0025 WASHINGTON SQUARE NORTH - BPA-08-208 What is the current use of the Building?
Material of Building? it dwelling,how many units?�
WIY the Building Conform to Law? Asbestos?
Architects Name
Address and Phone ( 1
Mechanids Name
Address and Phone
Construction Supervisors License It �" HIC Registration 0
Estimated Cost of Project S oOc� Permit Fee C—ft tion
Permit Fee Estimated Cost X S7/51000 Residential
-- _-- _ Estimated Cost X$41/51000 Cwwno efa4----- ---_An Additional $5.00 Is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays In Processing.
The undersigned does hereby apply for a Building Permit to build to the above s
speatfications. Signed under penalty Of Perjury aM
r
N
a �
V V V
OF
4- -
O
Crry—or
PUBLIC PROPERTY
DEPARTMENT
/:IW►FJ{hY D�ISUll1
VAYOe 130 WwtwN[.'K1N 5t18ar•
�Wsa�aasers 01970
Tm-97L?4&25 !•FAm M740Ae4&
APPLICATION FOR THE REPAIR. RENOYA3I0N CONSTRUCTION
DEMOLITION,OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUII Dtrt�:
1.0 SITE INFORMATION
Location Name: Building:
-- —- Property Address:-
So% IhLt O is -)a
Properly is kxwted In S.Conservation Ares Y/N HW"Ic Olehld YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
LAddre�=
1O
-
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIl!0 BUILDINGS 014LY
A c tl sr
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
E]det Description of Proposed Work:
�yc�lirxac� �2�, l/.e�.c.C� G�GC-caF�x�� . YID �Ct�ti
Mail Permit to:
CITY OF SALEM
;\ PUBLIC PROPRERTY
DEPARTMENT
w IUBF R I F.y DRIVA:ULL
M.ivt at 12L WASwxa lac STattT 4 SAIEM.MASSACI a\IiTaS 01M
TLL:970-745.9595 •FAX:9M74c.9846 '
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aunlicant Information n n - Please Print Leeibly
%4aMC (Buainess/OrganizatioNlndividual): C��'S e_oNSTRUJz7(olsj rt 9efa Jelld,=n
Address: �12Ibr�6 ST • Ulu I-T &r�
City,'StsteiZip: .S Q( e rir) th c Phone #:__ -g n �� P 16 - P 3 10
Are you an employer? Check the appropriate box: 'type of project(required):
1.❑ I ant a employer with 41.,R1 am a general contractor and 1 6, Q New construction
employees(full and/or part-tine).• have hired the subcontractors
2. I am a sole proprietor or partner- listed on the attached sheet. t �• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. Q Building addition
(too workers'comp. insurance S. ❑ We are a corporation and its !0.❑Electrical repairs or additions
required.) officers have exercised their
3.0 1 ant a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself.(No workers' comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] r employees. (No workers' nn �� �-
com in.+urancc rc uired. 13`. Oth r 1 '� 'T1
P• q 1
-Aay applicant nut checks box nl must also Jill wl the waicit below ahowins their work ni'cumpentauiun puiiey infurmuliwa
'I lumwtwmn who submit this Affidavit indicating they are Joins all work and then hire outside ct no=on meta nuhmil a new affidavit indicting such.
�Commion that chvsk this box must aaached an 2dt6tional gigot showing the name of the sub•eomractors and their workers'comp.policy inftxmatiun.
lain urt employer thur Ls providing)vorkers'compensadon insurance for my employees. Below is the paltry and job site
information. n
Insurance Company Name: P IQ 0,3 e See Q. OLQ.X.
Policy 4 or Self-ins.Lic. 1J '�,� ._.... .. .___. Expiration Date:
Job Site .Address:_� - VV'QS lM-J,J) Sig NgRTIt City/State/Zip: Salenrt met n C,-)a
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.\,IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment, as well us civil penalties in the form ofa STOP WORK ORDER and a fine
of up in S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Ot3ice of
lax emigations of dJc DIA for insurance covcrugc ecritication.
I do hereby ce under apt as ad p nalli ofperjury that the information provided above is true and correct
Si•aawret _ Dat : -
D - 3 ( 0
Oric ial wse only. Donor write in this area,to be coutpleled by Lily ar Iowa ojjicild
Cityor'rown: Permit/LicenseJl___,.
Issuing Authority (circle one):
1. Board orllealth 2. Building Department 3.Cilyffossn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
C'untaci Person: , _ _ __ phone N:
Information and'Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
.empress or•impli.ed,oral or written." -
:Art eompooyer is defined as"an individual,partnership,association corporation or other legal entity,or any two or more
Of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building.appurtenant thereto shall no[because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or total licensing agency shall withhold the issuance or .
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant wbo has not produced acceptable evidence of compliance with the insurance coverage required:'
.additionally, MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicautit
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),addresses)and phone number(s)along with their cerrificate(s)'of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the•affidavit. The affidavit should
be returned to the,city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you arc required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom.
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicease applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or
town)."A copy of therffidavit that has been officially stamped or marked by the city or town maybe provided to;thc .
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
t related to any business or commercial ventureyear. Where a home owner or citizen is obtaining a license or pennit no
(i.e. a dog licenm or permit to,bum leaves etc.)said person is NOT required to.complete this affidavit, - - - -
l'hc ot)ice of hlvestigations would like to thank you in advance for your cooperation and Should you have any question,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
o®ee of Investigations
600 Washington Street
Boston,MA 02111
Tel. Il 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
ACORD CERTIFICATE OF .LIABILITY INSURANCE 0DATE 8/0'N"°2007'
08/09/2007
PRODUCER (978) 922-4600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ARCHER INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
271 CASOT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BEVERLY MA 01915- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERAGRANITE STATE
GFS Construction & Remodeling Inc. INSURER B:SCOTTSDALE INS CO.
81 Bridge St INSURER C:
INSURER D;
,Beverly MA 01915— 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 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.
INSR ADD' POUCY EFFECTIVE POLICY EXPIRATION
LTR INSR TYPE OF INSURANCE POUCYNUMBER DATE MMIDDIYY) DATE(MIDM LMITS
B GENERAL LIABILITY SCOTTSDALE INS CO. TED 08/02/2007 08/02/2008 EACH OCCURRENCE $ 1,000,000
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED SO,OOO
PREMISES Ea ocwnenra $
CLAIMS MADE rX1 OCCUR / / / MED EXP we $ 5,000
PERSONAL B ADV INJURY $ 1,000,000
GENERALAGGREGATE - $ 2,000,000
GF.N'I.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,000
POLICY JECT LOC
AUTOMOBILE LIABILITY / / COMBINED SINGLE LIMIT
ANY AUTO (Ea aCddW) $
ALL OWNED AUTOS / / / BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS / / BODILY INJURY
NON-0VJNED AUTOS _
(Pw acadenf) $
/ PROPERTY DAMAGE
(Pw actltlent) $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / OTHER THAN EA ACC S
AUTO ONLY: AGO 3
EXCESSNMBRELLA LIAMUTY / / / EACH OCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE S
3
DEDUCTIBLE
RETENTION $
A WORKERS COMPENSATION AND GRANITE STATE 08/05/2007 08/05/2008 ] WVS TAMR-S TH
EMPLOYERS'LIABILITY O -
ANV PROPRIETOR/PARTNERIEXECUTNE E.L EACH ACCIDENT S 100,000
OFfICEMMEMSER EXCLUDED? EL DISEASE-EA EMPLO 3 SOD,000
1/yes,Eeswbe wWw
SPECIAL PROVISIONS b 1. E.L DISEASE-POLICYUMR $ 3.00,000
OTHER
DESCRIPTION OF OPER nONSILOC MONSNEHICLES/EXCLUSIONS ADDED BY ENOORSEMENTISPECIAL PROVISIONS
CERTIFICATE HOLDER - CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
GARY & JENNIFER SANTO FAILURE TO DO^10 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
25 WASHINGTON SQ NO INSURER ITS AGENTS OR REP ESEHTA
AUTOO DIy3,RESENTA
SALEM MA 01970-
A(�,C, ORD 25(2001/08) _ - -' ®ACORD CORPORATION 1988
I'6TM INS025(0108).OS ELECTRONIC LASF /RMS,INC.-(8W),T27-0545 Page iof2
RUG-6-2007 09:52 FROM:JOE GREENS IN5LRRNCE 17816313993 TU:1978(45d545 1'. 1
ACORD. CERTIFICATE OF IMSURAMCE DATE(MYIDOIYY{ oea2aT
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CCIWSRS NO RIGHTS UPON THE CERTIFICATE
JUE kfREENP INS Alh"Y HOLWJL IM CERTIFICATE DOES NOT AMEND,EXTEND OR
121 PLFASANrSf.P.O.130K 12 ALIM THE COVERAGE AFFORDED BY THE POLK2SE BELOW _
COMPANIES AFFORDING COVERAGE
MAKKLhKhAU,MA 0194S
COMPANY
2MG A CONT9W9TALCA5UALTYC08®AYY
Uis ultso COMPANY
B
M(KE KOBIALKA LANDSCAPE
(:ON'IXA(.-KW CX)MI'ANY INC COMPANY
126 JE WTSTRFET C
MARHL&Hk:k11,MA 0IM5 COMPANY
D
COVERAGE
Tlaa omasAPYTRATnN+a+c�amwulmuav�esaa«avEM�Iwummnre�nRa®aewelaR nswucv veloouocArea Rorw.nerAaawo
rsv Re�mumaLTmumcmm+mvcaawe0uaweroRonaem�mmrnmlu�oc�tmw+wn�r�rra:caaNAY�mwkvaaula�.s�on�s
ANCIroEoernePmwmo�aae®I�Im+semeamAuneTems. ,w000rnrolaaPworroue®.ufs�sNocRiwrw�vEem/a�acEuer
oA®CtMAaF
CO P"Y WF POUCYEiO''
LTTt TYPE.OFW=ANCE POLICYUMM DATEMMMY1') OATCPMOIRM Lmrs
GIDIHNAI.LIAMUTY GENSRALAGGREGATE f
COMMERCIALGENERILLUAMUTY PRODUCTS.COMPATPAGG. 5
Cuum MAM OCCUR PERSONALCAACV.INJURY 5-
OWNER96Q COMRACTORS PROT. EACHOCCURRENLE f
FIRE DAMAGE(Am me IT* S -
ME4.F:1L�EN.A' (MYme P=rJan7 5
AUTOMOFILGYAYYT/
ANYAUTO COMWE0 SINGLE LIMIT f
ALL OWNED AUIOB 8ODLY9UURYoWPel ) G
SCHFAMEAUTOS EOD2.YIKAIRY(PCTArdtfC $
HIREDAUTOB PROPERTYOAMAOE a
NOW)""AUTOS
GARAGE UJIBBATY
ANTAUT09 AUTO ONLY,SA ACCIDENT a
OTHER THAN AUTOOALY
EACH ACCIDENT S
AGREGATE S
EXCEAI LIAMUTY -
IUMIEI'APORM EACH OmURIMIICE 5
OTHER THAN UMBRELLA FORM AGGREGATE f '
WONUUM COMPOCAnGN AND -
A BMPOLYIEM UABLITY UB-49SX7520.07 04.29607 04-29-08 STATUTORYUMTS x
YHE PROPRIETOW EACH ACCIOFIIT S tUa,000
PARTNERSIFJMCUTNE X. mm OMEASE.POUCYLAIIT f 500,0(10
OFFICERS ARE I= OMEASE-EACH EMPLOYEE.. $ 180.000
OMIR
MSSCRPROII CF OPERATHNISLOCA7101WWVBNIClE61REWMICTgNS81YCWL ITEMS
THISRETLACFS ANY Ph=CEHTDTCATELl5MD TO THE CERTIEWATT HDIDPH AFSEC'IThe VRYLWMOne COYEBAGE
CERTIFICATE HOLDER CANCELLATION
vmOLPANT wT ARDYa PESCRIa2P PalaasgcNuca4tSO BBCAGTWG
OFS CONSTRUCTIONA REMODELING INC aISFIATCN aAT¢THaHSaA THata Nc Ca pP Y.tL RIDO.VOR MN ,
T� c OATS Wn7l4NC1'Le'O THE CERTfFGAM KMDEC R 10 TO'HE I.EFr.SLIT
QO V Y1 c�SE J� KFALURETOMAI B9NCN TIEWSPANYMSAD@ UP659 00_91ii MULBhRY OF#dY
86 —079T5 Al I T o-1 4 O S AUTNdI®RVRIq@MTATRR
5Q%ern , ma o14� d Dennis Do zis
AC.ORp.2Sx9.(91A8
)4C00 CERTIFICATE OF LIABILITY INSURANCE oPID DATE(MMIDDNVYY)
I!( KOBIA-1 07 31 07
'[ PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
444 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Joe Greene Ins. Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
121 Pleasant St. , P O Box 12 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Marblehead MA 01945
Phone: 781-631-5000 Fax:781-631-3993 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: pneB .. Toe,.. 21970
INSURER B: CNA
Kobialka Landscape Contractor INSURER c:
126 Jersey Street INSURER D:
Marblehead MA 01945
INSURER P.
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWTTHSTANDBN3
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.
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD DATE MM� LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
A }[ COMMERCIAL GENERAL LIABILITY FB1U57129 04/29/07 04/29/08 PREMISES(Ea occruence) s300000
CLAIMS MADE OCCUR MED EXP(Any one person) $5000
PERSONAL&ADV INJURY $ 1000000
GENERAL AGGREGATE $2000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000
POLICY PRO-
JECT LOC
AUTOMOBILE LIABILITY
COMBINEDSINGLE LIMIT $
ANY AUTO (Ea accident)
q
ALL OWNED AUTOS
BODILY IN $
SCHEDULED AUTOS (Per��))
HIRED AUTOS
BODILY INJURY $
NON-0WNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGG S
EXCESS/UMSRELLA LIABILITY EACH OCCURRENCE $
71 OCCUR CLAIMS MADE - AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND
TORY LIMITS ER
EMPLOYERS'LIABILITY IA
B ANY PROPRIETORPARTNERIEJECUTNE TO BE ISSUBD BI cau•ANY 04/29/07 04/26/08 E.L.EACH ACCIDENT $100000
OFFICEPJMEMSER EXCLUDED? E.L.DISEASE-EA EMPLOY $ 100000
It yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
LANDSCAPE SERVICES AND CONTRACTORS - JOB SITE WASHINGTON STREET, SALEM, MA
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 1 XPIRATIO
GFS CONSTRUCTION 6 DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN
REMODELING INC NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
ATTN: GARY F. SANTO _
q 0 (,(`CI< �I IMPOSE NO OBLIGATION OR LIABILITY OF ANY KING UPON THE INSURER,ff5 AGENTS OR
Ll;-I��� e140a REPRESENT
AUTOO
S 0.,PTh .M Cti Q(Q7L -
Joe G e u c n
ACORD 25(2001108) 0 ACORD CORPORATION 1988'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MY"ltiY O L
I2C W.\91NT:0DIS.REET•1.\ti V.\1.\V\(:':Il eLlls::9/.
Tit,:vw4s.•)m •F.%x:OM74C9844
Construction Debris Disposal Affidavit
(required for ail demolition a►xi renovation work)
in accordance with the sixth edition of the State Building Code, 780 CbiR section 111.E
Debris, and the provisions of M. GL c 40.S 54;
Building Permit M _ _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defiled by %4GL c
111. 4 150A.
The debris will be transported by:
— — (SIAMe ors hauler)
Tlic debris will be disposed of in
1 (11=C of fatHRy)
rd.:rcis of Cx:Lty)
-AW
J r� u.nmu•�ald �tl�
Board of Building Regulations and Standards
NOMEIMPROVEMENTCONTRACTOR -
Registratigp:._152158
Expirabotl-' B/4/2008. � ,
y- � ,Typ�Privatt\{eCorporation
4 1 •..
GFS CON 5 UCT r N'a EF. JNG
GARY SANTQ „�+'y
B1 BRIDGE ST ' peputy A� dmrnistrwetot }j
.+ IEV,J=RAY MA.01915 ,
✓/te&msvmm+a s a o�✓��a°°aa�urdsl _1
F_4 �' Board of Building Regulations and Standards `i
Construction Supervisor License
'.� Lic9int`e. CS 9726&
B i rthdat$i. 12/31/1944
r ExpiraBon. 12/31/2010 Tr# 9726E
Restncti 0 �
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GA SANTO ` 8-. � iy��
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Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978)745-9595 EXT.311 FAX (978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
1K Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: Washington Square
Address of Property: 25 WashingtnmSquare N
Name of Record Owner: Gary& Jennifer.' anto
Description of Work Proposed:
Repair/replace granite front steps, stone pillars, granite landscape edging, brick sidewalk and front porch
decking that were damaged by a vehicle accident to replicate what existed prior to the accident. No changes in
color, material, design or outward appearance. Non-applicable due to being in kind repair/replacement.
Dated: August 7, 2007 SALEM T C MMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
P Y
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.