28 MARLBOROUGH RD - BUILDING INSPECTION fUd allwOE#mpAAD APPROVED eY we
CITY OF SALEM
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PUSUC PROPIUM DEPARTMENT
120 WASNINay" aTaaaY,aao PLooe
SALZM,MA C1070
T[L(276)74E-0595 Orr.360
FAX (*78) 740-9646
STANLCY J. USOVICZ. in.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the Provisions of MC$,c 40,S34,I
ofBml&S Permit 0_ acknowledge a:a comditica
.all debris r>�niting firm the
Vvemed by this Building Peewit shall be disposed of in a MPOY licensed soH&wam
d VOW facility,as defwed by WX c IIL S1s0A.
7e debris will be disposed of at: ? e
Location OfFacehty
digof LP -7
Date
(PLEASE PRW CE EARL won
ofPe mi's AppYica�
C-
rum Name,rf an
S+ Ih9 9 p
Address,GYty k State
The above statute requires that debris firm the demolition,renovation,mhab or other
alteration of buDding or atremuft be disposed in a
fled*as defined by MM cM S150A,and the buel �lick solidwaste disposal
indicate the location of the facility. 1 °r licenses are to
' The Commonwealth of Massachusetts
1 Department of Industrial Accidents
K.
3 Office of Investigations
600 Washington Street
``- Boston MA 02111
Workers' Com ensation Insurance Affidavit
Property Owner Name:
Job Location: �c6 f 1GC ` {`7c yaN 0 A
City: (-X\ Phone 11
❑ I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity.
10
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I am an employer providing workers'compensation for my employees working on this Job.
Company Name:C ak"1 nc�,+e 1 Dol t M4 o, a F D+ Toc
Address:
City: PC, Phone#
Insurance Co. Policy#
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.,.::.:.m:4>:m>:4>:m»»'roa:..>,..nwn<;)e:?kkO::axa.S,2>n.u4a'e..m-,:.'tr.4:3:Qi�p•.nniaJ.::k.§.[av:445>Y:;:.w;m.,:a>.cd::��4..,Ao,).4. ,£.<:a 4"... ,iJ'u9SY:k'. •`4.oi>,`<7;6:II3i`: ik:..:;:.::::.❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'
compensation polices:
Company Name:
Address:
City: Phone#
Insurance Co. Policy#
I n
Company
...>,.,>._)..;.,,..u.;.v..a.:..J..n....;.......:a.u.x.a.:.a..�.....,.3?>+SA.L.,u,.4.w..).:L<,u.n>?4..:.Sv..o4 3.;`.A;A.,C,w...waxa.kxro;.a 4,:x,.`:9.n:Y.U.:CM.b>iNr:3.fi:..:,a.naa. ..fi.A.�uS,;Li..C..n»'.o..,:.,n,a..,a.�.`.4.,v0e.\.a..f.<a.%�e;:.2a.».xd.a•y.,a e Lnu.d l:�.'.'e,i vox;''.:'.v4to,.;x,:t sovD'a..,::z:�,.&.9L.p.ACo:;w.x.u.,.,L�....i..:`n»kLL>:.y'3?un34:;�'iCt,;,'a.a`.!Ya.tr.:.no:.#.^.„..,e>J.1;.!.J:.;,a::.":.:.u�.>3:.;.�i•^:n[f...!EY.:.
Name:
Address:
City Phone#
Insurance Co. Policy#
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Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a f nc up to S 1,500.00 and or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify r pains;and penalties er ury that the information provided above is true and correct.
Si tore Date —
Print Name tL Phone# CT7
Official use only. Do not write in this area,to be completed by city or town official
❑Building Department
City or Town: Permit(license# ❑ Licensing Board
❑ Selectmen's Office
❑ Check if immediate is ,mired ❑ Health Department
Contact person: Phone#: 11 Other
U4/28/2006 WED 13:48 FAX 781 581 7200 BENEVENTO INS AGENCY a 001/001
A9ZORQ CERTIFICATE OF LIABILITY INSURANCE CSR DATE(MWDDNYYY)
CABIN-1 Oa
vao"ucER 26 06THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Benevento ;ns. Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
497- Mumphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Swampscott, MA 01907-
Phone: 781-599-3411 Fax:781-581-7200 INSURERS AFFORDING COVERAGE NAIC#
INSURED
INSURER" PREMIER iNEsT�Ncz ATC
Cabinetry Unlimited Entagr�rise INSURERB: FRARTFORD INS. GROUP
PQtegr�Bagare1lla Prosident INSURER C:
P22e22ahadyrMA 01960 INSURER D: --
6 q -rJS�• (r INSURER 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 DOC1IMENT 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 UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NEW TYPEOFINSURANCE POLICY NUMBER OATS TIFFS YY PpATE MM/00/Yy UNRS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A x COMMERCIALGENERALLIABILT' I-680-4753B409—TCT 10/21/05 10/21/06 PREMISES RRENCEnml 11 .J6300,0,0
00
CLAIMS MADE OCCUR MED ERP(Ay yip P,Mgn) S5 000
PERSONAL b ADV INJURY S1,000,000
GENERALAGGREGATE S2 000 000
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS.COMPIOP AGG 62 OOO,QOO ✓
POLICY Tef 7 LOC
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMB $
(Ea ecGdm)
ALL OWNED AUTOS
SCHEDULED AUTOS BODILY INJURY
(Per pprspn) 6
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY $
(Per ecddeN)
PROPERTY DAMAGE S.
(Per Bccldenq
GARAGE LIABILITY _AUTO ONLY.EA ACCIDENT 6
ANY AUTO
OTHER THAN EAACC S
AUTO ONLY: AGO $
VED
VI LIABILBTY ;'a
6 CLAIMS MADE g 66$ --
S —_
WORKERS COMPENSATION ANp
B EMPLOYERS'LIABILITY FRANY PROFMETOR/PARTNMMECUTWE 6S6UB-7963A75-A-04 10/21/05 10/21/06 4100000 OFFICER/MEMBER EXCLUDED?
11 Y. dFPw ender EL DISEASE•EA EMPLOYE $100000
6FE6IAL PROVISIONS below E.L.DISEASE-POLICYUMR E 0000Q
OTHER S
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXDLUSIONS ADDED BY Pl1DORSEMENT 19PECLAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POLKNES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN
CITY OF SALEM NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO 00 SO SHALL
120 WASHINGTON ST IMPOSE NO OBLIGATION L OF ANY KIND UPON THE BISURER.ITS AGENTS OR
.4:SATM MA 01970 REP A
NY V7:N
ACORD 25(200110B) 0 ACORD CORPORATION 1988
FROM CEC ENG FAX NO. : 97B5315501 Sep. 21 2005 05:41PM PS
CEC LAND SURVEYORS INC.
7 WINTER STREET SUITE 4 • PEABODY, MA 01960 0 (978)531-1191 • FAX (978)531-5501
CEC
0 32 0 0
1.0 5 ROPOS�Pp,I \TN OBE 10 0 ��
�S WN�N NI�N i o e,cr
X-p PROPOSED O
2 7 IN-GROUND
EXISTING I� POOL o
DRIVE (TO E REMOVE m 32'X16'
\ f^ N 70% �
J ` O? „Q O�
w Azm `�' AZN
0 mNaa $8 � 0 (P. -G10
cn z z c EXIST
z 0 DECK
o � o
U O O O N
o �� a� EXISTING PROP S D �n o �=+0
o �� DWELLING FENCE PROP_ s� m
m 0 #28 3' GATE m
O o m PARCELS 88,89
9,580 S.F.t
1.0
j 9 r ° a VEwP E5�
O
O X m 21.8 y ALL SECTION
m o m
z(A TO BE REMOVED)
J m-1 c 4'Elf z
COMP
;0C)i 0 DEED BK 19,283 PG. 497
rn
F,X EXISTING N�3 3�2 c 1D PL SK. 55 PL #17
o R��N wN v14, LAND C7. PLAN #11802-1 1
p` ASSESSOR'S MAP 8
PCL'S 88,89
G
13 F 15'
MIN
I HEREBY CERTIFY THAT THE DWELLING SETBACKS IF
30'
SHOWN HEREON IS AS ACTUALLY LOCATED POOL SETBACKS
BY INSTRUMENT SURVEY AND SETBACKS SHOWN 6' MIN. PROP. LINE
HAVE BEEN CALCULATED FROM DEEDS AND PLANS 15' MIN. STRUCTURES
OF RECORD.
3�PNpk Of 446 I SITE PLAN .
ULUAMfor
R yc^ PETER BAGARELLA
D'vwAEMOM w O1
o wana
28 MARLBOROUGH RD.
SALEM MA
WILLIAM R• D'ENTREMONT :L.S. Nu��'p SCALE:1"=20'DlTE:9/2$/OS
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