0386 ESSEX STREET BUILDING JACKET . 1�4ir386 ESSEX- STREET
aCITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR
120 W,vSHINGTON S'rReisr � S,v-�o:M,JfAssnu IciP:n�01970
'rEI.:978-7-15-9595 ♦ FAX 978-740'98,16
REQUIRED INSPECTION
PROPERTY LOCATION 384 Essex Street
March 19, 2007
The DRR Real Estate Trust,
R. Barnard, Trustee
249 Green Street
Marblehead, MA 01945
Dear Mr. Barnard;
The above referenced property has come to the attention of this department for the following
reason(s):
780 CMR, State Building Code, Section 106; requires that these premises be inspected evert
five(5)years for Code Compliance)Life Safety Compliance. This property has ne,ler been
inspected per this Code, and this must be done forthwith.
Under the provisions of 780 CMR, Section 115.6, State Building Code, access to this property
must be granted for the purposes of inspection. Please call this office upon receipt of this letter
to schedule this required inspection. If this property has rental units, these tenants must be
notified in advance of this inspection, so that access to these spaces may also be accomplished.
This inspection must be completed on or before April 19`h, 2007; failure to respond to this
notification will be construed as non-compliance, and as such an Administrative Search Warrant will
be sought, so as to allow the lawful inspection of this property.
If you have any further questions regarding this letter; please call this office at
(978) 745-9595, extension 5640.
Sincerely,
Thomas J. St. Pierre
Building Commissioner/Zoning Enforcement Officer
CC: file, Health Dept., Electrical Dept., Fire Prevention, Mayor's Office, Councilor Pelletier
(:eammU NYmEx: B1!-0M 7OFPANCY
anA Numher B•16lNCommonwealth of MassachusettCity of Salem
Multi(amrl, 3+ RoddingcatedM. 9nMY9i1A . ...386ESSEXSTREET ojSale_m , __........ wMw�wIS HEREBY GRANTED A PERMANENT CERTIFIOCCUPANCYUBIt 1This Permit is parsed m conformity with the Statutes and OrdinancesnaexPaes ..._. N r Appfcablq_ _.__ unless sooner sued.
Ep NS OY
issud on: Thursday, January 17, 2019
n --OFs
PUBLIC PROPERTY �\\
7 DEPARTMENT _ �l
KMOMEY DIUSCOLL
MAYDR 120 WAMINa"SMEEr•may.MASSAC14MTrs 01970 O
TM-97&745-9S9S 6 FAX:976-7i498"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
r
ORMATION
e: Zg-6 Building:
ress:f
k7 S locata:Conservation Area Y/N Historic District Y _ .
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: AAz L—rY St
Address: CIO SAV C"t-,P4�
_ !z3;
Telephone: 8 — —
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
���r2 �rcIM,N.Ey.S .
6A0
0/9f S
Mail Permit to: �
What is the current use of the Building? M()LU t
Material of Building? WOO. If dwelling, how many units?
Will the Building Conform to Law? 9��'S Asbestos?
Architect's Name
Address and Phone ( j
Mechanic's Name �►��
Address and Phone 13 PST �� /� '; MAo.� l>. —0/f9j
Construction Supervisors License# 0/5��g6 HIC Registration#
Estimated Cost of Pro ect$ a a Permit Fee Calculation
Permit Fee$ �� � 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 Perm' to build to the above stated
specifications. Signed under penalty of perjury
Date
of
d `� 6�'
4G O o ill d O
C
Y
r•.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xaetu:Rtav sRacou.
MAvat to W&%0 CMStRM a&U 4.MASSAatUsaM01970
Tn-97V745-959s a FAX:M7409w
Workers' Compensation Insurance Affidavit: Bnilders/ContractersMededans/P(nmbera
Applicant Information Plesse Print Legibty
Name(BullinesdOrganiauoa/Wividuai):
Address: /-123
City/state/Zip:Lt%(6l�N.(—'4-!, Nk 019`/f Phone# / 63-?r
Are on an employer?Check roprlete best FfiR*jaideft
(regdre�:
I. j am a employes with 4. I am a general contractor and 1 , n>cHoa
employees("and/or part time).• have hired the sub contactor
2.❑ I am a sole proprietor or partner• listed on the attached shut t t
ship and have no employees These nib COnhaett�have working for me in any capacity. workers'comp.insuance.(No workers'comp.issuance 3. ❑ We am a corporation and its ddion
required] ofllca s have exorcised their 10•❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.(]Plumbing repairs or addition
myself.[No workers'comp. a 152.41(4),and we have no 12.0 Roof repairs
insurance required]t employees[No workers' 13. Other jr2 � 02 AeP/h
Comp.insurance rexluir"I
;Any APPHOW err dwdu bm e1 awd am tie out the e.etloa bdow t0awiea tea works'aampmtadoa t+.itay biltrmatlaa,
ltataeorram wlia submit tbia dttdrw mdtatlw�y a doles as week area ie.hkw name.ameaerera mote atbmb•taw etedavD btaiaNes mti,tCoubaermo tort cheek d"boa moat ateadted m additimW rear shreds the soma otte mbeomacoon rd tttetr warloea'comp Pam'talbematba.
I am an ormaaiwa employer that Is providing workers eostpensadow Gararawcejor m y
inl employees, Below 4 the po&7 and job.rlh
Insurance Company Name: 1
Policy t1 or Self-ins.Lie. ii: WG L�3 q��� (o( B— 1 Expiration Date:
Job site Address; 6 Cityistste/z;p:, fit /yr.¢ O/970
Attack a Copy of the workers'compensation Policy declaration page(showing the policy number and aspiration date).
Failure to secure coverage as required under section 23A of MGL c. 132 can lead to the imposition of tximinal
fine up to$1,500.00 and/or one-yea imprisonment,as well as civil_riesin penalties ofa
of up to f250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the OtRcs of din form of a STOP WORK ORDER a Rae
Investigations of the DIA for insurance coverage vaification.
J do hereby rdi3r under the Rahn and penalties ojprdi"Y that As lnjormadon provided a Is and correct
Ojjlrlal use only. Do nos write G thb area,to be completed by city or town ojjlclal
City or Town: Permit/License b
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.CRY/Town Clerk 4. Electrical Inspector 3.Plumbing Inspector
6.Other
Contact Persona Phone M'
Information and instructions ,
Massachusetts General Laws chapter 152 requires all empWYers su tn�ovide the service a moth under any compensation for their employees of hire.
Puraut to this stetuite.an a epfoyee is defined as ...every person
e�tx implieel,oral or written
as"an iudividual.Partnership'association,co son or other legal eased or any cf the
of Or more
her for"
p is defined and io¢�tM�represemtanva of a deceased empWY
of the fongoiva engaged in a joint eote:p�ae. entity.etaploYWa emPlOYeer' However the
of an ind►vidual.partnership,association or other legal of the
receiver or trustee and who resides therein.or the occupant
owner of a dwellin fi boos°havini net m°rs than toms s�eati maintmatim construction er�wodr on such dwelling hOmm
dwelling house of sootoer who emPIOys P tOsM�ll Seri because of such employment be deemed to be an employer."
or on the grounds or building
appurtenant
"every ataa W Weal dcasuing ageacy sbaa withk*1d the 1UuxMS or
MGL chapter 152.42�(��aO��that is tM cotameaweakh for any
to operate a business or to eoastrurt bauildho coverage required."
renewal of•tl has
or pew acceptable evidence of ebmptlsaea do lusurance
appacom who has not produced states"Neither the eomntonweSlth not any of its political sub"ainee shaft
AddinomAy,MGL chapter 152.$25Q7) of public"Nei h ert until manse evidence of compliance with the insurance
enter is of to chapter ban bian presented to the contracting authority"
Appnwb
Please fill out the worlccers' CO on affidavit completely.by checking the boxes that apply to Your sin of
enitm and,if
necessary.supply sub`cOrtns�a)name(°).addr Limit and abom number(s)along with their�°)other than the
insurance. Limited Liability Compaaiea(LLG)er Limited Liability n m tans a(LLP)
members or partners,we not required to carry workers•compensation tnstuanca• If LLC or LLP does have
etapWyees.s policy is required' Be advised that this affidavit may be submitted to the Department Of industrial
Accidents for confirmation of insurance coverage. Alan be sure to sign sad date the a8idavlf. The affidavit Should
be nuurned to tot city or town that the application for the permit or license is being requested.not the D°Partmetu Of
the law of if you are required to obtain a workers'
industrial��y, Should you have any gttestiooa regarding listed below. self-insured companies should eater their
compensation POlicy,plpleasetail the Depatteum�number
self-insurance license number on the
City or Town Offtlab Please be sun that the affidavit is compete 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 a nt
pplica .
Please be sum to fill in toe parmitilicense number which will be used as a reference number. in addition,an applicant
multiple�rmitAicense app lication°in any given year,need only Submit one affidavit indicating current
that must Submit "Iob Site Address"the applicant should write"all locations is__deity or
policy information(if necessary) or marked by the city er town may be provided to die
town)."A copy of the affidsvit that has been officially skimped or licenses. A now afudrvir must be filled out each
applicant as proof that a valid affidavit is on file for Auntre pia not related es. to any business err commercial venture
year.Where a home owner or citiaea is obtaining a license permit uired te toanycomplete sin affidavit
(i.e. a dog license or permit to burn leaves etc.)said person
is The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions6
please do not hesitate to give us a call.
The Deparmsent's address.telephone and fax aomber.
1U COMM=wealth of Mmachusetts
DOPUMMW of lnthlstdal Accidents
OtQp of IavesdVilens
600 WWhM9M Street
Boston,MA 02111
Tel. #617-727-4900 eat 406 or 1-&77-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.npampy/dia
CrtY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
t3s.,►Ooier�r,u�.fua.ar..�or�tsOtt►t.
,lu.t.7.&M W&74&"
Coasbvcdoa Debris Dlsposat AAWavit
(requicad s+tr datotidos tusd res1vs-9 woeir,
is scemdssm with&S Ae(w ��K CWk 7S0 C!2�Uot 111.5
'0+die is tend wish dw eoomos dws tm I I rattltles!rant
boil w"�e.disposed Otis.povwb Sommedw m disposal&dit a Mod by UM
1i1.st�o�.
ThO dd rU wiU be usmponad byt
P�� ' &tLzw-�- Cox -mlj-?
tmm stimm"
The debds will be disposed of in:
r.(mmso(Aailitq - r
(&!dross of rugby)
Siva"*(PWA apolcm 1
due
'�d,..a►ms
co D CERTIFICATE OF LIABILITY INSURANCE Cpggs� °ATfiINMTDYYYY
9A-M'm 1 30 06
PRODUCER - THIS.CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE`
John i"Walsh- Ing Agency, Inc HOLDER.THIS CERWICATE DOES'NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
. Phoyes9.7.6.745-3300 Fax c.978, 74g-955T INSURERS AFFOkDII'�G COVE��E ' a ,�.y�'9 NA7C#''-�
..
•y./� iNSURERB St Pe.,Y Trav♦leri: `
�I ,E6SeX"B,W T+- Q}SP�' p �n, INSLIP RC � •. '^ �n b.� Iw
..rr Tx ,E.,. � x.•r
v3 Piiasasit .� INSU ERA
COVERAGES
THE POLICES OF INSURANCE U$T6D EELOW HAVE DEEN I-1DEDTO THE NSLIRED,NANIED ABOVE FOR THE POLICY PEPoOD INMATED.NC'IMTTHSTANDNO -
MdY.RECUIREM4DDTTT.TERM ORCONDITION Of ANY CONTRACT OR OTHER DfjCuNENT W RN S$PECT TO YJMCH THIS CERTIFICATE MAY SE L%UED OR
...:MAY P.EATAIN.7NEIHSUPANCE AFFOROED BY THE P,,IOIES OESGRIBEC HEREI N IS BU BJE. TO ALL THE TEFN9S,EKCLUSIONS AND CONDITIONS OFSUCN
POLICIES AGGYEGA76lMRS4HGYM LMY NAVE BEENREDUGED BY PAID CLAIMS,
LTR N OFNSURANCE
mow POLICY NUMBER DA M E v�iTE M I UMrcE
cEtlERAL UPYILiTY EACHOCCLRR15"CE : E10AD000
S X' SAMwERCIu.GENERAL UAe!Lm 6E08591]653 OS/13/06 0p/13/07 PREW$S&R:oxwux. s300000
CLNMB MADE R OCCUR - . . I AIEO EXP WN.E!�H :'�; S 1 Q600
h LACY wRY s'li�(NboOo
SENERAL Rt REGAT�B $200A000:
cEN pccaEeaTELInrc APPusspnle Pkoauers'-�COAIRIDP isGa 'E 2D9A0 0'
'V.ROCICV" .PEP Ld'
.AUj'ONOBILE LN6ERK.., CONSBBIINEDDSINGLELIMIT
'. ANYAUTO " ,
::"C ALTOS Lr Nljav s
{TIEDAUTOS SODILVIN11XiY 'S
(aerRoaean0 -
VN1N-0 NLDAUTOS .
I PROPERTYDAMACB
' perema'
OA SLW9ILITV ,ANTO ONLYi-FJ1 ACCIDENT'- S
OTHM
7HAp EA,AC� S
1FNYAUTO' AUTO ONL`F,: AGG S
f
EYCE56NMPRELL� .
A''W�BE.RY .EACH OCCLIRRENCE S.
IOCLUR ' CLASS MADE �: I AGGREGATE 5
N E."•HE N)TENTN E .1 1• ?., S W1
iMgRSER$COePENSA'IDNfgND fTO
Aq EMPL6YERS LIABILITYy 4395466 08/24/06 OB/24/07 E.L EACN YccmENr sl0 AA 0'0
jANY,=GT R(3CL'UOF EckrNE: 1fi DISEnslk EAFSEPLOYE- s 10 DOA:
PIaD
amei' XrO - ' 'EL D Po�cruN4T' s 5,&Q4QQ.,.
$PEdAti' VI$IDN$LrlPo
Ttilwr i .` $9000
OESCRIM1ON OF OPERATIONS ILOCATIONS I VEHICLES EXCLUSIONS ADDED BY EHGORSEMENT I SPECIAL PRONSRINS -
.CANCELTION . . .o .... •.. .. A
CE:kT1FICATEM0I-DER LA
-- � " '
.. 0onan EHOUID ANY OF THE MOVE DESCRAIMO POLICES BE CANCELLED SEFORETNEEXPIRTION
DATE THEREOF,THE iESUNG INSURERWLL ENDcnvGR m MA L 30 , ,onus wRTZEM
City of Salem
. ,SUidling Inspector NOTICE TO THE CERTIFICATE HOLDER'NANW TO THE LEFF,BUT FNLURETO DO SO SHALL
..'TON# :Hall- WPOSe NO OBLIGATION ORLi"LirY OF ANY NINP UPON THE INSVRERjiS GENTSOR
Washington St . REPRESENTATIVES
'salem.M7L 01970 I
AURIORREO REPRESENFATN -
John J. W,1sh I -
:-' ACOkD'35(200'1I08) ''. ' ' - .. SI CORfI, RATION 7988
ZO 'd IL:pI 90OZ 06 ADN M694C0C6:> ed 37NBLOSNI HSIVM NHor
IMPORTANT
If the certificate holder is an ADDITiONAL INSURED, the policy(ies)must b e endorsed.A statement .....,
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED,subiect to the terms and conditions of the policy,certain policies may
require an endorsement.A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insUrer(s),,authorized representative or producer,and the certificate holder, nor does it ;
affirmatively or negatively amend,extend or alter the coverage afforded by the poiidiEs listed thereon:
ACORD 25(2001/09)
60 'd Il :bl 900e 0G hoN L9969Vzeks:xE3 30N+?aM! HSIYf NHOf
_ 1lle ( tnlnllU it%% -Ath ttl NI.r,NJL ITLISCH I _--,
t Bojid tit Illllldill� I1.egulJu0n, .utd S( uldmds ult
Nl;u>achu+ellS Sidle llmldin� Code. 7Sll ('MR. ?4 rJlUttn
I NI
13ulldin_ lie IIIIiI AppIieJ(ikill Fu Ct ]SIItlel. Repair. RrnllaJnt OI I)ellWlI I a
Onr'- nr ltrn-h�unrlr !)ItrllulC l _,.' v'
l'his Secuon For Oltirtal I',e Only - ^---- _--_--_-
l3o0ding Permit .Numb _ _ -- LIl_ue :\ppl:rd'
SICnJIure --- - -- -- - - - __ _ ._..
Iiuild.i V Ci.11llln"I' uu/ In.j,C.tor,d 11told I , ).it
j SEC"1'ION I: SI'I•E INFORM VI ION
1.1 Property ,address: j I 1.1 N+ 'anr.:. Map S. Para Numbers
I I.1 Is this all Jli Cpled NlrCel ' NCN -� IUt i 'P' '
1.3 Zoning Information: ! (.J Property Dimemions: --- --
1
1'rn{••,,,f•1 !•, i I of Area n;; J) E(unt:lge illt --
L5 Building Setbacks (ft)
Front Yard tilde Yard, Rear laid
Reyt.ncd ro PuJcd Required Pn N'Id:d R:yuued I Pest nl.'J
•1.4 Water Supply: iSLG L c. 40. §54) IJ Flood Zone Information: 1.8 Sewage Disposal System:
Zone Outside Flood Zone" Shmin al ❑ On .ua Ju vt,al sa Nlem ❑
Public PnN'aw❑ .-_ Check it yeN❑ _
SECTION Z: PROPERTY OWNERSHIP'
'.I Ow ner'of R�ecorrd�� �•s
.C7 G— 9;2 V , J-3 1 _L'(l tS� ter ' ALAI
N.tu. Punt :\ddre" for Sel,ice:
Sign,turn- Telephone
SECTION 3: DESCRIPTION OF PROPOSED NV•ORR irheck nil that apply)
ew Constructifn00j Esi,u ng Bwlding ❑ (Aaner-Occupied ❑ Rrpw o(N) [7Vnnt, ❑ wd a 'n ❑
Demolition I AcccN,ury 13lit ❑ Number
l3,let Deschon t1l PropuNed %V to
1'jl2t-s-iE -
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Ilan ENumated Coe(s: Official Use Only
(1.ahor •Ind %latenulsl _ _ _
1 13ullding9$::
t 6wlding Penult Fee: 'S Indicate hi,tt Icy 1N delcl unncJ:
S(andard Cit)/Town Application Fee
Electrical - ❑ otalProjectCost (ItemG) amuluplicr ____ aPlumbingQ� ? OtherPee,: S
(II\N1eih.lntc.tl IPii r'rtJl :\II Fces St ,rchml LL _ (heck No l3tjl'11eck .\ndnmr 30$--_( ,nh \m'wnt
(t Fowl Project Cosh S �00rj F"lid in Full ❑ Outadndln ' 13.d_m.e Due_
�� InG(:.t�e4 �Irdast,nofl� pswwtld-
�S
ZS
1�
SECTION 5: CONSTRUC'"rION SERV'`WES
5.1 Licensed Construction Super.isor (CSI.) i.il aQ
� ,�{� C �( LL:inr Number Ey n I).nc
\,ulc I (:SI I I IJer
' i,rr h:hila I
I nu•,InalrJ nl +lit :: 111111 u I I
R Re,unleJ I.k_ F.uni s I)wN uIc
Signame. �I \la,onn Unls
Rl RcslJ.nual R no linLl a nnv
i
frlrph�mr 7p�1 6M 2 26r -o \\1 1� .aJ,u(I.J \\ lid. .. .wd 1, l n
O r `f
�.2 ReKislerrd Ilomr Impn)rcmrn1 Cuntruclor IIIICI —
III('Cmnp,un Name or fit(' Recntr it Name Til
h auan \uniher -
l� 2,
Wdre+� — -- --
® ! g 6392k o Eapnatiou Date
� Signature telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M:G.L. c. 152. § 250611
Workers Compensation Insurance affidavit must be completed :end ,ubmuted"with this opplic:mun. Fadurr to pruaiJe .
this affidavit will result in the denial of the Issuance of the building permit.
Signed Atfidavit Attached" Yes .......... No .... .. ❑ - - --
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. .___ • as Owner of the subject property herebv .
authorize to act on my behalf. in all mauen
relative to w-.uk authorized by this building permit application.
-- - -- — � _
Sl ellaWll'UI (]Klllr Date _—
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agem hereby declare
� that the statements and in!iumariun c>n,the foregoing application are true and accurate, to the best of my knowledge and
behalf. � �.- I• ,, . n� --
Pant .Name �/L✓�7Cil.�i�(_% I �� --
Siena!Owner or Authorized Agent - date ._
(Si med under the arcs and penalties of (u )
NOTES:
1. An Owner who obtains a budding permit (o du his/her own work.or an owner who hue, an unregl,Icred alntra, Iur
(nut registered in the Home Impnr:emrnl 0m raclor (H1C1 Program), will not hase acres, to Ire .rhitiatwr
program or guar-ji fund under NI.G.L. c. 112A. Other Important mltgmunon ,it the HIC Program and
Construction Supervisor Lcen,mg WSL)can he found In 780 LAIR ReguLuiuns 1 10R6 .ind I to RI5'. rc,pealr.c;h I
When ,uhstantial work Is planned, proslde the Information below: -
Tutal floors area ISy. Fr.I uncluding garage. fi n,hed ba,ement/attics. decks ill pinrh,
Gros to Ine area l Sy. Ft.) Habitable morn Count ___________ -,
Number nt nrrplaccs Number of hedFIII Il11s
Number of hathnum s -
Ispe of hranng ss,tem —_- -_ Number .-t dcsk,i p-aahc, _ .. . .
I ape
). rural Project Square Footage" mare he ,ub,tauied his Total Prnlcc( ('list '
ACKNOWLEDGMENT OF SURETY"
STATE OF SOUTH DAKOTA (Corporate Officer)
COUNTY OF MINNEHAHA ( ss
On this llth day of July_ 2008 , before me, the undersigned officer,
personally appeared Paul T. Brullat ___, who acknowledged himself to be the aforesaid
officer of WESTERN SURETY COMPANY, a corporation, and that he as such officer, being authorized so to do, executed
the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself as such
officer.
I lti'Iy kQS.WHEREOF,.I hpve hereunto set my hand and official seal.
` S. PETRIK `
i EAL NOTARY PUBLIC Fa3 i .
i�SOUTH DAKOTA�C i Wary Public—South Dakota
�r�h\tiY\tiYY♦tiYti4�♦Ytititi�\
My Commission Expires August 11,2010
ACKNOWLEDGMENT OF PRINCIPAL
(Individual or Partners)
STATE OF ss
COUNTY OF
On this day of ,before me personally appeared
f known to me to be the individual — described in and who executed the foregoing instrument and acknowledged to me
that_he— executed the same.
My.commission expires
— �auorsslwwoO gv6lo VW'OV3H3l9iiV1N
! �� '3NV"1 M31AHO8LIVH g I
3N1i`d1O 0 OIAVC
STATE OF i00 uoµaNle@?J a
COUNTY OF } ss 4 600Z!ZI6 .uope+ldx3
tl OLGOZ 01
On this day of I g96g1 S0 `88ueo!'1
..Ue'.nl IOSINednS uollonJlSUoD
who acknowledged himself/herself to be the —I spJapuets PU�uollel uc �Jo�soR
of ^ -
such officer being authorized so to do, executed the foregoing ins - r...rvnes therein contained by signing
the name of the corporation by himself/herself as such officer.
My commission expires
Notary Public
� i 4
E. S1lQ' V(''t769ki911�n
U a m 3NLIV'PJ Gat! 1
o a -059N[dii(id)d l
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S
as.
t CITY OF SALEM
PUBLIC PROPRERTY
,G DEPARTMENT
MA tg L'.: \C n,ul>:�;:,��i:!u r.l ♦ inl : �t. \I�.,�� !It .I I
Tr, : 9-8-'4;.);oi F ss: 97s.74.'t841,
\porkers' Compensation Insurance Af ida\'it: Builders/Contractors/Electricians/Plumbers
\ t )licant Information Please Print Legibly
\;1111t; t llu:mc„ t.• I .t s,.la,la: /Qi— �+��,y,U-�V ��ir�Cr ✓✓Y�'L{��� Y
\,I it's,,: �rCNTa�����f''i,,•��13/nn{�`f`� 6//Irr((�TiC/ I y / �j q
City. State;Zip: f'" 4412,6LC94E N-� 046 q 1'TrrPhone 4: ! 0 v3 1
Are sou an employer:' Check the appropriate box: Type of project (required):
I I all, a employer with a 1 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).' [lace hired the sub-contractors 7. (Q'Remodeling
_'.❑ I ;un a sole proprietor or partner- listed on the attached sheet. * K�L-.
,hip and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. workers' comp. insurance. y. ❑ Building addition
No workers' cum insurance 5. ❑ We are a corporation and its
1. P ❑
required.] officers have exercised their 10. Electrical repairs or additions
3.❑ 1 ant a homeowner doing all work g exemption tion right of per MGL I l E] Plumbing repairs or additions
myself [No workers' comp. c. 152, $1(4), and we have no 12.0 Roof repairs
insurance required.] f employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#I must also till 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 must submit anew affidavit indicating such.
$'onmmtors that<heck this box must attached an additional sheet showing the name oft he sub-contractors and their workers'comp.policy information.
/ant an employer that is providing workers'c•ontpen,sation insurance far my employees. Below is tire policy and job site
information. i
Insurance Company Name:.
Policy #or Self-ins. Lis #: / !��p���- Expiration Date:-
Job
��
(� i5� O 1 City/State/Zip:c� ,1 '�" 9-"t "f �'0
Jub Site Address:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
F;tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 antL'or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a fine
of up to S-150.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
hi,c,ri_:iiuns of the DI:\ for insurance cuccrage ccrification.
/da hereby(
' ! iJj• under the pains and penalties of perjury that the injorttation provided a ove/ys true and correct.
\'\��V\�� Der
i 111i.11 of �f/ �
Phone 4 "7 81 — 6,31 ,2.6 O -
Uflicial use only. Do not rrrite in this area, to he completed by city or town officiaL
_--
Issuing .\uihorily (circle one):
I. Board of Ifeallh 2. Building Department 3. City/I'ossn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other __-----____--
Contact Person:_——___--— _-------__— Phone
1
Information and Instructions
\Ias.arlwscus GencraI Laws chapter I5' rrgwres all cmnplo%ers it, pro%ide workers' compensation Iortheir cnmplo)ecs.
PUtsn.lm to this stanne, an enrplgree is datincd as -- every person in the service of another under :my contract of hire.
c vptcss or implied. oral or vv ri tie n."
An cnrplurer is defined as "an individual, parntcrshfp, association, corporation or other legal cnuty, or an) two or more
„f the fotcgoing engaged in a joint enterprise, and including the legal representatives of a deceased cutployer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employ ing employees. f lowever the
uvv mar of a dwelling house has ing nut more than three apartments and who resides therein, or the occupant of the
dwelling house of.mother who employs persons to do maintenance, construction or repair work on such dwelling house
01 011 the grounds or building appurtenant thereto shall,not because of such employ nwnt be deemed to he an employer."
\Il 1- chapter 152, s25C(h) 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 contmunsvealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, ` GL chapter 152, §25C(7) states •'Veulier the commonwealth nor any of its political subdivisions shall
enter into any contract for time performance Of public work until acceptable ev idence of compliance with the insurance
roquirenments of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) nanmeks), 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
nnennbers 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 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 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 till in the permiulicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pemmitilicense 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 burn leaves etc.)said person is NOT required to complete this affidavit.
fume ()tf ice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
plcaSc do not hesitate to give us a call.
I he Dcp:utrmncnt'S address. telephone and fax nunmbee
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
5-_b-U5 Fax # 617-727-7749
I(ev iced
www.mass.gov/dia
7 CITY OF SALEM
I,y PUBLIC: PROPRERTY
` DEPARTMENT
Construction Debris Disposal Affidavit
(reyuircd liar all demolition and renovation work)
In accordance \%itIi the sixth edition of the State Building Code, 780 CAIR section I I L5
Debris, and the provisions of.ti1GL c 40, S 54;
Building Permit rt is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I I L S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
AlMflfei d� mW(PJG-
(name of facility)
I,IJJresv u(pcililvl _ _
�ignaturc of pe nnrt .ytplirant
,I e
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(mM17/08
CSR MM
9ESSE01 07 17 08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
John J Walsh Ins Agency, Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P O Box 4407 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Salem MA 01970-6407
Phone: 978-745-3300 Fax:978-745-9557 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: GRANITE STATE
INSURER B: St. Paul Travelers
Essex Building CO. INSURER C'
C/O Mr. David Clarke
12a3 Pleasant St INSURER D:
Marblehead MA 01945
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.
LTR NSRI'D TYPE OF INSURANCE POLICY NUMBER DATIEYMEFFECTIV
W M E PDATE MMIDL ICY /EXPIRATION LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
IJAMAGEW
B X COMMERCIAL GENERAL LIABILITY 68085912653 05/13/08 05/13/09 PREMISES Fa occurence) $ 300000
CLAIMS MADE [X] OCCUR MED EXP(Any one person) $ 10000
PERSONAL B ADV INJURY $ 1000000
GENERAL AGGREGATE $ 2000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2000000
POLICYF_j PROT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person) 1-,
HIRED AUTOS BODILY INJURY' $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR E71CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND TORV LIMITS ER
EMPLOYERS'LIABILITY
'a' ANY PROPRIETOR/PARTNER/EXECUTIVE 4395466 08/24/07 08/24/08 E.L.EACH ACCIDENT $ 100000
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 100000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ SOOOOO
OTHER
Trailer $9000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
0001003 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Salem DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
Buidling Inspector NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Town Hall IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Washington St
Salem MA 01970 REPRESENTATIVES. - i•StiNC}M,INO'
AUTHORIZED REPRESEIaT"WWN
John J. Walsh n t
ACORD 25(2001/08) presiderg A ORD CORPORATION 1988
Certificate Number: B-18-489 Permit Number: B-18-489
Commonwealth of Massachusetts
City of Salem
This is to Certify that the .............................................................Multifamily 3+ Building.__._...._............ located at
Building Type
...........................................................................386 ESSEX STREET in the .....................................City of Salem
........ ..... ................................................................................................ .................................................
Address Town/City Name
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY
Unit 1
DAVID CLARKS, MGR
This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and
expires Not Applicable unless sooner suspended or revoked.
Expiration Date
Issued On: Thursday, January 17, 2019
Commonwealth of Massachusetts
Citv of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Permit No. B-18-489 TO BUILFEE PAID: $132.00
PERMIT
DATE ISSUED: 6/7/2018
This certifies that 386 ESSEX ST REALTY LLC CLARKE DAVID G TR
has permission to erect, alter, or demolish a building 386 ESSEX STREET Map/Lot: 250101-0
as follows: Other Building Permit UNIT#1:
INSTALL NEW KITCHEN CABINETS. INSTALL SHOWER IN PLACE OF TUB. '
Contractor Name: DAVID G. CLARKE
DBA: ESSEX BUILDING COMPANY LLC
Contractor License No: CS-015386
6/7/2018
Building Official Date
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request.
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same.
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
H I C#: "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.1 42A).
Restrictions:
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
i
Commonwealth ;f Ma:.scAc;husetts �
Citv of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Structure CITY OF SALEM BUILDING PE MIT
low
Excavation
PERMIT TO BE POSTED IN THE INDOW
Footing INSPECTION RECORD
Foundation
Framing
Mechanical
Insulation INSPECTION: BY DATE
Chimney/Smoke Chamber
i
Final
Il Plumbing/Gas
Rough:Plumbing
Rough:Gas
Final
Electrical
Service
Rough
ire Department
Preliminary
Final
Health Department
Preliminary
Final i
Certificate Number: B-18-669 Permit Number: B-18-669
Commonwealth of Massachusetts
City of Salem
This is to Certify that theMultifamily 3+ Building located at
Building Type
...........................................................................386 ESSEX STREET........................................................................... in the .....................................0 tv of Salem
.................................................
Address Town/City Name
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY
Unit 2
This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and
expires Not Applicable unless sooner suspended or revoked.
Expiration Date
Issued On: Thursday, January 17, 2019
Commonwealth of Massachusetts
City of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Permit No. B-18-669
FEE PAID: $160.00
PERMIT TO BUILD
DATE ISSUED: 7/9/2018
This certifies that 386 ESSEX ST REALTY LLC CLARKE DAVID G TR
has permission to erect, altos, or demolish a building 386.ESSEX STREET Map/Lot: 250101-0
as follows: Repair/Replace INSTALLC:-NEW ZABIN18T.8,8 01 0Ut t ' ; ktANGE TUB TO SHOWER
Contractor Name: DAVID G. CLARKE
DBA: ESSEX BUILDING COMPANY LLC
Contractor License No: CS-015386
7/9/2018
$uildi tfici0l Date
This permit shall be deemed abandoned and invalid unless the work autl�oiftOd idlis' iB'r"b Xx=HkAnt m**-months after issuance.The Building Official
may grant one or more extensions not to exceed six months eaoi�upwt.trt�gttet,.
All work authorized by this permit shall conform to the approved apCn and the approved constructit)ft'diltirtir} Iftlt4 lhis permit has been granted.
All construction,alterations and changes of use of any W"V and structures shall be in compliance with the kx ia�i**ty and codes.
This permit shall be displayed in a location clearly visible lrotn acsiss street or road and shall be maintained opert';Yo 491W n for the entire duration of the
work until the completion of the same. z 4
The Certificate of Occupancy will not be issued until aq•; )006"AlgraWres by the Building and Fire Officials ari,'**Wd t s ermlt.
HIC#: Persons iAbb '#Wyfund"(asset forth in MGL c.142A).
ry 1 M. i y 4
Restrictions:
'F L
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
OT Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Structure CITY OF SALEM BUILDING PERMIT
Excavation PERMIT TO BE POSTED IN THE WINDOW
Footing INSPECTION RECORD
Foundation
Framing
Mechanical P
H
Insulation INSPECTION: k «_ y ''s DATE
� �
' JFK
Chimney/Smoke Chamber
i�
4-:
Final
Plumbing/Gas q i Y
F
Rough:Plumbing
Rough:Gasp
�
Final ��,.
Electrical
Service`
Rough
�l `v1 f w
Final #
Fire Departments$
Preliminary
Final
F.'..
Health Department
Preliminary
Final
Certificate Number: B-18-669 Permit Number: B-18-669
Commonwealth of Massachusetts
City of Salem
This is to Certify that the Multifamily 3+ Building located at
.... .. ...............................................................
Building Type
...........................................................................386 ESSEX STREET........................................................................... in the .....................................City of Salem
.................................................
Address Town/City Name
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY
Unit 3
This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and
expires Not Applicable.............................. unless sooner suspended or revoked.
Expiration Date
Issued On: Thursday, January 17, 2019