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109 CONGRESS STREET - BUILDING JACKET� E 109' CONGRESS STREET coNUIT� N•. CITY OF SALEM, MASSACHUSETTS BOARD OF APPEAL --- 120 WASHINGTON STREET♦ SALEM,MASSACHUSETTS 01970 KIMSERLEY DRISCOLL TELF:978-745-9595 ♦ FAX:978-740-9846 -< o MAYOR r L July 29, 2015 Decision x , City of Salem Board of Appeals v r^ rn Petition of CONGRESS & DOW LLC of the NORTH SHORE COMMUNITY WEVELOPMENT COALITION, INC. requesting a Special Permit per Sec. 3.3.3 (2) of the Salem Zoning OE3inance`to alter an existing non-conforming structure for a substantially different purpose to restore the first floor of 105 CONGRESS STREET from a residential unit to a commercial space for retail or a restaurant and a Variance per Sec. 5.1.8 Tabk of Required Parking Spaces specifically from off-street parking requirements for retail or restaurant space to allow seven (7) off-site parking spaces & on-street parking at the property located at 105- 109& 111 CONGRESS STREET (Map 34,Lot 169) (B 1 Zoning District). A public hearing on the above Petition was opened on July 15,2015 pursuant to M.G.L Ch. 40A, 4 11. The hearing was closed on that date with the following Salem Board of Appeals members present: Peter A. Copelas (Vice-Chair),Jimmy Tsitsinos,Mike Duffy, Tom Watkins and Paul Viccica (alternate). The Petitioner seeks a Special Permit from the provisions of Sec. 3.3.3 (2) Non-Conforming Structures of the Salem Zoning Ordinance, to alter to provide for a substantially different purpose to restore the first floor of 105 Congress Street from a residential unit to a commercial space for retail or a restaurant and a Variance per Sec. 5.1.8 Table of Required Parking Spaces specifically from off-street parking requirements for retail or restaurant space to allow seven (7) off-site parking spaces & on-street parking. Statements of facts: 1. In the petition date-stamped June 23, 2015, the Petitioner requested a Special Permit from the provisions of Sec. 3.3.3 (2)Non-Conforming Structures of the Salem Zoning Ordinance, to alter to provide for a substantially different purpose to restore the first floor of 105 Congress Street from a residential unit to a commercial space for retail or a restaurant and a Variance per Sec. 5.1.8 Table of Required Parking Spacer specifically from off-street parking requirements for retail or restaurant space to allow seven (7) off-site parking spaces &on-street parking. 2. Attorney Grover presented the petition on behalf of the petitioner, North Shore Community Development Center. 3. The petitioner proposes to convert two (2) first floor residential units located at 105 CONGRESS STREET to a commercial retail or restaurant space provide seven (7) on-site parking spaces that service the proposed commercial and residential uses for 105-109 & 111 CONGRESS STREET. 4. North Shore CDC proposes to rehabilitate the existing buildings to restore the historic character of the original building as the location is newly designated as a National Historic District. 5. The petitioner intends to leverage funds from the proposed commercial space, state and federal historic tax credits and other financing to rehabilitate seven (7)properties including the buildings on 105-109 & 111 CONGRESS STREET. City of Salem Board of Appeals July 29,2015 Project: 105-109& 111 Congress Street Page 2 of 3 6. Currently, buildings located at 105-109& 111 CONGRESS STREET have eight(8) residential units each with seven (7) existing off-street parking spaces. 7. There are two primary structures located on one lot and are non-conforming. 8. The property is located in a B-I Zoning District ang a d the proposed uses for the property, in din retail space or a restaurant without service of alcoholic beverages, aze allowed by right. 9. The requested relief, if granted, would allow the petitioner alter an existing non-conforming structure for a substantially different purpose to restore the first floor of 105 CONGRESS STREET from a residential unit to a commercial space for retail or a restaurant and a Variance per Sec. 5.1.8 Table of Required Parking Spaces specifically from off-street parking requirements for retail or restaurant space to allow seven (7) off-site parking spaces & on-street parking. 10. At the public hearing, one (1) member of the public spoke in support and one (1) member spoke in opposition to the petition. The Salem Board of Appeals, after careful consideration of the evidence presented at the public hearing, and after thorough review of the petition, including the application narrative and plans, makes the following findings: Findings for Special Permit: 1. The proposed alteration of an existing non-conforming structure for a substantially different purpose to restore the first floor of 105 CONGRESS STREET from a residential unit to a commercial space for retail or a restaurant would not be more substantially detrimental than the existing non- conforming structure and will significantly benefit the social, economic or community needs served by the proposal. 2. There are no impacts on traffic flow and safety, including parking and loading compared to the existing conditions. 3. Adequacy of utilities and other public services are sufficient. 4. There are no impacts on the natural environment,including drainage. 5. The proposal conforms to the existing neighborhood character. 6. The potential fiscal impact, including impact on the City tax base is positive due to the anticipated rehabilitation of the residential units and new commercial space. Findings for Variance: 1. There are special conditions and circumstances generally affecting the land, building and structure generally not affecting other lands, buildings and structures in the same district in that the existing building size,location and density consumes the entire lot and it is physically possible to meet the off- street parking needs required. 2. Literal enforcement of the provisions of the Ordinance for off-street parking would involve substantial hardship to the applicant as not all the variance would prevent the applicant from using the building for any other use and as presented would prevent the owner from making renovations to the buildings on this property and others to rehabilitate low-income housing an the rod provide another economic development opportunity at this location. Further, th provide e opportunity to rehabilitate the e to a manner the Variance will at is needed h the community in this location. p p City of Salem Board of Appeals July 29,2015 Project: 105-109& 111 Congress Street Page 3 of 3 3. Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent of the district or the purpose of the ordinance. On the basis of the above statements of facts and findings, the Salem Board of Appeals voted five (5)in favor (Peter A. Copelas (Vice-Chair), Jimmy Tsitsinos, Mike Duffy, Tom Watkins, Paul Viccica (alternate)) and none (0) opposed, to approve the requested Special Permit to alter an existing non-conforming structure for a substantially different purpose to restore the first floor of 105 CONGRESS STREET from a residential unit to a commercial space for retail or a restaurant and a Variance per Sec. 5.1.8 Tabde of Required Parking Spaces specifically from off-street parking requirements for retail or restaurant space to allow seven (7) off-site parking spaces & on-street parking to allow subject to the following terms, conditions and safeguards: Standard Conditions: 1. Petitioner shall comply with all city and state statues, ordinances, codes and regulations. 2. All construction shall be done as per the plans and dimensions submitted to and approved by the Building Commissioner. 3. All requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 4. Petitioner shall obtain a building permit prior to beginning any construction. 5. Exterior finished of the new construction shall be in harmony with the existing structure. 6. A Certificate of Inspection is to be obtained. 7. A Certificate of Occupancy is to be obtained. 8. Petitioner is to obtain approval from any City Board or Commission having jurisdiction including, but not limited to the Planning Board. Rebecca L/ Board of Appeals A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK Appeal from this decision, if any, shall be made pursuant to Section 17 of the Massachusetts General Lams Chapter 40A, and shall be filed within 20 days of fik'ng of this decinon in the offire of the City Clerk. Pursuant to the Massachusetts General Laws Chapter 40A, Section 11, the T/ariance or Special Permitgranted herein shall not take effect until a copy of the decision bearing the cerliftcate of the City Clerk has been filed nn'th the Essex South Registry of Deed,. t �� �k� ��y� �� The Commonwealth of Massachusetts � L �,I� Dupartment of Public Safcty f. ,. � \I,u..�rliiuctlstil�itcl3uildin�;CuJc(78UC\IR) . Duilding Pcrmit Application for any Building other than a One-or'11vo-Family Dwclling '-w ('I'his Seclion Pur Offiei.il Usc Onlv) IIuilJingPcrmitNwubec .—.----- D,dc:\pplird: _--- UuildingOlficial: ' � SGClION 1:LOCA"IION(Please inJicate liluck R and Lot#fur lucatiuns fur which a street address i�not available) q o � �. ._ � �'J I _C_ N F�. SS ---b�--- O���Q_.--- --- ------------- Nu.aud tiUrct Cily/�fo�vn Zip Codc N.unc ut Building(il applireblc) SGC"170N 2:1'ROPUSED WOItK +' IiJiliun ut�\IA St,�m Cudc u+rd.—_ I(Ncw Cunstruction rhe��k hcrc O ur dmck.ill N�.it appl�' in�hc t�vu nn�:�hcluw 1�� � � Ii�isling6uilding0 Repair :\Ilcroliun ❑ Aildili�m❑ Ucinolition O (Ploasefilluut.mdsubmit:\�,pcndixl) � ChangcufUse ❑ ChangcufOrru��enry ❑ Othcr ❑ Speci(y:------ :\rcbuildingplansdnd/urrunslru.ti�rndiw�umcnlsbcingsupplicd.ispartufthispennitapplieatiun? Y'es ❑ i�'u 0------ . Is en Independent Slruitural Engincerin� Peir�eviuw r¢uired? Ycs ❑ Nu ❑ 6r�fA�+�pN1i�Prop��sed �vurk:_K�PLfl E ��ZAt11ivG � 1jEGkIN6 0€ FlL_L. Fou(L— SEC.'7'ION 3:COMPLETETFIIS SCCTION IF HXIS'iING BUICDING UNDERCOING RENOVA'I'[ON,AUDCf10N,OR CFIANCE IN USE OR OCCUPANCY Chcik here if an Gxisting Building Investigation and Evaluatiu�is encl��sed(Sce 7NU C�IR.la) ❑ Exisling Usc Cruup(5): ___ Proposed Usc Group(+):__ __ SECTfON 4:BUILDING HEIGkI'I AND AREA I � Esislinq Prupi»ed Nu.ul Flom:s/Sturics(induJe b,�srnunt Icvcls)1Sc Am�i Pcr Fluur(sy. ft.) I r���;d :���.,�.y.r�.�.��,�i r�,�al Hcight(ft.) SECI'ION 5:USE GRUUP(Check ae a licable) � :\: Assembly A-I ❑ A•?❑ Plightdub ❑ ,-\,i ❑ A-}❑ A-i❑ B: Businese ❑ G Educational ❑ P: Pecto F-I ❑ F2❑ H: Hi h Hat.ud H-I ❑ H-2❑ li•.{ O li-a❑ li•i❑ I: lnslitotional 1-1 ❑ I-?❑ I-i❑ I-J❑ �I: Mcrcantilc❑ R: licyidential R-I❑ R•'_❑ R,1❑ R-1❑ S: 5furage SI ❑ S�'_O U: Utility� Special Use�and please Jcscrib��beluw: � ti��rcial Utic ' SEC'I'ION 6:COYS'fRUCI'ION�IYPE(Chcck ae a licable) IA ❑ IB ❑ IIA ❑ � IIB ❑ IIIA ❑ Illli ❑ IV ❑ V,\ ❑ YIS ❑. . � ' SflCI'ION 7:51"fE INFOIiM1IA'lION�mfer tu 7N0 C�IR t11.0 fot details on each item) � Watrr Sup Iy: 19oud Zone Infurmation: S.wage Uisposal: �french Pennit Debris Rcmural: Nubllc� Chrrk il aulsidc IlaaJ Z��nc O Indie,itc municipal� .\ trrndt �cill nut bc I.irruseJ Ui.pu.�il tiitc❑ � Pri��,itc❑ ur indcnlil�'Lunc: oran ailc s��strm ❑ rryuirrd�ur Ircnd� or spcii(}".. .._ � . . —.—_�— . prnnit i.si•nrinsrd ❑ _._ .. ... It.11IlUd�I flhllbUf-IY.Iy: IIJ/JlJS�11 :�If NJYI�JUOp: V � i�:�.i.�� , • .�;.�:�:,.. �. . _ ., , . .� . .\'��1 :\pplii,ihlc C� Is titrurhirc wilhin air��nrt appro,ii h arcd.' Is ihvir rcrirw r��mplrl��J.' . ��rCnmrnit�� NudJvnclu.rd ❑ 1cs0 ��r.VD� I YcvO �\'�� ❑ . ti[C'I'IUN N:CUNI'IiN'I'OF CIiIYI'IIICAIIi UI'UCC'UI':\NCY II: lili��n � I l�d�, . _.. _. l\rC.ruu��l+l: . . . I\F�r��ICnn.lrwln n: lkrup.wt LnaJ prr I-L�or. I�i�. ihr I uJJin�;c��nl un,m�prinAb r ti�-�lam'� ti����i,d�ti� ul ih��ns: � . s f tiGC'I'IUN 9: PROPI[R'fY UWNGR AU'I'11U1tIZA7lUN �ianm,mJ AJdrevs ut Proprrly O���ncr — — �t4riZ�f� �� i2 MFit� si , f1 ED��Kp P1A ��-LS� - --------------- ...----�------- ------------ ---- -- ---- � i�', m(Print) � u.,mdtitrcet CitV/Tuwn Lip Pruparty O�cncr CunL�et Infurm,�liun� �+ . . IYAr� AG�_ `l�l .S�1S 9�OW ��5� IbA�9�I �t1 . I'itl� — --- 1'cicphune N��.(bu.ciness) Tcicphone�lo. (ccll) c-ntail ddJress � II applirable, Ihr proprrty owncr hrreby,�uthurizes � T�n_ W�N;o __tS �tC���vS _�e__ R��I.Ei�En�__ t1q __o�S' . -�- N,unc StrcetAJdress . Ciry/Tuwn St.�tc Zip ' lo act on th�� �ru crt uwncr's bdialf, in all m.mcrs rrlativc tu wurk auth�vizrd bV this buildin �crmit a >>lic,�tiun. SkCI'ION 10:CONS'CRU�TION CONTROL(N�eaee fill out Appendix 2) 1(bu i1Jin�is Icsa th,in 1j,UW cu.ft o(endusrd s�ace and ur not under Constntction Control then check here O anJ ski Sediun 111.1 � tU.l Re istercd Professional Res onsible for Cunstructiun Conhol -Ar���e 7A��'ti�rw q�x.�5g 2�As 2�� 5 N.ms�3 c�istr,nt) .. cleph,nc Nu. c-m.iiladdress Rc tstra �on Numb� _g� K�IL_�AA A�� �aW�i r� ol�jG � ��G� I z�IZ , Slrcct Addnss City/Tuwn State Zip Discipline. Exp mtion Date 10.2 C.neral Contractor ' � oUFy CmNs7P�vcr �flni 6( �E�1�b�i tr� G G�mpany Nan c T'�r, In�� �No B �� � S N.ime uf Pcrsun Rcspunsiblc for Cun+truction Licaise Nu. aud Typc if Applic�blc l�" 41tC��r�S �p MA���.flicR1� �1R ol� �S' Slrcrt Address City/Tinvn State Zip �gl S�2L 9321 .Skn{ � Tcle�hune Nu. business T�de�hune�lo. n:ll ¢-mail address SECT(ON1L•tn�u:�.l�.l::,'�i�au'r��F;�rI��� I,���UR.\.\�'r.u-ril�,�cll M.G.L.e.152. 25C6 � I, __... _- -- - -- -- - --__- -- - .. ' A Wurkers'Cumpensatiun Insurance Affidavit kum the MA Deparhnent uf Industrial Accidunts must be cumpiehd aud submittrd wi�h thic applicatiun. Failure tu pruvide this affidavit will msult in th¢denial uf the issuance of the building penniL Iv.�si�ned A(fidavit submittitil with ihis u lic:�tion? Yes❑ No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Itcm EstimateJ Custs: (Labor and�\latcri.ils) Tuf.il Cunstructiun Cost(from Item 6)'S— I. Uuilding g 20 000 . Building Pcrmit F�r=Tutal Cunstrucfiun Cust r_(fnscrt hcre '_. El�tlrioil S appropriatc municip.il(actur)=4 t. Phunbing 5 �. ,\I�r'hanir,d (HVAC) S �Jutc: �linimum fcc=`5 (cuntact mwiicipalilV) 5, \Icchanit.d �Othcr S Fndusi thetk pa1',�blc tu n.�I'ul,il C��st S Za O o a (cunt,�ct municip,dih�),md�crite rh�rk numbcr hrm ----- — SECTION 13:SIGN.\'t'URE OF UUILDINC PEIiMIT APPLICANT 14v cntcring my n,mii 6�4uw, I hi�rcbv�ittrst widrr thc p.iins,md p.�neltics af perjun' ihat.ill uf thc in(unu,iti�in eontainrd in Ihis .ipplir,iiiun is Iruc,mJ aeruratc lu thu br+t o(m�' knualcdgr end unJcrslanding. - ��--�_��r�o-- fQE���iE���-- - �`�i. �z�. �3z� - 'lyl°z — _ --- ____- --- -- -- -- -- - 19ra.r print,md .i�;n n,unc I'illc �f�li E,honc Nu. I7alr is _ _ al�cci_Ns .. _ �,a. _ h��B���6r.� h�1 _ _ . �at�sr _ ..___.. ____ i ti1fCC1 :\��i�fC]5 LII�'%�i�K'❑ } . �IFI \funicipal lnspc.tor tu fill uut Ihiv nectiun upun application appruval: "�""' ""�'��- [ ------ ----�-- -- -.... ..-�// - .__----�- — --------�C�unc - --- 1��ilc---.. : � CITY OF S��LEi�i, �'L'�SS.�ICHL'SETTS I • BtiIIDG�3G DEP.iR'I1tEDiS • ` a l�O WASHII3GTON STREET,3�D FLOOR '� '0� 'I�i_ (97� 745-9595 F�:t(978j 740-9846 I ({I\[gERI,EY DRISCOLL 1�fAYOR Tf[onus Sr.P�ens � , DtRECTOR OF Pl'HLIC PROPEAtY/Bl'II.DCVG CO\L�QS$IO�iEA Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumbera Ann�icant [nformation Plcase �'rint Le iblv Vameteu5�m5s:o��,��:ar�oNi�a+��a„�i�: �nVFl CaNS�UCTIa{V uC I�fl'�o���-�N� Address: �� NI�GINS �� Ciry/State/Zip: MPRg�NEfl� (�'P 91`1�s phoneq: �181 �S'2,1 - �132'� Are you an employer?C6eek the xppropdate box: Type of proJeet(requtred): 1,0 I am a cmployer with 4. �I am a�;ncral conhaclor and 1 6. ❑New conahucuon employees(fuil anNor part-dme).• have hircd the sub-wntractors 2.� I am a sole proprictor or paMar- listed on the attached sheet.� �• ❑2emodeling �hip and havn no employcca These sub-conVactory have 8. �Demolition working for ms in xny capaciry. workers'comp.inauntnce. g, �guilding addition (No workers'comp. insurance 5. � We aro a corporntion nnd its required.j officers have exeroised their �O.Q Electrical repairs or addiqons 3.� 1 am a homcowncr daing all work right of exemptiun per�GL 1 I.0 Plumbing rcpairs or addirion9 myulf.[No workera'comp. c. !52,§I(4),and we have no �Z.� ��p���y insurancercquired.Jt employens. [Noworkera' �RLGoN'� Q��I S comp. insurance requi�ed.J 13'���� 'Any uppliauU ihpt ch�v:Ye bpa 91 musl alw fill uul Ihe seclioa 6clowshow(ng thcir�Wrlcers'cpmpaneatiun policy infwmation. t 14+meuwn.�n whu sutunit tAis alfldavit indicating ihry a�e doing ail wqrk and thm hiro ouKide rnntmemre muat auhmit a nmv afllJavil indieming euch �Cumrtayon�M�ch.xt�his Lwe mvs�anacheA an aJdlional shae�shuwing iM nnme o(the subKontrectan and�he4 wahem'comp.poliry iofunwtlon. /um an employer thaNs providtng workers'comprnsadan Lesurance for my empluyees, Be/uw Is the poilcy andJab rt�e injormuiioa I In,uranceCompanyNamr. `���� � � ��T��L� Policy H or Solf-ins.[.ic. q: ��C l —3� S — 3� �-�� O Expiration Date: � �g I Z ' Job Site Address: �O � CpN�Q�SS � Ciry/State/Zip: SflI,E h �(-� ,�ttacb a copy af the workers•eompensatioo policy declaraUon page(showing the pollcy numbor and explrotlon date). Failure ro secure coverage as required unJer Sec�ion 25A of MGL c. 132 can lead to the imposition ofcriminal penalties of a fine up ro S�,500.00 anNor one-year imprisonment,as wcl!aa civit pen•rlties in the form of a STOP WORK ORDER and e fine of up co 5250.00 a day against ihe violaror. I3e advi.sed chat a copy uf�his statcmcnt may be forwurded to the OfPce of Invc�iga�ions af thc�IA for insurance mvcmgc vcriticatian. /dn Irereby crrf jy��iJ t(ir pulns urod yenattlet ojperjury lhat the informudon praviJrd ubuve is true und carrret I Siau�nure• L � �d�'�.� �/�/fn` Date m �: �$ 1 - sZi - �32� � O�cin!use urtly. Do uol wrife in Ihis urea,to be curapleted by city ui town o�eiaL City or Tu�vn: Pcrmitll.(cenye# IssuingAulhori[y(circleonc): �i � i. Ifuard uf ile•rlth 2.Ruildin�Dupurtmen� J.City/fown Clerk 4,Electrical Inspector $, Plumbing lospeetor 6.Othcr Con�act Pcrsan: _ _. Phone#: � - - - � ,f .�;, C(TY OF S.11.E.�[, �tiL1SS.�CHL'SETTS � 9t,�►LOLVG DEP.1RTlE\t I_'O W.1,iHLVGTON ST7lF$'r� }'O�QOA � ���s� �;s-�s�s K!J[HF�tlFsY DRlSGOLL F,Vc(97� 7�98.� ,bUYOR 7�1a.wA!ST.PiF.tas D�RELTO�OP Pl,BLIC P40PFIl7y/8l'p_p�G COJOlISS[OV E� Constructloa Debrts Dlsposal AYtldavit (required fo�ai�demalidon and renovation work) (n accordance with the sixth editton of the gtatQ Building Code, 780 CMR sectian I !I.S Debri�, �d �e P�����a�of MCL c 40, 9 34; Building p���� y i� isaued with tha condltion that the dcbris resulting fnom ihi� wvrk�ha11 be dispascd of in a properly licensed wn4te di�poaal fsciliry y� defincd by ti1GL c l 11, S i SOA. The deb�� wi11 be cransportcd by: N«-�2 v�5����� roame of nau�ey The Jebri� will be disposed of in : �tLt2 IGV�15T't �ispns-fr_ (namao—ffa_ ���.—'---- I � �.�vc�s-r�� 'M� 7�� 3j r�ddn�,or r�.�i��y� ���-- �iyn�tu�e o(permrt ipPl�c�nf �' zt ��, �lue �— . �,n��..d l.. � .u, i�Li.s:ichu�cus - Dcp.u'imcn� ol Pid�lic S:dct� � ,• � �3u.ird �.�f Buildi��_ Etc_uLuiun. .ind lhuiJ:�rds �T ✓li.� �om�rna��e`�[./ i( '/��b—. ConstructionSupervisor License �, Officeot onsumerA ajrsseB sicess eguaM1on License: CS 89905 � _- HOMEIMPRON�MENTCONTRACTOR � Resnictetl to: 00 Registratwn: 146850 � Type: > ��-�. � , � Expiration 5/20/2013 Private Corporetio: TOMASZ A WABNO ' N� - CONSTRUCTION&Rc'MODLEING, INC. 15 HIGGINS RD e�: MARBLEHEAD, MA 01945 ; - ' � TOMaSZ WpBNO ._ . " ,5 HIGGINS FD. � Q�� i—�� ��' Ez iration: 6I4I2012 MARBLEHEAD;MA 01945 � � �� P Undersecretary (lmuuis.ionrr . Tr#[ 26405 .. � `, w � �. • �1 �`c Ro o� CERTIFICATE OF LIABILITY INSURANCE �TE�MMID�'YYYY) 7/13/11 TFOS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AINEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLJqES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S), AUfFpRIZED REPRESENTATIVE OR PRODUCER,AND THE CERfIFlCATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ia) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statemeM on this certifinte dces not confer righis to the certificate holder in lieu of such eMorsanent(s). PROWCFR N A NAME: Circle Business Ins. Agcy, Inc P�NE . 9']H 777-5619 FqX N : (978) �77-aave 247 Newbury Street ao�Ess: PaulaHalas@CircleInsurance.net Danvers, MA 01923 vaoouwa 1061 INSII� SAFFOROINGCOVERFGE NAICp irsuRm INSURERF:NOLt.}113Rd Ins Com an Nova Construction S Remodeling u+sursEae:Travelers Insurance 15 Higgins Road ir+sueffec:Libert Mutual � Marblehead, MA 01945 INSIIRERD: INSUREFt E: INSURER F: COVERAGES CERTIFICATENUMBER: REVISION NUMBER: . THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LJSTED BELOVJ HAVE BEEN ISSUED TO THE INSURED NAMFD ABOVE FOR THE POLICY PFftIOD INDICATED. NONNTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHICH THIS I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONpTIONS OFSUCH POLICIES.LIMITS SHONM MAY HAVE BEEN REDUCED BY PAID CLAIMS. �� INSR ApDL5lI8R POLICY EFF POIICV E%P I LTR TYPEOFINSURNJCE POl1CYNUhEER MMIfDIY NMIDdYYYY LIMTS GENERALLIABILITY EACHOCCURRENCE $ ], QQQ p00 li X COMMERCIALGENERALLIA9WTY WS073626 5�18�11 5�18�1'2 �AM4GETORENTED E 1�0 Q�0 CWIMSMADE �OC�UR MEOIXP�Aryorepersm) $ �j 000 ' PERSOI�NLBADVINJURY $ 1 OOO OOO GENERALAGGREGATE $ P OOO OOO GEN'LAGGREG4TELIMITAPPLIESPER PRODUCfS-07MPIOPAGG $ '2,000.000 PCLICY PRO- L� $ /WTOMOBILELIA61pTY _ COM6WEDSINGLELIMIT S B arvrAuro BA1427R926 5/18/11 5/18/12 �aecciaerc� ALLOWPEDAUTOS BODILYINJURY(Perperson) E lOO OOO X SCHEDULEDAUlOS BODILYINJUftY(Petacitlen�) $ jOO OOO HIREDAUTOS PROPERrYDAM4GE S (Pe�accidenq 1���00� X NQNdWI�EDAUTOS g 8 UN�FELLALIAB OCLUR EACHOCCURRENCE $ E%C6SLIA6 CLAIMS-MAOE AGGREGATE g DFDUCTIBLE S REfENTION $ E WVRKERSCOMPENSATION WCSTATU- OTH- PNDEMPLOYERS'IIABILITY ��N X C PIJYPFtOPRIETOR/PARTNERIEXECUTIVE N/p WCl-31S-366560- 5/18/11 $�18�12 E.LEACHACd[EM $ 100 ��Q OFFICEfLMEMBEREXCLIpED? � (Nla�abryinNH) E.L.DISEASE-EAEMPLOYE $ IOO OOO Hyes,tl�cribeuntle� ELDISEASE-POLICYLIMIT $ �j00 QQQ DESCRIPTION OF OPERATIONS Oelaw OESCRIPTION OF OPEPATONS I LOCNTIONS/VEHICIE$ (Aqac�ACOR�101,AtlEltlonal Re�rerNs Schetlule,'rf more s�sce Is requretl) CERTIFICATE HOLDER CANCELLATION SHOl1L0 ANY OF TiE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE E%PIRATION DA7E THEREOF, NOTICE WILL BE DELIVERED IN City o£ Salem ACCORDANCE WITH T1E POLICY PROVISIONS. 120 Washington St. , 3rd Floor Salem, MA 01970 AUIHORIZED REPFESENTAINE Paula Halas °�"°�°"°�°�' ..eco�.n Ws.e. 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JAQUITH ARCHITECTS N - _ - 81 RAILROAD AVENUE, ROWLEY, MASBACHUSETTS 01969 � � jaq uitharchRects@ mac.com The Common%ccalth of l\Ia5laChtr.lCtt5 �— --- ' pal I t y 13alarJ of Building Regulations anJ SIanJ;trds It SrJ i a r Massachusetts Stale Building Code, 7SO (AIR, 7"' edition 1I! V Il II' III 1 Building Perini! ,lpplic;uiun i Construct. Repair. Reno%ate Or DCrnuliat a R, 01 ur Iru-Vamilr Dtrr 2 _ phis Section For Ottici;J Use Only \ Building Pennil Number. Date AppG J:e -- ! Siunarure: Bwldinl. 'uinnn"ro m rn+r(It Bw Wines D:uo — SECTION 1: SITE INFORMA PION -- -- — 1.1 Propero \ dressy 11? Assessors .11ap & Parcel .Yumbcrs —..--- - -- i I la Is Ihia an accepted irrCCt:' }es_ nn_ :}lap \nnlhrr F.RCe! .\umhcr 1.3 Zo.rting Information: LJ Property Dimensions: !.5 Su:iding :;cC ::;;ks If.; R e,'I�ired T- 4-----_--_ Im.r Y ard .ti ule Yards hear Yurd I Fn i---•..Pnn ufcd Rcc uL')Iloce I onded Re q uu tJ FIB::�drJ Wa c y'uPPI': CI.G.L,c 111. §4I ! 7 rloodormation. s 1.8 Seaagr ! rsposal System: Privale ❑ - Zo°c: e FLrld 7_urc7 k it yes❑ •Ytun up,.l ❑ On sire dislrl,a: ,yscla ❑ SECTION 2: PROPERTY OWNERSHIP' 3.�1I(/t)pw�rrer of-R- I. d: 1`!•S Inrt L _ 12 nAlti sT Eb��e hA o2i s'S' Addnssk S=;:eice ----- I Telephone SE:TIC;v 3: VESCRIPTION OF PROPOSE© CIRK'(check all that aplrly) r. .- _ _ .yi n ❑ ( E< •:[ B Ic!n ! U'.ancr tk:uptcd 0 RR_�paut,(,) G I %lrcrauonl, —/- - -- -- -' n ❑ Acce,sory Bldg J ?Number u! Unu. . Other ❑ Hri l ;le % - Y ;.,:n r P, posed Wart . KITC EN _— H & IH __tL_ RCN _ (tv�— oPEN=I+JAZ�; �o%IE� �dITB NEII GYPStt1 ggAQd! _fllg V IrJAL�S -- - y iLSTI+L( _k3TCA�_ caKin,E —__ - — 3—.-- SECTION-s h,D'I►rU4'icC: "tW!'Srsr;r:Tl�;NCASTS -- - I(Lrn Official Use Only I abor amJ Materials) � I II:rIJul ;� I OOo I. Building Permit Fee: $ Indiu[e hu%% !�c a JuumutLJ: '_. Flet MLal !� ❑ `standard City/Tnwn Application Fee -- ❑ "fora! Project Cost' (Item GI timultiplier__—_ s __ J. Plumbing — �. Mechgnicai IH1':\C) —_. _ �. .MMILInic:d (Fire I_SI n� �eiun) 'rural All Ices: A C heck No. -_ \Check :\nuur.t ('-I,h .1m„unc I o -Fatal Project Cost I y --- ❑ Paid ;n Full____ ❑ QuUlanding B:danLr Uuc: _ f, i' SECTION 5: CONSTRUC"rION SERVICES _____._ 5.1 Licensed Construction Supervisor ICSI.I bJLir�cnu>e Number Ilolder NRRg LEFI ENI� r\g Lhl l.'SI_ r,pc t,ee below) _IS 411G/Iti< Rb _ lit v, c Des.'n ,iron WJres - C l'n",to tcJ R Rew idcJ Id:2 Fanuls Dss ellinc —J >1 masonrN 1)nk --� ]I nnlnle e�pt r , RC Rt>iJ:nual Ku ne - \\'S Raa Jrnt uJ \\ird nJ..„ .inJ iiJin_ relcphnnu _ jL._ - SF Kr�iJrnu.il S�ihd Purl low lone \ „li.in.; Im),I Lnnu p ItcaJrnlidl Ucn)oh«an —--1 51 q1�e istered Ilome Imprve tent C�ntractorPICI A1n1/rA Co NsTP. IX Ehcbl f ICNam or f C�b Rcg)sl �) F1 N ��LEHEA. 11a o 'l%l-, L- 32`� Fxpouti it Dutr Tekphonr 5)g,n urr '— SECTION 6: WORKERS' COviPENSATiON INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and Nubmitted with this application. Failure to pn,$)de this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached'! Yes .......... No _......... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT f76 /✓/ as nee of the subject property herebv N/'T/1'v «, act on my behalf. in all m:uterN au[horizr - i x!ative to \v->�' .uthoriz y' `t:'s building permit application. Si nature of Owner 6<^'f -y-•— ( SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION I, as Owner or Authorized Agent hereby' declare l that the statements and information on the foregoing application are true and accurate, to the best of my knowledge an behalT-� Ag do Print N ne ` S o$ - Date Signa«lre wn or AtithonzeJ Agent (Signed under the ❑ins and enallies of r(u NOTES: I. An Owner who obtains a building permit to do his/her own work, ur an owner who hires an unreg61ercd c""Ir:'`I"r I (nut registered in the Home Improvement Contractor (HIC) Program). will not have access to the ;land Lion program or guaranty fund under M.G.L. c. I-12A. Other important in6nmatiun on the HK' Program and Construction Supervisor Licensing ICSLI can be timnd m 780 CMR Regulations I IO.R6 and 1 10.R5. respec""IN When sobstanual work is planned, pnrv)de the information below: garage, finished basement/attics.N. decks of porch' . Total flours area(Sy. Ft,I _ Hahinthle room count —----- 1 Grins living area )Sy. RA Number of bedrooms _-. --------- Number of fireplaces : Number of lwk/halhN _--- _.--.--- --- - I Number of hathiooms O , // Number ut decks/ p,,rchcs ------ Tvpe of heating Nvsttm — // r l:_n,hscJ _Open - -_-.- - -- Type of cooling systCm - z. Total Project Syuarc FooCt b may e subsu led fnr 'ToLll Pn,.leet Cosf' 1 CITY OF SALEM ;.. r PUBLIC PROPRERTY ^' DEPARTMENT . Ill. •/�Y '{i 7i45 ♦ 1 \S: 978 74:9841, Construction Debris Disposal Affidavit (required lur all demolition and renovation work) In accordance ill] the sixth edition of the State Building Code, 780 CNIR section 1 1 L5 Debris, and the provisions of MGL c 40, S 54; Building Permit It is issued with the condition that the dcbris resultin.- front this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c t 11, S 150A. The debris will be transported by: Alca h.15favL— (name of hauler) I he debris will be disposed of in : 1411�� 44,tSv'6 b15•P�sfi1. (name of facility) CC,o4cESiE4- MA o0 -91 (address of Facility) —_- Signature of permit applicant -" Hate Massachusetts- Department tit'Public Safet% p Board of BuiWinu, Re-ulations and Stand.u'tls � 41 611NIR 111 aAll n�✓�r!a,uru/u.;�e!!J Construction Supervisor License Board of Building Regulations and Standards.. License: CS 89905 ul HOME IMPROVEMENT CONTRACTOR Restricted to: 00 Registration: 146850 Expiration: 5/20/2009 Tr# 128646 TOMASZ A WABNO Type: Private Corporation 15 HIGGINS RD MARBLEHEAD, MA 01945 i a',x NOVA CONSTRUCTION&REMODLEING,INC. ' TOMASZ WABNO ��- 15 HIGGINS RD, —� Expiration: 6/4/2010 MARBLEHEAD,MA 01945 t'�aum lsi,mei Tr#: 26006 Administrator Restricted to: 00 j 00- Unrestricted License or registration valid for individul use only 1G- t 2 Family Homes before the expiration date. If found return to: Board of Building Regulations and Standards j One Ashburton Place Rat 1301 Boston,Ma.02108 y Failure to possess a current edition of the Massachusetts State Building Code I is cause for revocation of this license. Referto: WWW.Mass.Gov/DPS Not valid without signature d:a4 22 DB 08: 34a Richard Bertolino JR 9785310710 ,P. 2 ACORD M CERTIFICATE OF LIABILITY INSURANCE Ol/22J2O88 PROWLER THIS CERTI CATS IS I AS A MA OF INFORMATION Richard Bertolino 5r insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT ANEND, EMEND OR 1200 Salem dt 8121 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lynnfield, MA 01940 INSURERS AFFORDING COVERAGE NAIL M nauRBD R6 MA. Penn Millers Nova Construction N ERII: Mass Workers Comp Rating Bureau 15 Higgins Rd NSURER c: Marblehead Mass 01945 INsuPFA°' _ INBMER@ — COVERAGES THE! POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED M 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. i LTR OBRO mEOFITauRAxtE PONCY MMBER p"lE M�WWAYI vO1M�E 1SlAmMT L0.VA A cFNmALUnBBlSn' 09/30/2007 09/30/20DO EAcnacLRRExcE 31,000,000 s1,DOO,.000 CadMERLIaL CEFCAPL LUYRLm ' PrE3,llsss lEa xcurercel CLAIMS VLLE UOCCIR AEUEJR WIY OR PeOvp $1,000 PERSw IAOVw RY S1,000,000 GENERALAGGREGATE $2,000,000 GENLAGGPEOATEUMTA PUF_SV9L PRWJLTB-LOLYIOP AGG $1,000,000 AO. LOC Pol1CY ¢CT AYTOYOBLE III.OGnY COA 9.0,... .11 3 IEL acCNeRI efry AUtO NL DINE°AVfJ3 (BOD1LY 1, ,uWY 3 SC W1 OAIROS HIRED AUTOS SOULY INNRY S (Pe,ectiOeMl NONOWlEO AUf05 --- PROPERTY D—M 3 -- i IPB lean) cARAw LasuTY AUTOO IVY.Ekx-Soe r NT RO OT£R T. GACC S AtrtOOxLY: AGO S ETCE33NMBPk11A WBIIffV EACHOCVUI F E S T—�OCC1Rt ❑CWMS MADE AGGPEGATE 3 OEDUCTBIE RETENTION f 3 B ygR13ER5 CONPENlATpN PND 09/10/2 008 04/10/20D9 Tart LIMITS ER ERPLOYERY UABll1Y E.LEACHa MOEW $100,000 qNV MOPRIETa1FaRfNFPlEXELVi1VE OFRCERAEM�t E%CLuxO, E.L.OISFI.SE-EA FMROVE£ SSOQ,DDD I RYSS Reanm ama E.LOISEASE-P000YDNrt S 100,000 -SPECVLL PRONSIOHS Mvw OniEfl I pEgCgPlgry OF CPEAATIOIAI/LOCATONBfV 10-ESIEICLUSAY3 A°°E°BY EN0016EMFNlt9PECNL V.Oflsoom Separate cart has been ordoraa £Or holder from the Maas Workara Camp Rating Bureau CERTIFICATE HOLDER CANCELLATION SHOULD ANY Of THE AB°VE O MIBED POLX1F °E eWCBLL BEFORE 1NF FJiP°NTNYI Jupiter rV LLC OATS T3FnEOF- THE sSMNc wswEfl lNu. EImFl.VOR TO AwIL_DAY! wtnTEry 12 Main St Y NOTICE TO THE CERTCATE HOL°ER pAtlm TO THE LEFT, BIfT FAA.YpC TO °O 9 9NALL Medford Hass 02155 MW03E NO OBNGAI%M! M WBIDIV OF ANY p11m UPON TIE -S-m ITS POENl9 OR Fax 781-593-7881 RE3'RESENYAT Au3Nowim pE➢Ne1ENIATNE Richard Bertolino O ACORD C RPORAITON 1988 ACORD 25(2001M) 1 CITY OF SALEM PUBLIC PROPRERTY 3 , f DEPARTMENT I'! 1 v'8.'i;.,;d; \'forkers' ('ompcnsation insurance Allidaxit: Builders/ContractorsiElectriciansi Plumbers Please Print Leflibly \ f ih\ant Infurmrtiun N,lllit: IBn.tmc., illy.uu In+ln:du.dC I oM �VFy�NO \old Iess: lS I INS fli!I, ('11y Stifle Zip: VAAV9U9(kb hR D1"i Pltt)ne 4' \re you an employer'! Check the appropriate bolt: Type of project(required): I :tin a anpluyer\l i1h 4. 6 I4 1 :tin a general contractor and 1 New construction I ❑ ❑ employees(full and'or part-time).' hale hired the .,ub-contraoors 7. Remodeling listed on the attached sheet. �.❑ I .I'll J d le,Ie no proprietor or partner- I hose sub-colltraclors hale 8. ❑ Demolition ;hip and hale no employees workers' comp. Insurance. y. ❑ Building addition working Cite me in tiny ctpacily. . �No workers' comp. insurance 5. El are a corporation and its IU.❑ Electrical repairs or additions rcyuircJ.J officers have exercised their fi ht of exemption per b C. 1GL 11.0 Plumbing repairs or additions 5 3.❑ I am a homeowner doing all work 152. $1(4), and have no 12.❑ Roof repairs myself. [No workers' comp. insurance required.] t employees. [No workers. •13.❑ Other comp. insurance required.] \uy applicam that checks bus-nl nlmt also till out the section below+bowing then workers'cumpensol ion policy information. t I lonteuwners who suhmit this afrrdavit indicating they are doing all work and then hire outside cuntractors most submd a new affidavit indicating such. '('otor:iclors that check this hox nla.+t attached an addttwnal+h"t showing the name of the sub-cuntractors and their workers'comp.policy information. I inn on employer that is providing workers'compensation insurance/or ofy employees. Below is the policy art site injorriturion. Insurance Company Name: Policy d ar Self-ins. Lie. Al: Expiration Date: .lob Site Address: City-State/Zip: attach a copy or the workers' compensation policy declaration page (showing the policy number and expiration date). Fitilure to secure ctnerage as required under Section 25:\ of`IOL c. 152 can lead to the imposition of criminal penalties of a line up to S 1,51)o,off and'or one-year imprisonment. as well as ci%i1 penalties in the lilrm of a STOP WORK ORDER and a fine ,,I tip Ill S291J O a tlav at!anbt file +iolator. Be ads ISed that a copy W ill's sfalcnlent ntay be lorwarded to the Office of Inl c.0_coons of the DI:\ for insui.utce cancrage lcrtlicanon. l Ja ht.•rrh}' rrnif I�I rJa dse pains w1J penalner uJ pa•r/ury that the information pros ided abut a is fate and a orrecL fkk.,� . Dat . �/� tog ri,uura a o iritd u+e Iodt'. no oaf to rite in rhis area. to be.,t Into leted by city or itnsvf o//ia iaL I'ermil/License All -.._. ..— Issuing \ufhnrily (circle one): 1. Board of llealih 2. Budding Deparfmcnt i. its, fnssn ('lerk 4. Electrical Inspector S. Plumbing Inspector 6. Other ('ontact Person: __-- - ---- -- Phone _—._-- Information and Instructions \LL i,I.u,:u, I.tencr.11 I .rs, :h.gncr I s' Icquuc, .III onplotcI, to lute, ide porkers compCllsation l,r�thcx cniplovecs. Pill,u.lnl uo this ,l.nutc. .ul crriploiee i, lcl n.cd .is , ct cn pet,on tit the ,cn tcc of.unthcr under .ury contracl-of lure. :slit c,, ,,r ngJicd. oral or t,tier... rmplo I.•r t, JcI incd .i, .tn :11,11%:d LiAl. pm n:cr,h 1). .t,,,,:tarot, ,orporauon or other cnuty. „r .up rtvo or inure I Ilie lolc oink :n_.Igcd in a lino duel pn,e. .uid Inclu,lulg the Ic_alrc dc dpv er. or tile n `.cttcr „r tru,lee ,rf ait Inds idua1. p.0 tticnh ip. .i„oc I,l fan or other IeL!al cnun. cmplat ulg cinplovee,. I lo"ever the •.,acr 011.1 ,hv riling hou,c ha% fie not more Ih.m three .ip.iruneni, and tv ho rc,tdc, therein. or the occupant of the d tt ci'mu Iiow c of another „ho cm q,lot, person, to do m.unt cnime. con,Irucrion or rcp.ur tt or on ouch ohs eling house , I Sul the _bumf, or building .Ipptutco.tnt tlic:cw .liall not hec.m,c )I 11ch cuy,lot meat be deemed to he .m empluter.'. \Il.1, cli.tptvr 1>2. 2-'SC(b) AN,,. late, that 'esery Mate or local licensing agency .hall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptablees idence of compliance with the insurance cos erage required." \ddirtonally. sIGL chapter 152, �2i( I-) ,tares 'Netdler the ctnnniomvcalth nor any of os political subdiv Lions ,hall :tiler into ally contract far the perl,11111altee al public stork until acceptable a%Idence tit compliance with the Itl,urallce rcquucnncnts of this chapter hove been presented to the contracting auihority.•' \pplicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-cuntractons) nanne(s), addresses) and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP) with no employees other than the nienibers or partners, are not required to carry workers' compensation insurance. If an LLC or LLP dues have employees, a policy is required. Be advised that this affidavit may he submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The at idavit 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 are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their .cut--insurance license number on the appropriate line. City or Town Officials Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the attidav it fix you to fill out in the event the Office of Im'cstigations has to contact you regarding the applicant. Please he sure to fill in the permit,license number which will be used as a reference number. In addition, an applicant that must submit multiple permMicense applications in any given year, need only submit one affidavit indicating current policy intbrmation (if necessary) and under"Job Site Address"the applicant should write "all locutions in (city or low ny" A copy of the affidavit that has been officially ,tamped or marked by the city or town may be provided to the .g,plicant :is proof that a valid atfidavit is on tile for future permits or licenses. A new affidavit must be filled out each y car, W here a home owner or citizen is obtaining a license or permit not related to any business or commercial venture it e. a dog liccn,c or permit to burn leaves ctc.),cud person is NOT required to complete this affidav it, t he t ill-ice of Investigations would like qt thank you in advance fix your cooperation and should you haft any questions, plc.t,c do not he,ttate to give its a .all. I hr D patnnnu', iddress. telephone and tas number: The Commonwealth of Massachusens Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Inc. , col � 'o-n5 Fax # 617-727-7749 www.mass.gov/dia A /oo , 1 \ qr4w+ww 4n wr fe WLOM By Im CITY OF SALEM wrra MOOG a- h IiMmk YM_No dIMe19� � LMtLo� of a.uas.a /09 �m�cre�_ M Aapwly Low"ti , / : b Owrwwdon ANO YL NO SQL Per AP�AIM POft Pannfl lo: (Chb vdidowu apW Roof. R not, kwW OWS CUTA l— aok fTI4 PooL PUIM PLL our LPL Y&COMPLATELY TO Avon DE AYi M POW OB TO THE INVECTOR OF BULDING& Tho undaralpmd hmmby appke for a pom* to buid -mom di, fo Mn.1clo�il 0~6 Noma r eoer\� C Ad*W A PhOM 4D �7; 1 AmhbWs Name Ad*M 6 Phan ( 1 WdWdoa NWft • Ad*Ma A Phorn t 1 w o Mar pmpm er madw 1� 1 1lrlwN di i C N ad for how m"l- 1 M ON wN ftd*q=dM b kW S ArorOot 00 tea. pi.7w�e of Appkat INO■1 M MALTY' OP PORAW oU�l AP wi011K TO a om CA -i d:vloc- i1= G� s rUeed e MA L PMMI 'O 0� c ;VYC r ,�: -.._, � � �, cH m •;;;.V�.aiC. i Rely �n_ _,r A . ' .�A1 M. al`y ' � '� �' R•, .1J.P.,l.aaef e��.4�ial�ailab- 600wy..�l. 6 5L.Od 1 eaate.a Bedomi. /1�aaaA.Ai 021 Workers' Compensation lummium Affidavit . . W10.0 prindpal place of business ac- �� � u do/hereby'cert/y under tpe palms and peniitln of perjetir, than l`J I am an employer providing wwken' cegVemd" cowrais for i eiayloreo working as (.S i ' �� -�•. �� A2� 1A . &Rav vc i`i 2 zi Insurance compoey Pol q Number 1 awl a sok proprietor and haw ao one working fdr me is my eapedly. () 1 and a Sole proprienx, general commoor or heln awner (drde one) and have hind the coaatrscton listed below who•have thi following workers' compensaden po6dan n i3ic ,9 zzj CA"mactor Insurance Company/Po Nua bor Conaacgw Insurance Company/Policy Nun law Conaaetor Insurance Company/Posey Number O 1 am a homeowner performing all the work myself. • waaa7uwe ma a can/of di au.eant we N Awwreed M dN Olen A la.edtaaao of ON 01A Ier cvrwata.wlaudan am am Oboe e.Msrt cewratr a rrao►re~SRda.SSA N MGL 152 can Nae w uN:neenin a/eAnwar sonde cerwint at a fined w w41.500.00 ardor w ream'iraereeenrrnt a dd vemwo inghc lore a/a STOP WORK ORDER s a f ta4 ar el S 100,00 a an+ 1 ML Signed thl �(� day of V k . :ices ii'Fermhtet emldln: Department :.jcensinf Eoard Selectmen Office =calth Deparmer; =... . _ . ee(.r Yet _ 40e 40e 40e 77c 4 rusLlG rROrwff DSFM1Tmna . 120 V"Hlmwm aROaw 300 Ftaon &MXW.MA 01 arf0 To-(978)7411-MM ar.sago ' FAR (sop 74040" STAMl tlr rCO tlsovlC><. 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