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12 CLARK STREET - BUILDING JACKET 12 Clark St. Chi#� of �$ttfnn, fflastarhuse##s �1. ?Kaplan, 9-A, (Ilhairman 004n T. zsamev, P.".19. James ?Rinsella xealt4 .Agent �Kglanre �. 'para Date: May 23, 1963 Mr. John J. O'Rourke Inspector of Buildings City Hall Salem, Massachusetts Dear Sir : Permission is hereby given to construct a private sewerage system on 12 Clark Street in accordance with plans ou file in this office. Very truly yours, LrOR rn�D OF iLTH 1�J1 N J. TOOMEY, D.S.C. Reply to: Health Agent Mr. George O'Connell Plumbing and Sanitary Inspector :cc : Bstey & Ritter 2 Rowell Ave. Beverly, Mass. 3 6116 Plans must be filed and approved by the Inspector prior to a permit being granted CITY OF SALEM p� n No. ��9C/ Ward �) HISTORIC DISTRICT? Y N 9 Date � lS i IF FOR SIDING, HAS ELECTRIC +y Home Phone !0 g PERMIT BEEN OBTAINED? Y N Bus. Phone -V36F:-1 APPLICATION FOR PERMIT TO TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's name and address '?A,( t'1)14 Architect's name N /A YT Builder's name C2 I k6ieu �J Location of buiPding, No. ' Z /' fL,+e� 'i-�1 What is the purpose of building? � l J If dwelling, # of units? Material of bldng? / Will building conform to law? Asbestos? y Estimated cost City Lica/ 8 State Lic.4/3 _ /5sp312- Signature of Applicant /o /237 SI ED ER THE PENALTY OF PERJURY DESCRIPTION OF WORE TO BE DONE 'ILA�'l oG 1A� IUC-CL 2mIf- 1,vYS r -'9dQ ` A/S 0�, ae, 5 5,0e:/ ca- Mail Permit to: I owCO ^AiC� HU l� �— po)Se�fy�T��.xlw No. 9� Ward APPLICATION FOR PERM IT TO ROOF REROOF OR INSTALL SIDING Location ERMIT GRANTED 1e,y Approved Building Inspecto COMMONWEALTH OF MASSACHUSETTS DEPAICTMENt OF INDUSTRIAL ACCIDEN'T'S 600 WASHINGTON STREET fames. Garnooee BOSTON, MASSACHUSETTS 02111 �:o-^ss one, WORKERS' COMPENSATION INSURANCE AFFIDAVIT (I,censeu perm i nee) with a principal place of business/residence at: ( '1 P 1a- (City/Statc/Zip) do hereby certify, under the pains and penalties of perjury, that: [ ] I am an employer providing the following work ' compensation Covera a foremployees working on this AWICEZ N+TO�A 126 �f�ft9S G2 \\\ 5;PP08 & 0-4 37 -04 insurance Company Policy Number 1 am a sole proprietor and have no one working for me. (OZP [ ] 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation insurance policies: Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number [] I am a homeowner performing all the work myself. NOTE: Please be aware that while homeownen who employ persons to do maintenance,construction or repair work on a dwelling of not more than three uniu in which the homeowner also reside or on the grounds appurtenant thereto are not generally considered to be employers under the Workers' Compensation Act(GL C. 152,sect. 1(5)), application by a homeowner for a license or permit may evidence the legal status of an employer under the Workers' Compensation Act 1 understand that a copy of this statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for coverage verification and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to 51500.00 and/or imprisonment of up to one yew and civil penalties in the form of a Stop Work Order and a fine of$100.00 a day agai r men. Signed chis day of t 19 C License rmirt c Licensor/Permittor CERTIFICATE OF INSURANCE: GAGECON CSR DH O1 21 94 PRODUCER THIS CERTIFICATE IS ISSUED AS A 4 TTER OF INFORMATIOI 2L AND Dan Hurley Insurance Agency CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE Chestnut Green, Suite 24 DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE Seven Federal Street POLICIES BELOW. DanversMA 01923 ---------------------------------------------------------------------- COMPANIES AFFORDING COVERAGE PHONE 508-777-9394 ---------------------------------------------------------- ---------------------------------------------------------------------- INSURED COMPANY LETTER A American National Fire Ins Co ---------------------------------------------------------------------- COMPANY LETTER B ---------------------------------------------------------------------- COMPANY LETTER C Gage Contractors Inc. --------------------------------------------------------------------- 14 Corningq Street COMPANY LETTER D Beverly MA 01915 - -------------------------------------------------------------------- COMPANY LETTER E > COVERAGES <____________________________________________________________________________________________________________________ THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERN 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 TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. --------------------------------------------------------------------------------------------------------------------------------- CO TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR DATE DATE --- ------------------------------- --------------------------- --------------- -------------- ---------------------------------- GENERAL LIABILITY GENERAL AGGREGATE YES- -------------- A ES-------------- A [ ] COMMERCIAL GEN LIABILITY SPP0886437-04 02/01/93 02/01/94 PROD-COMP/OP AGG. 300000 ------------------ -------------- ] CLAIMS MADE f ] OCC. SPP0886437-05 02/01/94 02/01/95 PERS. & ADV. INJURY 300000 ------------------- -------------- [ ] OWNERS'S & CONTRACTOR'S EACH OCCURRENCE 300000 PROTECTIVE ------------------- -------------- FIRE DAMAGE [ ] (ANY ONE FIRE) ------------------ -------------- [ ] HED. EXPENSE (ANY ONE PERSON) --- ------------------------------- --------------------------- --------------- -------------- ------------------- -------------- AUTOMOBILE LIAB COMB. SINGLE LIMIT ------------------- -------------- ANY AUTO BODILY INJURY ALL OWNED AUTOS (PER PERSON) SCHEDULED AUTOS -------------- --- -------------- HIRED AUTOS BODILY INJURY NOR-OWNED AUTOS (PER ACCIDENT) GARAGE LIABILITY -ROPE---------- - -------------- PROPERTY DAMAGE --- ------------------------------- --------------------------- --------------- -------------- ------------------- -------------- EXCESS LIABILITY EACH OCCURRENCE EUMBRELLA FORM ------------------- -------------- OTHER THAN UMBRELLA FORM AGGREGATE --- -- -------------�------------- --------------------------- --------------- -------------- -- - II---------------- ------------ TATUTO WORKERS COMP AS ACCIDRYENTLIMITS AND DISEASE-POL. LIMIT EMPLOYERS' LIAB DISEASE-EACH EMP. --- --------------------- --------------------------- --------------- -------------- ---------------------------------- OTHER -DE RIPTION OF OPERATIONS/LOCATION /VEHICLES/SPECIAL ITEMS---------------------------------------------------------------------- > CERTIFICATE HOLDER <____________________________________> CANCELLATION = SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE For Information Only. If = EXPIRATION DATE THEREOF THE ISSUING COMPANY WILL ENDEAVOR TO NAIL certificate holder wishes to = 10 DAYS WRITTEN NbfICE TO THE CERTIFICATE HOLDER NAMED TO THE e named, contact the Dan = LEFT BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR Hurley Insurance Agency, Inc. = LIWLITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. -------------------------------------------------------------------- = AUTHORIZED REPRESENTATIVE ACORD 25-5 (7/90) Daniel J Hurley c 4sx JS "l�Z ;5,r2xcc-)z1 �II- P7 N i W c N QJ V - a .. i � T G Business Certificate Citp of 6aiem, Atassacbusetts r9�Ct�WNL' GATE FILED O�� Type: ❑ New Expiradon Date—Z4�4z -1f.1- -2-2;9,Number ?get / / T M, Renewal, no change ❑ Renewal with chance In conformity with the provisions of Chapter one hundred and ten, Section five of the Massachusetts General Laws, as amended, the undersigned hereby declare(s) t a business is onducted under the title of: �DwRrZ) N/vcic0w5Kl te- MM at. Z CL 4 /�-' ��_ S4 LE � Tel .# II� type of business144--CAL-i: of Cwt-L- P3S'i.4wtyS 6z)L)I'If /u ,. e, gL by the following named person(s): (Include corporate name and title if corporate officer) Full Name Tel .# � Residence A �2 > t�ysle wSKI IZ C' Lrf e k S, Ztl BvI A of 5-7 o S. s -- -- ------------ -- ---- - ------------ --------- --- - --------------- ------------------------------------ on t-4 0 the above named person(s) personally appeared before me and made an oath that the oregoing statement is true. --- --- ------ -------------C I T Y----- - --- Notary Public (seal) Date Commission Expires idervification Preserved State Tax I.D. # 0 t{ - 29 3 00 3 9 S.S. # (if available) In accordance with the provision of Chapter 337 of the Acts of 1985 and Chapter 110, Section 5,of Mass. General Laws, business certificates shall be in effect for four(4) years from the date of issue and shall be renewed each four years thereafter. A statement under oath must be filed with the town clerk upon discontinuing, retiring, or withdrawing from such business or partnership. Copies of such certificates shall be available at the address at which such business is conducted and shall be furnished on request during regular business hours to any person who has purchased goods or services from such business. Violations are subject to a fine of not more than three hundred dollars ($300.00) for each month during which such violation continue~. -