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429 HIGHLAND AVENUE - SIGN PERMIT B-17-359 DUNK DON. sown DL City of Salem Sign Permit Application Worksheet 1-May-17 5F, Dunkin' Donuts 429 Highland Avenue r'I OR P 3: 10 1� Zoning (res/non-res) B2 Entrance Corridor(Y/N) Y (� Lot frontage 450 feet t Building frontage 43 feet #of businesses on site 1 Bldng dist from street center <100 feet Multiplier 1 1 Building and Blade Signs maximum area permitted 43.00 sq ft total proposed sign area 29.44 sq ft Surface Sign 18 sq. ft. length 36.00 inches height 72.00 inches 21"x 15"within the 18 sq. Cup only ft. Directional Signs 2.8594 sq. ft. length 13.50 inches height 30.50 inches Four(4)total directionals 11.438 sq. ft. Freestanding Signs maximum area permitted 32.50 sq ft (per side) maximum#of signs permitted 1 signs maximum height permitted 12.50 ft tall sign 1 proposed sign area 31.83 sq ft length 47.50 inches width 96.50 inches proposed sign height 15.00 ft sign 2 proposed sign area 0.00 sq ft length 0.00 inches height 0.00 inches proposed sign height 0.00 ft Application meets guidelines set forth in the Salem Sign Ordinance yes Recommend approval yes Surface sign will remain, with the exception of the cup logo which will be replaced with a new cup. Four directional signs will be refaced. The Freestanding sign will be refaced. Existing height exceeds maximum. Awnings will be wrapped with no signage. Permit Number APPLICATION FOR PERMIT TO ERECT A SIGN E C E I V E D TNOTE: BUILDING PERMIT MUST BE OBTAINED BEFORE SIGN IS ERECTED Location, Ownership and Detail Must Be Correct, Complete, and Legible it 1 s iT Salem, MassachugftT. OF PLANNING g To the Building Inspector: COMMUNITY DEVDatilPMENT i The undersigned hereby applies for a permit to u Erect, ❑Alter, ❑Repair a sign on the following described buildings: Street Address Zoning r2 2 ❑ Urban Renewal Area ntrance Corridor 4 CJ ❑ Historic District ❑None NAELLb � MKRUftjW Cm r--EM Use of uilding Telephone _ — 1• flcor. L, 7. — - tAR 014104 Jp L 4 2 floor Address _ 3 floor Telephone I_ebb_ 2� 4 floor E-mailIC Q, How many businesses are in the building? If a corporate body, nameFrontage of responsible officer Building linear feet Construction Sup's License No _ _ 1 Applicant's Space(if multi-tenant) linear feet Address t� t I� Properly 5 linear feet Telephone 1 Mail Sign Permit to E-mail LCQ0hghLLaLWGVUP8l _ ❑Sign Owner Sign Erector ❑Other: posed Signs(If more than three signs are proposed, attach additional sheets)' Si•n 1 Sign 2 S ign3 1 Surtace ❑Surface ace ❑ Right Angle to Building ❑ Right Angle to Buildinght Angle to Building ❑ Free Standing �ree Standing 'TJ rUF5L.E 5 e Standing bf7U gtTc S i OH'O ❑Awning ❑Awning ning ❑ Portable(A-Frame) ❑Portable(A-Frame) able(A-Frame) ❑other(specify) 2�2i81 ALS p ❑ other(specify) { {jt' Qt� er(specify) tc (Z Pt arc— Sign Materials Sign Materials aterialsIrePVC- q 10 42h ti aph 4 Sign Dimensions Zl 0yl„" Sign Dimensi ns i ensionsqb0 z ..w = �,' ��, 2.. Aj Sign Ardt Sign Area Sign Area S 31 s ft 3 sa s ft g 2.q SO.F s i sq it Sign Height(if free standing) Sign Height(if free standi g) ( Sign ei ht(if free standing) r Estimated Cost of Net Work $ I ' Existing Signs Type Sign Area To Be Removed? Sign Owner ❑Surface sq it ❑yes ❑no c ❑Right Angle to Building sq ft ❑yes ❑no ''��A r't :;En ❑Free Standing sq It ❑yes ❑no Sign Owners Authorized Representative bAwning sq ft ❑yes ❑no ❑ Other(specify) QE—W121FW sq ft ❑yes ❑no HO �l��Ls Property Owner S rz� AT-r l; Internal Review L= Plan ing&Community Development Department Historical Commission Approval Building Inspector OW4/10 w zl � ,.. Ld:aa cTez-Tz-al�w Landlord Authorization St4N OLA)N�Z ViewPolnt Date:---3115/17 SIGN ANn AWNIN4 35 Lyman Street To whom it may concern: Narlhboro, MA 01532 I 6 , 508 393.8200 508 393-A2A4 Fax Owner of the property located at _429 Highland Ave. (ounNit Donup) sign-OVlewPointS ig n.com w v.ViewPoint$ign.com _Salem, MA 01970 INTERIOR/EXTERIOR SIGNAGE Do hereby consent to allow Sean Donovan or Sandy Lupien of ViewPoint Sign and Electric Aranil«IarGl Awning to act on my behalf pertaining to permitting and installation of signs and or Dimensionol awnings for the property named above. Waylinding Channel LeHers LED/Neon Electronic Message Centers Sincerely, Digital Graphics AWNINGS Commercial Mcklif CanvasRcirwable Address SIGN SERVICE /� Telephone11c AU-bE,�7 U ARCHITECTURAL METAL FABRICATION Email • Con` VEHICLE GRAPHICS (Please tint carefully) MEMBERS Deeded name of property: Massachusetts Sign Assoc;wion V C 1 nw Rhode retard Slgn As ration hnernational Sign ASSMiGYlae Northeast Stoles Slgn Associaiwn North Eost Coro&Products ASSociobw I.ndwtrid FG6rics Associalian Inlemmionol uL LISTED FABRICATORS 6� IZ 21-11118• IHO (a41N timer) / — ,7 D®N�UT - - OO (On Bhcked•DD) _...� e•-A. rad f `. A, E®®'a - Iftl99 WON Elavatlort(Otr i)118388.5 Replarenlenl CW Icon - �4a�Ry -1—I s-%`�etr�r u 21-11/18•x l -a/B•-2a1 Ba.R. 6�® (C ty 1)Replacement PVC Cup Icon •Panted 3/4'PVC cup icon -_— — - •Weal high perfomyatr:e vinyl graphics •New Cup bon to replace existing an wall sign - No • ta:Existing well sign to be brought beck g - to shop to be repaintl ted/.turshed and �_ ' - reinstalled into previous bcedon with new �* �p g,+, • hardware as regWred DONUTS _ Logo/Icon: Fb Colors: •PVC Cap -Painted V file �j Phob Elovahon Views g}oposed s Existing) •Vinyl Graphics -W Orange HP.3M 220-14 -DO Magenta HP.Mon#M s 6rareeo DD S.H.P.3M 220-18 . ..— m,:--- •Frame -Periled BM Ng"Shade p2118-10 •Existing GrepMOrancs-Painted DD OrengaAS4 8c _ -PanteDD Magenta P PIc • Existing Border -Pantedd OD Orange PMSM65cBlH85c Installation: •By VrewPont Job: Accamf Manager: Dole: Revisions: Revisions: • G Iowr Appwd x0.h'l+ Aptaod Prod.aion Appwd L. k.ti Domds SemDonawn D3.17.V R.45 DLO -/ ViewPoint 1,508.393.8200 Location Fde: Designer: 429 FW4"Ave,Salem,MA DD idem 4lNfgNad ap ical k.pll Pete Rivera SIGNANDAWNING FAX 1.508.393.4244 2-112" -12'Cut Size VIF Flanges OF 4742" DUNDKH �# ODONU S Cut SeeDON wF CPS' :J: DRIVETNRU DRIVE THRU Bordw Ebvation(Qy 2)#83862 Replacement Pylon Feces DONM• Description: n (Qty:2)Replacement pylon faces. •Pan-formed polycarbonate faces •Embossed cloud graphics - • Second surface applied translucent virM graphics •Faces installed into wising pylon _ cabinet,Pylon repainted/mfuoished at trtne of installation Typeface/logo: _ •Art on#le :P - Colors •Vryl GMgliics-DD Orange trans 3M#3630-3123 -DD Magenta trans 3M#3630-1379 _____ -DD B.trans 3M#3630-$9 •Pylon -Painted BM K%N Shade 1121,6-10 InstaVation: �' _ •By Viewpoint Photo Elevation Views(Proposed&Fxistig) Job: Account Mmager: Dote: Ravisiom: Rerisions: G t.AW" Diaikiri Dow,s Sean Dorwvm os.v.n D.75 & ViewPoint 1.508.393.8200 Locatiom Z. Desgner. VIF 429 Hillard A.,Sden„MA D05dan 42%ig4oid pylon 6c%maR Pate Rivera SIGN SIGN ANO AWNING FAX 1.508.393.4244 30-10 CUt siZe-----� 3D-1n•Cut size----7 I--3o-1rz•at s:e F----3(I,112"Cut spa--I 13-1 P 2• 13.111 OC` 'in0ENTER, Flanges 'iz '0ENTER F'a"�8e iL � EXIT ' F�"�= �� ' e1 EXITFlanges s� 5� see Sim Bavation:IOtr 311183882 Elevation(olx 3)48388.2 �tIon:(Oty:1)1183882 Elevation:(Oty 11 Ma3862 Replapemmt Oimctional Faces Replacement Daasb ut Faces Replacement Directional Face Replacement Direclionel Face DirectionalEnter •nal H2 a*,Oir6ctio • ENTER' ENTER' 'ENTER '� EXIT 77 7— y ENTER' _t :yxTK+ ENTER' 'ENTER _ �yA f Photo Elmdon Yews(Pmpused 8 Existing) Description. Typeface/logo: colors: nsta3etlon Note: All Directionals Are Double Sided (Oty.8 Total)Pan-formed replacement faces. •Art on file VnYI G2plics -DD Orange bans 3M#3630-323 •By t/awf 1 •Pan-formed polycarbonate faces •Second surface applied trans vkrA -DDD&A'o�w"tlnm s 3M#3� 33� 6y fFaph,cs Cabinets 8 Posts-Painted BM Night Shade#2116-10 •Faces instated Into existing directional cabinets.directionels repainted/refurbished at Bme of Installation Job: Accounf Monger. Date: Revisions: Revisions: • • Gniaw AW.,.I ecr.Mugs/•mad hodxw�Anyo,ol DuriRin'Donh SemDorawn Q3pll D1.5 I VlewPoint eearian: Fe. D.dgne.. 1.508.393.8200 429 fig Aw.,Sdex,MA DD Sal.Mfglloddodandl.1.0 NisItivero SIGN AND AWNING FAX 1.508.393.4244 8'(96")� I M-(102") Description (OMOty.1)Gable style awning recover and (Oty..1)Shed style awning recover. • Existing aluminum tube frames •Recovered with Arlon FB Brown Solid fabric (gable)and Arlon FB Orange Solid fabric(shed) •Relamp IgM fixtures 32" Replace eggcraling L Reinstall awnings onto previous locations with new hardware as required 6,4.. 10" J Colors: (64") d 1, • Fabric-Arlon FB Solid Brown#SPDD-tl(gable) -Arlon FB Solid Orange#SPDD-10(shed) Elevation(Otyc 1)#8388.1 Shed Style Recover Location Drive lhru Side -Over Right Side Windows Installation: 24" • By Viewpoint Elevation:10M 71#8368.7 Gable Style Recover Locatlon Drive Thru Side-Over Order Window 5'(60")- F4- (64") '(60")5,_4" 32" L Gable Side View Shed Side View Photo Elevation Views(Proposed d Existing) lob: Account Manager: Dote: Revisions: Revisions: a `r Custaw Pprro�J Pcc�ry�„a„ .� Prodki Aawa nl Dunkin'Donuls Sean Donovan 03.17.17 D.75 VI@WPOI■ .rY Locotian: File. Designer: v G y 1.508.393.8200 429 F5gIlmd Asa.,S.6,MA M W.42%41ed di nxxa laps,IPata R^,>b , SIGN AND AWNING FAX 1.508.393.4244 �E•(102• soy -- ■on — �= ~ on 32 VII : -. 011 , son 19 Elevation:(Qty 21 k&?88.1 Shed Style Awning Recovers Locations:Front Fstmnce-Ovar left&Right Windows -- -- - - �99� ��J 7 I� ��a•e > AAS �■�' ' t�l� ��7�: � ■�� [ ' ,�" W. Sam COMP �ir��P�•.— REQ €4 6i� a�® ism 32' '— lor ME Skhi Mew R1Photo Elevation Mews(Proposed 8 Existing) `*` i�poeoraiatira "�� F Description: colors: (Oty.2)Shed style awning recovem. •Fabric-Arlon FB Sold Orange fISPDD-10 •Existing aluminum tube frames •Recovered Win Arlon FS Orange Installation: Sold fabric •By ViewPont •Relamp IigM fixtures _ •Replace eggcmtng - - - -- • Reinstall awnings onto previous locations with nen hardware as requlmtl lob: Account Manager. Date: Revisions: Revivons: Dunkin'Dorwts Sean Donown 03.17.0 D.5 v1eWPoint Custan:r Aaa:�d n.a na.raw:od sodrzme Annrod Location: File: De,igrer. 1.508.393.8200 429 Rgilond A.,Solent,MA DD Sdm:4Nt OW 61 a wsr kp Pete Rivers SIGN ANn AWNING FAX 1.508.393.4244 YA ViewPain� ApriC14, 2017 SIGN ANo AWNING DE7p7- 0- City of Salem OOMNtUIyITY DaVE,LOPrOENT 35 Lyman Street Planning and Community Development Northboro, MA O1532 120 Washington St. 3'"Floor 508 3938200 Salem, Na. 01,970 508 393-4244 Fax signs@ViewPointSign.com Re: Dunkin DonutS, 429 .'/-lighlandAve. www.ViewPointSign.com Hi Amanda, INTERIOR/EXTERIOR SIGNAGE Enclosedplease findthe application andassociated Electric Architecture] documents for alterations to existing signage at the above Dimensional location. Wayhroling Channel Letters I have encloseda check for the fee basedon the value of the LED/Neon Electronic Message Centers sign. I have provideda self addressedstampedenveCope for Digital Graphics the permit once it is issued. AWNINGS ?hank you very much for your help with this project. I Cook Commercial forwardto hearing from you. Bocklit Canvas Retractable Best Regards, SIGN SERVICE Lauren Cronin ARCHITECTURAL Permit .Manager METAL FABRICATION "Vietivpoint Sign andAwning VEHICLE GRAPHICS 35 Lyman St Northboro, Ma. 01532 MEMBERS 508-393-8200 x21 Massachusetts Sign Association LCronin@viewyointsign.com Rhode Island Sign Associalion International Sign Association Northeast Stales Sign Associotion North East Canvas Products Association Industrial Fabrics Associalion Internalional UL LISTED FABRICATORS City of Salem Department of Planning & Community Development p� CHECK RECEIPT AND TRACKING FORM DATE 2- C7� BOARD pLIJ STAFF AVV\ V✓ A G . CLIENT: ff } Gt l/�VI PROPERTY ADDRESS: CONTACT NUMBER: U PURPOSE FOR APPLICATION: CHECK # S ZZ AMOUNT RECEIVED: VIEWPOINT SIGN AND AWNING SOVEREIGN BANK NA 38229 35 LYMAN ST. DATE NORTHBORO, MA 01532 667269/2313 AMOUNT Apr 14, 2017 Memo: 429 Highland Ave. DunkinDonuts 38229 $ *******$49. 00 PAY Forty-Nine and 00/100 Dollars TO THE ORDER OF: Town of Salem AURA MS MA 11.038229,1' 1: 231372690: 7674322572u$ 4/6/2017 Unofficial Property Record Card Unofficial Property Record Card - Salem, MA General Property Data Parcel ID 03-0125-0 Account Number Prior Parcel ID — Property Owner BOSTON STREET REALTY, LLC Property Location 429 HIGHLAND AVENUE Property Use Restaur/Bar Mailing Address 80 BOSTON STREET Most Recent Sale Date 3/24/2006 Legal Reference 79414-037 City LYNN Grantor DRIVEL REALTY TRUST, Mailing State MA Zip 01904 Sale Price 1,050,000 ParcelZoning B2 Land Area 0.382 acres Current Property Assessment Card 1 Value Building Value 460,500 Xtra Features 17 600 Land Value 407,600 Total Value 885,700 Value Building Description Building Style Fast Food Foundation Type Slab Flooring Type Ceramic Tile #of Living Units i Frame Type Wood Basement Floor N/A Year Built 2006 Roof Structure Gable Heating Type Forced H/Air Building Grade Superior Roof Cover Asphalt Shgl Heating Fuel Gas Building Condition Good Siding Clapboard Air Conditioning 100 Finished Area(SF)1753 Interior Walls Drywall If of Bsmt Garages 0 Number Rooms 0 #of Bedrooms 0 #of Full Baths 0 #of 314 Baths 0 #of 112 Baths 2 If of Other Fixtures 0 Legal Description Narrative Description of Property This property contains 0.382 acres of land mainly classified as Restaur/Bar with a(n)Fast Food style building,bullt about 2006 , having Clapboard exterior and Asphalt Shgl roof cover,with 1 unit(s), 0 room(s), 0 bedroom(s),0 bath(s), 2 half bath(s). Property Images Disclaimer:This information is believed to be correct but is subject to change and is not warranteed. http://salem.patriotproperties.com/RecordCard.asp 1/1 Massachusetts Department of Public Safety Board of Building Regulations and Standards LicenseCS-076718 _ Construction Supervisor c F .O. DAVID J RANDA 8 CIDER HILL LANE SHERBORN MA 01770 Expiration Commissioner 03/15/2018 Construction Supervisor Restricted to: Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit: WWW.MASS.GOVtDPS ACO CERTIFICATE OF LIABILITY INSURANCE DA9/7/20166 DDIY � 9/7/ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject 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). PRODUCER CONTACT NOME: Elizabeth Bortone FM Walley Insurance Agency Inc plc6 0 E_ , (781)326-8383 ac No. pe1>326-e3e7 475 High Street ADDRESS:ebortone(Iwalleyinsurance.com P. O. Box 469 INSURER(II)AFFORDING COVERAGE NAIC S j Dedham MA 02026 INSURERA:Travelers Indemnit Co of CT 25682 INSURED INSURERB.Charter Oak Fire Insurance Co 25615 Expansion Opportunities Inc WSURERC.The American Insurance Co an 21857 DBA ViewPoint Sign & Awning INSURERD:Travelers Casualty & Suret Co 19038 35 Lyman Street, Suite 1 INSURERE: Northborough MIA 01532 INSURERF: COVERAGES CERTIFICATE NUMBER?016 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Ili TYPE OF INSURANCE POLICY NUMBER MM%DDY EFF MMIICODm Y LIMITS X 'COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMSNADE OCCUR �. PREMISES aoavnenre E 100,000 630-56090939 9/14/2016 9/14/2017 MED EXP(Any one person) $ 5,000 PERS014AL 3 ADV IN,URY $ 1,000,000 GENT AGGREGATE LUIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY E PPOO ECT LOC PRODUCTS-CJMP/OP ACG $ 2,000,000 OTHER E AUTOMOBILE LIABILITY Eaealaerv' L S 1,000,000 B X ANY.AUTO BODILY INA)RY(Fe ,Penson) $ ALLOYddED SAUTOSCHEDULED BA-0123T720-16 9 14/2016 9/14/2017 BODILY WJORY Per accbenli f AUTOS SCHEO / I PX HIREDAUTOS X AUTOS FFeiTacntlentDAMAGE $ UMBRELLA LIARX OCCUR EACH OCCURRENCE $ 5,000,000 C X EXCESS UAB CLAIMS-MACE >GSREGATE $ 5 000 000 DEC I I RETENTION SSB 00015244213 9/14/2016 9/14/2017 $ WORKERS COMPENSATON ER 'R'H- ANDEMPLOYERS'UA81UTY YIN X STATUTE ER AM'PROPRIETOR?N2TNEREXIECUTYE E L.EACH ACCIDENT OP:ICERIMEMBER EXCLUDED NIA $ 1 000,000 D (MandatorySw NN) us-9A699605-16 9/19/2016 9/14/2017 EL DISEASE-EA EMPLOYE E 1 000 000 Il ya5011w under DESCRIPTION OFOFERATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000 OESCRPMON OF OPERATIONS LOCATIONS 1 VEHICLES (ACORD 101,AddlOanal Remark.Schedu)e.may ba anached If more space Is requinr0 CERTIFICATE HOLDER CANCELLATION (508)393-4244 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Expansion Opportunities, Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN DBA Viewpoint Sign & Awning ACCORDANCE WITH THE POLICY PROVISIONS. 35 Lyman Street, Suite 1 NOrthboro, M 01532 AUTHORIZED REPRESENTATIVE Frank Walley III/BETH 04 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025('014ni) \ The Connnonivealth ofMassachitsetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 ivivw.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED 13'ITH T11E PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organizationnndividual): Expansion Opportunities dba ViewPoint Sign and Awning Address: 35 Lyman Street City/State/Zip:Northborough, MA 01532 phone #:508.393.8200 Are you an employer?Check the appropriate box: Type of pr71n I am a employer 48 employees(full and/or part-time) 7. ❑New 2❑1 am a sole proprietor or partnership and have no employees working for me in $, Remodeling any capacity [No workers'comp insurance required.: ❑ 3E]I am a homeowner doing all work.myself [No workers comp insurance required 11 9• ❑Dem 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property I will 10 ❑ Buildensure that all hn o emploeither have workers'compensation insurance or are sole I L❑Electrcal repairs or additions proprietors with no employees 5 f7I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp insurance.: 13.❑Roof repairs G❑We are a corporation and its officers have exercised their rieht of exemption per MGL c 14.E]Other 152,§1(d),and we have no employees [No workers'comp insurance required.J Any applicant that checks box lift must also fill out the section below showing their workers'compensation policy information r Homeowners who submit this a(tidavit indicating thev are.doing all work and then hire outside contractors must submit a newv affidavit indicating sell :Contractors that check this box must attached an additional sheet showing the name of the sub-contmcturs and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp policy number. I ma an employer 1/1111 is providing workers'compensation insurance for my enrplgpees. Below is the policy«ort job site information. Insurance Company Name:Travelers Casualty & Surety Co NAIC#19038 Policy#or Self-ins. Lic. „: UB-4A698605-16 Expiration Date:09-14-2017 Job Site Address: U�Q City/State/Zip: Qf EM. fre--D10110 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.0o 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify tinder the pains and penalties ofperlttry that the it formation provided above is trite and correct. Signature: Date Phone#:508-393-8200 Official rise 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 i, Plumbing inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Sj 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-17.359 FEE PAID: $0.00 PERMIT TO BUIL D DATE ISSUED 5/4/2017 This certifies that BOSTON STREET REALTY, LLC has permission to erect, alter, or demolish a building 429 HIGHLAND AVENUE Map/Lot: 30125.0 as follows Signs SIGN PERMIT AS APPROVED FOR: DUNKIN DONUTS Contractor Name: DAVID RANDA DBA: VIEWPOINT SIGN & AWNING Contractor License No: CS-076718 5/4/2017 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 stnictures 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 appibable signatures by the Building and Fire Ofhcials.are provided on this permit. f H IC#: 'persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A). Restrictions: i Building plans are to be available on site. i7 All Permit Cards are the property of the PROPERTY OWNER. to