117 CONGRESS STREET - BUILDING JACKET 117 CONGRESS STREET
I
STREET PERMIT No 70
'^< g (Oftae of 3myrrior of Vuilbingn
City Hall, /9 y�
Permission is hereby given to
to occupy for purposes
in front of estate l ? � I--
of
—of sidewalk, of street.
`Chis permit is limited to 3,) 19:V, subject to the provisions
of the ordinances and statutes in relation to Streets and the Inspection and Construction of
Buildings in the City of Salem.
,4'/_ Dire r of Public Services Inspector of Buildings
Signature of Applican
lctl sc 410-ee / ,
r
®UFLEQ°`E E STREET PERMIT No , 70
f
(IDiffirr of 3na}rrrinr of Buildings
gFUIgINf.WN` '
City
Haall,/ 2- 7 19 1
`Permission is hereby given to
L ,
to occupy for 1:24 ✓ purposes
in front of estate Wd.
of sidewalk, of street.
`Chis permit is limited 10 �7�. 1'� 194/subject to the provisions
el
of the ordinances and statutes in relation to Streets and the Inspection and Construction of
Buildings in the City of Salem.
&4 Y L
Director of"Public Services Inspector of Buildings
Signature of Applica t s- -
PC21 2C 4.29.00
Citp of balem, f aggacbU2;ettg
Public Propertp Department
Nuilbing Department
One 9palem Oreen
745-9595 (ext. 380
William H. Munroe
Director of Public Property
Inspector of Buildings
Zoning Enforcement Officer
August 6, 1991
Carol McGowan
Salem Housing Authority
27 Charter Street
Salem, MA 01970
RE: 117 Congress'St er eta,
Dear Ms. McGowan:
I spoke with Mr. Robert Marsilia regarding the removal of
of porches at the above referenced property. I concur with Mr.
Marsilia regarding the structural deficiencies, it is my opinion
that just the roof replacement,and other repairs that were needed,
would have been every bit as costly as the removal of the porches.
Sin r ly,
David J. Harris
Assistant Building Inspector
,DJH:bms
I'
II�I�I I SOUCY INSURANCE AGENCY,INC.
201 WASHINGTON STREET
P.O.BOX 4484
SALEM,MASSACHUSETTS 019708484
INSURANCE SINCE 1S0T TEL:160e1 744-71100
FAX:1608)741 20059
July 81 1991
City of Salem -
City Hall
93 Washington Street
Salem, MA 01970
RE: Atlantic Building Contractors, Inc.
Dear Sir or Madam:
Please 'be advised that our insured, Atlantic Building Contractors, Inc.,
-has obtained a street permit bond through our office on this date. The bond
has been issued by the Hanover insurance Company in the amount of $1,000 with
the City of Salem as Obligee. The bond number is BLN1896232.
This bond has been issued and is effective 7-8-91. We anticipate receipt
of the bond within a fear days.
Should you have any questions, please do no hesitate to contact our office.
Thank you for your kind attention to this matter.
Very truly yours,
SOUCY INSURANCE AGENCY, INC.
�,.
Paula M. Reed
�OApD pF q pp-F4
s CZttg of �$ttlent, aselacbuse #s
!fou y �
Aire department �Ieabyuarters
dames j_ rennru� 48 �E2t Vette �treet C1ryoRteF/�E> 8
QIhief �tleltt, tt. 01971T X44
November 3, 1982
Salem Housing Authority Res 117 Congress Street
27 Charter Street 26 Prince St./
Salem, Mass. 01970 33 Park St,
Sirss
I have this date signed the Certificate of Occupancy for the
apartments rebuilt and under your jurisdiction, on a conditional
basis.
All conditions are satisfactory, except the electrician has left
out the required trouble buzzer for the fire alarm system, which
should be placed in the front hall of each structure.
I have signed the C. of 0. so as to not hold up occupancy, but the
trouble buzzer is a necessary part of the fire alarm system. As a
result of a conference with the Architect, it was found that the
specifications did not contain the required trouble buzzer as a part
of the proposal. However, this trouble buzzer is a part of the
National Fire Code Standard 72B, which should be understood by all
that it belongs located as a remote signal, which will inform all
concerned that the system is in trouble and should be reset as soon
as possible, for the protection of all occupants.
The Architect, has said that because the electrician of record had
wanted an exhorbatant fee or sur-charge for adding this trouble buzzer,
it was agreed upon that the Salem Housing Authority would place the
trouble buzzer in each building afterwards, and be able to do so
at a more reasonable cost.
Full approval of both buildings hinges upon installation of these
trouble buzzers. Please inform this office when they are installed.
Rle/.sspteccttful submitte 4AAA4, ,�
ccs Mr. Robert Sca liotti Capt. D /�/�
Bldg. Inspector Salem Fire Marshaln
L r
Electrical Inspector
file
Medford Woodworks Corp.
200 BOSTON AVE. - MARTIN BLDG.
MEDFORD, MA 02155
09 �
f� p
Fg�o
$ e
N
March 31, 1982
Commercial Construction Company
103 Grover Road
Medford, Massachusetts 02155
Attention: Ms. Lillian Gately
Re: Salem Housing - .Project #705-2 — Wood Doors
Gentlemen:
As per telephone conversation with Bob Scagliotti
and Lillian Gately, all entry doors will be solid ;
core Birch.
The use of these doors was permitted by Building
Inspector of Salem.
Very truly yours,
Me o d W dworks Corporation
Charles Trickett,
President
/�Q3
270alff fktat ski P,
4�FFyF //��
-081m,l�a"Otl6ew otm GEORGER�t�BERTIiY airman
YVONNE Ll S*. Vice- hairman &Treasurer
'�PXt'�IhtlltC 744-44M HENRY J. LaPD E,State Board Representative
STEPHEN ZISSO Member
RICHARD T. FEBONIO,Asst.Treasurer
WILLIAM J.FARRELL,Executive Director,Secretary
January 8, 1982
Richard MacIntosh
Building Inspector
City of Salem
One Salem Green
Salem, MA 01970
Re: Salem Project 705-2
Family Housing Rehab
Dear Mr. MacIntosh:
We request permission from your department to waive the fee
for a building permit on Project 705-2 , Family Housing Rehab.
The project is totalling rehabing buildings at 117 Congress
Street and 33 Park Street in the Point Area and, as such,
is intended to upgrade and improve a distressed area of the
City of Salem. Any extra charges would prevent us from making
the necessary improvements and we would appreciate your
continued support and any allowances you could make for us.
Very truly yours ,
Salem Housing Authority
By,
ElayQ M. Hart
Asst. Executive Director
q C tt of
N
r0 @r ,r Aire PeNurtuient �ieabquarters
�amea �j. 'idreanan 4$ (tu£xettr r 1rCCtCp ,OP 51.j.€;�' �h3. . .
tllhfef $ztteni, 4 lu. 0:19711
Sept. 16, 1981
Mr. Robert I. Scagliotti, A. I. A. Re: Plan review
15 Derby Square —Congress Street
Salem, Mass. 01970 Salem, Nla.
Sirt
Plans submitted for review on Sept. 15, 1981, for substantial
renovations to the structure at 117 Congress St. are not approved
as submitted.
The following items shall be noted and new plans submitted with
corrected data.
1. Plan E-1
a. Smoke detector shown shall be relocated to a point nearer
the base of stairs.
b. Based on approx. 8, 976 sq. feet of area in the basement,
the two heat detectors shown in the open areas shall be
changed to smoke detectors.
c. Notes all new fire alarm systems installed now require a
silence alarm switch to be provided on the Fire Alarm Control
Panel, with the key to be provided the fire department. This shall
be so noted on the plan.
d. Diagram shows extra horn and light unit on right leg of diagram,
which should be only a manual pull station unit, for 1st floor.
e. The eight boiler units shown are acceptable, but the location
and type of fuel oil storage tanks shall be indicated. Storage
is limited to 1320 gallons in a basement, unless the tanks
are enclosed in a concrete block bunker. Plan shall indicate
proposed storage area and shall show the construction of the
enclosure.
f. Oil burner switches shall be placed just outside boiler rooms.
2. Plan E-2
a. Smoke detector located in center stairway shall be located
at base of stairs leading to second floor.
b. Move manual fire alarm pull station from stairway to flat wall
in right stairway. Pull stations located on stairways have a
tendency to be pulled needlessly.
c. Locations of audible and visual alarm units may be placed
above the manual pull station on the first floor, on a flat
wallo for ease of installation.
3. Plan E-3
a. Individual oil burner switches as shown on plan in each apartment
may be kept, however plan E-1 shall show the primary switch
for each oil burner unit located just outside the boiler room.
Page #2-Plan review, 117 Congress Street, Salem, Ma. 9/16/81
3. Plan #-3 continueds
b. All smoke detectors shall be located at base of stairs,
just as it starts to go up. Except the unit required at
top of stairway, which is located on ceiling near top of stairs.
c. Smoke detectors located within apartment units shall be
single station type, and shall be so identified on the plan
and a symbol for same shall be added to the legend, on E-1.
d. Add a single station smoke detector, one foot within Bedroom
#1.
4. Revised plans should be submitted for review.
5. A form #81 shall be filed by the contractor or architect for
obtaining stamped approval of the plans, and before application
is made for a building permit. Three sets of plans are required
for stamped approval.
6. A Form #81F must be filed by the electrical contractor, prior
to initiating work. A Form #82 (Certificate of Completion) ,
will be required upon completion and at final inspection.
Respectful y submitted,
Capt. David J. Gc/ n f/
Salem Fire Marshal
ccs Salem Building Inspector
Salem City Electrician
Salem Housing Authority
M,E.A. Engineering Associates, Inc.
105 Washington Park, Newtonville, Ma.
file
`�
3
FIRST DISTRICT COURT OF ESSEX
APPLICATION FOR A COMPLAINT OR WARRANT
gS• Lt David J. Go }n `<
�Om
cc - Lt
Fire Mahal ADDRESS 48 Lafayette 5t:Sale
QJ�1c1F# D DEFENDANT _Richard Tanzella ADDRESS 61 HU11 St, Beverly,
G pF (If House.Contains More Than One Family, Designate Which Apartment)
p��alem Fire Code Section F-140. 01 F1211. 0 & JAOF•B1RTH $
Chapter 14g, Sect}on 28B Gen. Laws 44f Comm. o Mass;
OFFENSE _ Chapter 148, Section 5, Gen. Laws oi'. the Comm of Mass.
r (Give Chapter and Section of Statute, Ordinance or Regulation Violated)
March 30, 1978 & continuing b
DATE OF OFFENSE _ g PLACE OF OFFENSE 117 COrig2`@88 St
` (Or if for Non-Support, Length of Time No Support Had) - aj.
a STATE IF DEFENDANT ARRESTED YES X NO
I — DATE OF ARREST R•J'! -
1 ,
WAS DEFENDANT BAILED —YES —NO AMOUNT $
INFORMATION TO BE GIVEN ON MOTOR VEHICLE VIOLATIONS
4 LICENSE # ISSUED r"
a REGISTRATION n n
ISSUED —
OWNER
•i INFORMATION TO BE GIVEN ON JUVENILE COMPLAINTS
? JUVENILE
ADDRESS 'y
AGE.
FATHER z" Y
t
` ADDRESS �f'
MOTHER ADDRESS a
s FACTS UPON WHICH YOU RELY FOR COMPLAINT TO ISSUE
y Upon complaint received from citizen, an inspection was made of":the
`+ premises, consisting of eight tenements= ,where it was found that. s'ever
`• violations of the fire and building laws existed. A copy of the',
a .• original notice issued on March 30, 1978 is attached, sent by regular
A copy of the Notice of Fire Code Violation issued upon reinspection
conducted at 10100 A. M. on April 6, 1978 and sent by Certified 'Mail
i is attached. Hearing is requested as a result of failure to respond
on the notice by the defendent.
WITNESSES City Electrical Inspector Dennedy, Salem Health Inspec"tor' Cra(
i{ and Building Inspector Munroe.
DATE OF APPEARANCE IN COURT
a# SttlPzn, usstttl�uPtts
3Firr iT¢vgr2mrni lIRxilqugrSrrs
NOTICE OF FIRE CODE VIOLATION
Owner, Occupant or Violator Mr. Richard Tanzella, owner
Location Of Violation 117 Congress Street, Salem,.,Mass,
Date of Violation March 30, 1978 &continuingTime: 2130 P,M.
As a result of an inspection or an incident observed by an irigpector
of the Salem Fire Department, the following violations 'of Mass, ' Gener
Laws and/or Salem Fire Code were found to exist, as followss
Failure to respond to initial notice of violation issued on March 30,
1978 concerning violations of law under Chapter 148 Sections 5.'& 28;
and Salem Fire Code Sections F-140. 0= F-1211. 0 and F1213. 0
Blocked egresses, rubbish accumulation in stairways, electrical hazar,
Violation of G. L. Chapter 148 Sec. 5 & 28 ani saiPm Pira nndag
M. G. L. ; F. P. R. or Salem Fire Code
TYPE OF NOTICE:
1.' Warning Notice : 2. Court Action Notices X
3. Violation Ordered to Cease Immediatelys X
4. Violation to be Corrected Within one Days of R'his. Not
5. Return Written Report of Corrective Action to be Taken, Requested.
6. Contact Fire Prevention Bureau, for re-inspection. x
Notice:
A record of this violation has been placed in our files and may.b'e a
basis for furthur actions, as the legal need arises.
I.
Such furthur action shall be taken as the law requires, for failure
1 to comply, with any of the above requirements, within the stipulated
time. (References Mass. General Laws, Chapter 148; Section 30. ) ,
Method of Services Dates 4/6/78 Time!_ 3: 00 P. M.
Hand Delivery Del, by: Recd by:
Regular Mails
Certified Mails Cert. # 916739 Receipt R ted Y s
Per Order o$> f <�,�ca to
ccs Salem Health Dept. Title Salem Fire rshal
Salem Building Inspector
. Salem Electrical Dept.
jForm #26B (Rev. 1/78 )
Gttg rrf *Irtm, Augsadjuutts
° r 3irr 199w1mrnt 3iraaquartrrs ,.; 4
k
38=88 MM Date March 301978
QEhit(
;• Nape , " Richard Tanzella ng ; 117 Congress Stree p
:'aAddre4s . 61 Hull Streeto Beverly, Mass.
Salem, Mass. 01970
As a' result ,of an inspection this date of the oremises , structurepzioperi
land .area or vehicle owned , occunied or otherwise under vour contrry0
,, the following recommendations are submitted :and -stall serve as a iiotice .
of• violation of fire lays . These recon-endat.inns are ^jade to the ..inter-
est ,;of fire prevention and to correct enndi.tions that are or tn'a become
dan�zetrous as a fire hazard or are In violotion of the 1'riv.
YouYare hereby notified to remedy said violations npmed hel�w within>`" <
iii three days of the above date .a;.
" Sueh furthur' action will be taken as the law recuires , for fa lure2; o
comply. with the above recuirements wit'-in the stipulated time : ,=•p -`
', (RefePence : General Laws of Commonwealth of Massachusetts, Chsp tori. tl
X14 r
Section 30; and the.Salem vire Code Article
Rear 117 Congress St. street floor egress door locked frotn` inddidAdS.
y-,Egress must be maintained available to occupants at all times,
:.; 2• Rear 117 Congress St. Rear stairwell blocked by mattreaseai shin,
N sand rubbish. All stairways and hall areas are to be maintained free
.of any materials which prevent free egress from all floors in the =.
w ' event of fire or for normal use. F ;,-
' �g4 ,,1ront 117 Congress St. stairway and hallways are blocked by fUrfiiehin,
and rubbish. All stairways and hall areas are to be maintained fared
iof any materials which prevent free egress from all floors in the`
(,MLi'syent .of fire or for normal use.
, Front?117 Congress St. second floor hall has open wiring
dight'switch. This is a probable cause for fire and shall be
, rxhimmediately corrected. � r
' ,s Several overhead light sockets appear to be in a state 0fdisrepair.
WiAll �eleetrical wiring shall be repaired and subsequently inspected
, i :by the 'City Wire Inspector for compliance 'wiith the Mass. Electric Cod,
r6+,±It is recommended that the basement stairway be kept locked
„�t 'q tiprevent ' ingress and possible vandalism.
i.Y
7RyThe refrigerator located in the stairhall at Rear 117 Congress' St. ~
°shall be removed and upon removal if left in any position available'
children, shall have the door of same removed. Chapter 281 GL;
Building Inspector„
Electrical. Dept.' Pe%or
�(
Health Dept.
Lt. David J. e Co in �/Sa1
m Fire Marshal
�ne7(''rtnr, —ire,
ire
Form 9Cq (°ev. 8/77 )
t +�
. -.yam \'�,
UNITED STATES POSTAL SER ------
OFFICIAL
"°-�A#
OFFICIAL BUSINESS O -�'"' a 'rc.eo
PENALTY FOR PRIVATE'e--+=w
SENDER INSTRUCTIONSyacle.
USE TOO AVOID PAYMENT
Print your name,address,and ZIP Code In the sn F POSTAGE..S300��"�' '"" "^+
• Complete Items i, 2, and 3 on the rove /
• Moisten gummed ends end attach to frog,/ •^°" ...v.- _ MALAML.,.,,.
it apace Permit.. Otherwise affix to becEnders article "Return Receipt Reque
cent to number.
RETURN
TO
Vi
I,
Mr. John B. Powers , Insp. of Bldgs
(Name of Bender)
i
C; t�L Hall Annex, One Salem Green
(Street or P.O. Box)
Salem, Massachusetts 01970
(City, State, and ZIP Code)
�+ 0 SENDER: Complete itema 1,2,and 3.
S Add your addms in the "RETURN TO" apace_on
3 Meru.
1. The following service is requested (cheek one).
❑ Show to whom and date delivered............ 15f
E] Show to whom,date,&address of delivery.. 350
w ® RESTRICTED DELIVERY.
Show to whom and date delivered............. 650
RESTRICTED DELIVERY.
Show to whom,date,and ddress of delivery 850
a 2. ARTICLE ADDRESSED TO:
!3 Mr. Richard Tanzella
z 61 Hull Street
z
Beverly, Mass. 01915
19
n 3. ARTICLE DESCRIPTION:
REGISTERED NO. CERTIFIED NO. INSURED NO.
945296
y (Always obtain signature of oddrenae or age ill
9 I have received the article described above.
Si SIGNATURE ❑ Addressee E] Authorized agent
i
° mann
WC �'
„I DATE OF DELIVERY^ ' POSTMARK
b
p
S. ADDRESS (Complete only It requested)
D
T
6. UNABLE TO DELIVER BECAUSE: CLERK'S
INITIALS
>
r
{r GOP:19�203-45e
April 11 , 1978
Mr. Richard Tanzella
61 hull Street
Beverly, Massachusetts 01915
REt 117 Congress Street
Salem, Massachusetts 01970
Dear Mr. Tanzellat '
In response to a complaint from the Salem Fire Prevention Bureau,
I inspected the premises located at 117 Congress Street on April
11 , 1978.
The inspection revealed that both required egress stairways were
obstructed by various household furnishings, toys, etc. This is
in violation of Section 605.3 0£ the Massachusetts State Building
Code.
You are therefore ordered to immediately correct this condition
upon receipt of this notice and to contact me for a re-inspection.
Your failure 'to"oomply with this order will result"~ii 'legal action
being taken against you'by this Department and the 'Cty of Salem.
Very truly yours,
WILLIAM H. MTWOE
Local Building Inspector
cc: Lt. David Goggin, Salem Fire Prevention Bureau
WHM/mlr
Certified Mail #945296
�ratyP "'9' y -� � L
a
. a
+� yg7�fLDiNG DEPTr,
,, C�itt of "5zzlPm, C assadjuutts
' Q'i g 39 Aire bepunmrnt livabquarters }
�^ REGI IYLD ,Y
Date March 30, 1978
` �
.r� ; l}
Richard Tanzella 117 Congress Street ' '
e :
It',61 Hull Street Beverly, Mass.
y iAdslre-9;.s.W r Y Salem, Mass, 01970 .
,•� ���x�
afire ulYof an inspection this dgte of the DremisIs , structure open $
rgar* Vehicle owned, occupied or oth.erwt.=e under your control, t.
tttdff611owiric� . recommend tions tar submitted and slhall serve as`. s notice :
0, kr" o, ation�'of fire laws ., These recommenda`,ions qre made �.n 'the inters ,
e �gft i *Hq prevention and to correct eo dittons that are or, mal,7, becomell
ia,93za , fire hazard, or are in violation of the la4 l
1'91}' a�^d hereby notified to remedy said vi.olations nared helnw within
5�y
a4xhreQ<d qs . of the above date . ;
Supplb.Ot,,action will'be taken as the law rer,uires , for failure , to J,
e0%9 with the above recuirements witl^in the stipulated time. , £�
�Re,Vi . rice ,1General Law@ of Commonwealth of Massachusetts, Chapter 146;
«4(Section 30;' and the -Salem Fire Code article 1. )
R$ar 117: Congress' St, street floor egress door locked from inside.
Eg�py s must be maintained available to occupants at all times,' '
ll•?_.Congress St. Rear stairwell blocked by mattresses, furnishinSa14
_dlrubbish. All stairways and hall areas are to be maintained free'
tA
any materials which prevent free egress from all floora,;in .the
` ' eyent�of fire or for normal use.
rt a 1^rq t ll? Congress .St. stairway and hallways are blocked by' furnishing
►d,,rub.ieh, All stairways and hall areas are to be maintained free'.....
r Q3„alny,mater ials which prevent free egress from all floors„in the l
# seVent "of fire_, or for :normal use.
i
91-1 7 Congress St.'” second floor hall has open wiring ata
� htsYttch. This;is a probable cause for fire and shall be
corrected:
y },gvgra+ overhead light sockets 'appear to be in a state of disrepair,l r
electrieaI wiring shall be "repaired and subsequently inspected 4
e�City_ .Wire Inspector for compliance with the .Mass. Eleotric. Cod� `
�> � reoommend
ised that the basement stairway be kept locked to «`
8 rent ,ingress and ,possible vandalism.
�It' ��fefrigerator located in the stairhall at Rear 117 Congre@s St. ! �
� stllbe” removed and upon removal if left in any position availableI
<o ildren, " sha# l have_ the door of same removed. Chapters 281 GL'. r
efilBuilding Inspector
�m .. Per r r, ;
Heeotrical Dept,
= HeQlth Dept. 7 x f
Lt. David J. o�ain. alem Fire Marshalp
7nPne'c t,,)r, t*):lerTM lire
z
x 2' r
No.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
19
APP VED
INSPECTOR OF BUILDIN _
DATE:__ to e
Cltp Df a1Emy §fta!9!atbu5ettq
PLANS MIST BE FILED AND APAROVEWBY THE
1N.SFECT0R••PRIOR'TO A AERMIT';B49ING GRANTET)
Location of Building 117 coayc�s sf
Building:HtsFml,R Application For:
'(Circle whichever.applies) Roof,Reroof• Install Siding. Construct Deck, Shed, Pool
Addition, Alteration,(kVair la , Foundation Only, Wrecbing
Other: ;1
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned herebyr applies for a permit to build according to the following specificati—s:
Owuerti Name: SALe.-A aeo5sap Au l4bA-W y Contractor: ta�tnaa.t�art� fi r s/aaA�76�
Street A -) ciAMUM s� City sruc-.-\ Street /6 t 4z, L De- City �a�tpX
State 01A Phone (979') 744 -443t State Phone 910J
Arcbitect: 4)6_gz4Pb ✓C«tf(o Achy/ City of-Salem Lick
Street t tfiu' City
tn4"LeJaw State Lick
ese46s33q, HIPa 1l7`�'Jo
-�-
State r _ Phone (79 t ) G 5 I -Al 4 el Homeowners Exempt Form -yes—no
Structure: (please circle) SinEle Family. Multi Family k ✓ Other
Estimated Cost of job S -9
WiRtufllilingconflrm.twlaw',�yes no
>•Description'of wot^kt ba dooe:__ i�EPtr�-c,£ poo2y � ERp,Mz� T
DrewingaSubmitted: des no Mail Permit to:
% £rJJttlaa.tMr,��., Rc�roan-n�
Stgoature ofApp'Itcr*0on,1,_G _ ER THE PENALTY OF PERJURY
320TRO °1DMa B !WT;9,D W1T01N SQC (t4ML)NTIIS OFTERMITkISSUTD DATE
Department use,only Pev�(.0 �r'2,00 Z'ning Map/Lot
Permit fee S q
COMM ITS:
------------
/yn /1 1L
lr LYE COm.mORwi:a&L 0/ /4a6jacLJetL7
5 _LJeparlmanl ool Jr ullrial 4cc;/,LCJ
600 sukinglon .3lretl
James J.Camovell 92osloa, MassacL.Us 02
C ommrsssoner
Workers' Compensation Insurance Affidavit
1, _ �c1JIRCA'tl01SZ+L Rf�51ofifd764%
<ama•e�..r.ieee) .
with.a principal place of business at:
L±�4Qs7d=AD A)� o>v41
(ClryrstawLyl -
do/hereby certify under the pains and penalties of perjury, that:
(y I am an employer providing workers' compensation coverage for my employees working on
this job.
12'AJCLb'tU PR0?6PV CA IA-LTy wcGl( o047cx 1 7z-40Z
Insurance Company Policy Number
I 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 policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I understand that a covy of this statement will be forwarded to the Office of Invesdpuard;of the DIA for coverage verilk3dan and that failure to secure
coverage as rtdured under Section 25A of MGL 152 can lead to the 6nvostdon of crenime oenaities consisting of a[me of uo to-S 1.500.00 and/or one
years'imvruontnent as Vera as ci a denalda in the form of a STOP WORK ORDER and a fine of S 100.00 a an against me.
Signed this day of 7110 16 5
Licensee/Permittee Building Department
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 517-727-4900 X403, 404, 405, 409, 375
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, 534,I aclmowledge 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 III, S 150A.
The debris will be disposed of at: A ort.rr4 en--. 1Z C
Location of Facility
7�i6�o3
Si tore of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Kann ryetF7-la
Name of Permit Applicant
EnlJirtc-Jm s,,srqt- rbxo-PaJ
Firm Name,if any
Address, City& 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.
4
°T/rc �omiinoxueald a�.�anoarlume/fia
k
LATI
BOARD.OFBUILDING- -REG
ULATIONS O
4 " License:..CONSTRUCTI ON SUPERVISOR
Numtier.�CS'
i 046839 �.
'- Birlhtiato: 08f16/t963
F�paes_':,0&1Sf20,03 Tr.no: 3249
-- - -- Restricted:`00-
KAMM G WEHANI� -
90 CUTTER HILL RD
ARLINGTON, MA 02174
Administrator
a
I� I �/lP V/ONLIIf(1MAllC(L ��dd?l,/Rl(dE� i C.�
BOARD OF BUILDING'REGULATIONS
i' License: CONSTRUCTION SUPERVISOR
Number: CS 069323 r,<9
Birth date: 05/15/1946
"•
Expires: 05/15/2004 Tr, no: 24149
Restricted: 00
FREDERICK L STENQUIST �.
321 WESTON STdr
WALTHAM, MA 02154 Administrator
00-35,000 cf enclosed space
I (MGL C.112 S.601-) .
IA-Masonry only
1 G-1 8 2 Family Homes
Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
i
DIG SAFE CALL CENTER: (888)344.7233
07/10/03 THti 10:18 FAX 8172616661 HOUSING INV. 10002
IL
Preservation of Affordable Housing. Inc
Amy S.Anthony, prm m(
By Farsimife and Mail
July 9, 2003
Mr. Fred Stenquist
Knollmeyer Building Corporation
10 Henshow Street
Suite 2 0M
Woburn, MA 01801
RF,: Salem Heights Apartments,Salem,MA (the "Project')
Dear Fred:
We are pleased to award to Knollmeyer Building Corporation the construction contract in
connection with the proposed ren(tvations at the Project. As you know, this Project is an
important endeavor for POAH.as we work with the residents and the managemem
company to rehabilitate and preserve the Project as an attractive and affordable
residential development.
We anticipate that the amount of the total construction contract will be $2,672,870. The
scope of the construction contract will include, without limitation,replacement of the
heating system,replacement of roof on Building A, replacement and repair of the
elevator system,replacement and repair of the parking field, and updating of the
bathroom and kitchen cabinets and fixture%. We expect that you will begin to mobilize
for renovation by the end of July and begin work on or about August 1, 2003 and
complete the job (including the punch-list items) before the end of the calendar year
2003. 'The formal terms and conditions will be set forth in the construction contract.
We look forward to working with you on this Project.
Sincerely, —
Wata u M suyas
40 Court Street,Suite 650, Boston.MA 02108, 61J 261 9898, fax 611 261 6661, www,poali.org
EIT�QF-�LE1Gr --
' PUBLIC PROPERTY
DEPARTMENT
KINWRLEY DRliCOLL
MAYOR 120 WASHINGTON SfRFzr♦$
ALLK uA,csACHt;st-,-is 01970
Ili 978-745-9595 0 FAM 97&740-9U6
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATON
Location Name: Building:
Property Address: /%7 a y-7rsS S 7`
Property is located in a; Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: S E.y nvJ� �v02r�
Address: .1>
___
Telephone: 7 _ — '/143 /
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIING BUILDINGS ONLY
Addition Existing C7(
Renovation 5( 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
Brief Description of Proposed Work: /2C 00
U1V
Mail Permit to: -
What is the current use of the Buillddiing? Ao 1`M TAT r
Material of Building? Oct«-\ If dwelling. how many units?
Will the Building Conform to Law? t S Asbestos?
Architect's Name I ✓t o Ni 1--MYLIZ AL s 41t io,, s
Address and Phone 2 S Afi4q - .57 /�/1� I P- /�7
1 o�r1/ 1
Mechanic's Name `a fQ A' 56,v /1
Address and Phone'Q��2�^L S J r2�''l I rl S�$ 6 2g- 'SSG Z
Construction Supervisors License# C S 4/T 2 Ild HIC Registration#
Estimated Cost of Pro ect$TSB ^ Permit Fee Calculation
Permit Fee ��5 Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
Date
I
P
N �
O
•.n y N
u
1
CITY OF SALEM
6
t, ` PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET * SALEM,MASSACHUSETTS 01970
TEL:978-745-9595 ♦ FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information yPlease Print L/e¢ibl
Name (Business/Organization/Individual): A-11JIr Ro g2'ij 4- J /E 'Wy
.I
Address:
City/State/Zip: Ffi /k?z64/.Q/h 111A o/b2 Phone #: SOS' G 2 -6'5_65 7
Are you an employer? Check the appropriate box: Type of project(required):
1.� I am a employer with 1� 4. ❑ I am a general contractor and I 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12$Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.❑ Other
*Any applicant that checks box Al must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.Insurance Company Name: /C /i F //YS (fe j
Policy#or Self-ins. Lic.#: A-C 2` 3/5 - Expiration Date: `3////O5
Job Site Address: /17 C9�,kt S'S S-f City/State/Zip: �r1/it �,0.
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 MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify un t%%%ll���l =den ofperjuty that the information provided abbove iisstrue and correctSignature' �®> Date:
Phone#: S O1�'6 2k- 4QE��z
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
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,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint 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 not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that"every state or local 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 who 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."
Applicants
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),address(es)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
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 may be submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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 are 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 fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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 the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
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
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-26-05
www.mass.gov/dia
CITY OF SALEM
' PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL '
MAYOR 120 WA-SHINGTON STREET ♦SALEM,K$SACHUSETIS 01970
TEL:978-745-9595 0 FAX:978-740-9846
Construction Debris Disposal Affidavit
(required for.all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The
debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
/
� D ,-
date
drhiiaa(fdac
AC. ORD I. CERTIFICATE OF LIABILITY INSURANCE M."PV0Off"
OS/30/2006
PAmm THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
CHRISTOPHER J ROCHE INSURAANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
426 MASSACHUSETTS AVE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BOSTON, MA 02118
INSURERS AFFORDING COVERAGE NAIL q
.... ._...
RELIABLE ROOFING c SHEET METAL LLC
RLI NO,AIERA WESTERN WORLD INSURANCE
'"` .. ..
PC.1BtGR B: LIBEILTY MUTUAL FIRE INS CO
101 FANEVIL STREET
W3MRCR c.
BRIGHTEN, MA 02135
INIIORlCR OI .. .
COVERAGES
THE PUL1UIty OF INSURANCE USTCG BROW HAVE BEEN ISSUED TO THE INLURI31 NAMEO ABOVE FOR THE POLICY PERIOD INDICATED NOTWTHSTANUNG
ANY RCOUIREMCNT TERM OR CONDITION OF ANY CONTRACT OR OTHER 006UMENT WRN RESPGCT TO WSIICH THIS CERr n,ATE MAY 01% 1.41"M OR
MAY PFRTAIN THE INSURANCE AFFORDED SY THC POUCICS: DESCRIBED HEREIN IE E'UO.SCT TO ALL THE TERMS EXCLUZIONS AND CONDITIONS OF SUCH
POLICAES AOOREOATE LIMITS SHOWN MAY RAVO LREEN REDLICED BY PAID CLAIMS.
INOR AOVL ....- .. P nOiOulATidN'� .. ..—
LM INMO TREOFW]IRMNVE FEYAYN118P1 "TF PATH MNV
aFr¢RU Lumnr lFAO1CCCLN1A c Wm22,000,000
I ONN.O610'RE
A x x CWWERCML CPORAL�L�IA INLITY NFP1017566 :03/16/04 03/16/07 PREABveO Se...oAee.1 1100,000
r"W MADE I^ 0m Mw DO,(An'.R.PM.sy.. 55,000 ..
�_ „I FCROONALBAOVLWUNY ,1,DUD,aDo
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BFMl wtulNpiATV UMA'AW tas KA FROOWT3.COMF/OP ABM f2,000,COO
POLICY 1p.Y LOC
AUTOMO UAYIu'IY COMBWEO ONCLC UMR
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M9PERlY MUMCE
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OCCUR n cLABaa MAOn AOMREBATE _..... i
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.WURNUtS[IxOYN9snox AMJ X TCRYLIMITm LER
B AF(Y FRUNiICRAN1Nk'RAO(ECUIIVE WC2-31s-358763-0 03/11/O6 03/11/07 4eL urnncclOurt {100,000
'txHlxnARMB UCLUCCOT EL vzI .C'CAGIPLGYOE A100,00(
SVnYAL4Huwaw�wa eew EL GIBEACE-POLICY DOT It500,000
RTNfF
C BUILDERs KX.5K I BR63915997 06/01/06 06/01/07 1 $53,000
I
OEBCRWTgN OF oPEAanuaf 1 LounONR�YewcLeF r BxcwMONe KOm Pr mmMR➢lOLIBR rYFGuI MOMWmq
THE SALEM HOUSING AUTHORITY AND THE COM40NWEALTE OF MA89ACw=TTS/DEPART4
COMMUNITY DEVELOPMENT ARE LISTED AS ADDITIONAL INSVPZDS VXTR RESPECT TO BUILDE
CERTIFICATE HOLDER CANCELLATION
SALEM HOUSING AUTHORITY aI u ANY OA DO mow OEFCBIem POU=. W ms TT1E Exwwm
27 CHARTER STREET OATO TMOSP. RED IAMNO WNRM W" RHPNAVOR TO MAIL _ 90 wvA YANM1iA
BAT.en7, MA 01970-36" NOTION TO DO OCA'MCATE HAD= MMU TO THE LEFT. BUT FAR.MRB re PP FO FNALL
O@WB NO CWIAATON OA UAGRITY OF AM arm WON DS OmuM. Rs AC tl OR
OOKM CNTAVVVk
AUWOIIIOO RON=WffA?M
CERISTOPHER J ROCHE
ACCIRO 25)20OT/08) 61 ACORD CORPORATION 119011
M
/e �o �mueatico� aa� uan
BOARD OF BUILDING REGULONS
- License COON�STRUCTIONSUATIPERVISOR
tMum'ber"kCS �' 0�19P40 a
ts�irthtlat�,03/OS(;1951
03/05(2�08 Tr no :14130,
'q
r 4RICHM6D P TOMKINSON
5 12TWST a
ONSET; MA 02558