POLICY NUDISM DATS(MNIDBIW) DATE IMNIDDIYYI LINTS
GENERALLABILTTY / / / / ACH OCCURRENCE r.-.., 1,000,000
D MA O RENTED
x COMMERCIAL GENERAL LIABIL'ffY PREMISES LE.Rcc.. �� 50,000
CLAIMS MADE OCCUR .-9CU6117 11/14/2006 31/14/2007 MED EKP� RIa .son ._ 5,000
PERsoruLY ADV INJURY 1,000,000
GENERAL AGGREGATE i. 2,000,000
GIRWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPgPAGG •_ 2,000,000
POLICY JECaT lDC / / I /
AUTOMOBILE LIABILITY / / / / CDNSNtlEU SINGLE LIMIT
ANY AUTO (Ea aCm811I)
ALL OWNED AUTOS / / / / 8=LYINIURY
SCHEDULED AUTOS lPar pemwlj
HIRED AUTOS / / / / BOIALYINJURY '
(PBreACf02 N) 1
NON-ONTIm AUTOS .
PROPERTY DAMAGE
(FmP[diCINJ 1
GARAGE LIABILITY AUTOONL,Y-EAAGCIDENT �••
ANYAVTO / / / / OTHER TOAN FA ACC ,.-
A'JTDONLY: AGG 1 -
ETXCESUIUMBRB.LA LIABILITY / / / / MLIC?I OCCURRENCE 1--
OCCUR CLAIMS MADE AGGNEGATE I i
1"
of UCTIBLE
RETENTION S I
B 'oo_aaa OB/10/2006 .-' ,:0D9 TO r IAMrr O
tPA
ANY PROPRIETOfUPA.RTNERIEXECURJE EL EA ACCIDENT s_— 100,000
OFFFICERMENBER,EXCLUDED? / / / / E.I..OREA5E-EA EMPLOYEE 1 100,000
Ilea.NBecrbe WWA .--
SPECMLPROWSIGIIIS v. EL,BISEASE-POUCV DMrt 1 500,000
onus+ / / / / •.
DESCRIPTION OF OPrRATGNSRACATXMSATi4IC1_F3M"^'U9 41 ADDED BY BIDOR.8EIGWD5PEC1AL.PRONSIMS
CERTIFICATE HOLDER CANCELLATION .
SHODUD ANY OF THE ABOVE O6SCAMW FODCJES BE CANCi A.BD BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING MSIIRER W" EI CEAVOR TO MAIL
SO DAYS WAITIEN NOTICE TO THE CBRW4CATE HOLDER NAMIE 1 TO THE LEFT,BUT
ror S.esured I s records .. FAAARM TO OO SO SMALL MPOSE.NO OBLIGATION OR LIABILITY Of L V KMO UPON THE
INSURER,ITS AGENTS OR RERRESENTA'RVES,
AUTOO S TATNE
aACORD 25 G0001108) ®ACORD O:IIPORATION 1888
W�W S025 ID1aSLO3 ELECTRONIC LASER FORMS,INC.-(&W)=T-0SCS Pepe 1 W 2 .
Board of Buildin Regulations and Standards
g � License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration. 116568oil r. One Ashburton Place Rat 1301
Ezprr ation12/2009 Tr# 129332
Boston,Ma 02108
private Corporation
NOYSA HOME IMPRWErMENT-SERVICES,INC
MARC RIGGILLO ,
66 LORING AVE
SALEM,MA 01970 Administrator t valid without signature
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