203 ESSEX STREET - SIGN PERMIT (2) ��3 �s5oa `v�.
B� rem_.
f VIS
�e APPLICATION FOR PERMIT TO EREC
4 NOTE: BUILDING PERMIT MUST BE OBTAINED BEFORE SIGLocation, Ownership and Detail Must Be Correct, CompleG
PMF7JT/—/�
Date
To the Building Inspector:
The undersigned hereby applies for a permit to ❑ Erect, c Alter, ❑ Repair a sign on the following described buildings:
Street Address Zoning District
❑ Urban Renewal Area ❑ Entrance Corridor
cT A3 ss 77 T 77 777;
❑ Historic District ❑ None
•
� Use of Building
Telephone 1` floor
6
• Nd f 2 floor
Address CWN .f— S floor
Telephone .!j8- S_ 9- 5- 4 floor
E-mail C 6 I'll- How many businesses are in the building? 2
If a corporate body, name Frontage
of responsible officer
Awe Building O linear feet
Construction Sup's License No Applicant's Space(if multi-tenant) linear feet
Address Property D linear feet
Telephone . Mail Sign Permit to
E-mail -Sign Owner o Sign Erector c Other:
Sign 1 Sign 2 Sign 3
c Surface ❑Surface ❑ Surface
❑ Right Angle to Building ❑Right Angle to Building ❑ Right Angle to Building
❑ Free Standing ❑ Free Standing ❑Free Standing
❑Awning ❑Awning ❑Awning
❑ Portable(A-Frame) ❑Portable(A-Fra ❑Portable(A-Frame
t�Other(specify) ��', Other(specify)me) I gOther(specify)
Sign Materials ` N Sign Materials ; Sign Materials I
Sign Dimension If ft q Sign Dimensions It Sign D' en ions V r f
15 Iq 2 -zz ' 8f60
Sign Area Sign Area .Z ft Sign Area Z
A-Vo s t 7 sq It
Sign Height(i fee standing) Sign Height(if frees n ing) Sign Height(if free standing)
Estimated Cost of Net W k
Existing Signs
Type Sign Area To Be Removed? Sign Owner
❑Surface sq ft ❑yes ❑no -
❑ Right Angle to Building sq ft ❑yes ❑ no
❑ Free Standing sq It ❑yes ❑no Sign Owner's Au rorize�.{te resentative
❑Awning sq It c yes. ❑no Sf 7
❑ Other(specify) sq ft ❑yes ❑no
Property Owner
Internal Review
Planning&Community Development Department Historical Commission
Building Inspector
08124110 rev
1 � -
City of Safe ---- — — —
m Department Of lolannin
Check 9 �' Community Development
/Cash Receipt and Tracking Form
Please complete form --
and make two copies,
Date Received
Amount Received �l
Form of Payment
Check
Cash
eED Sign Permit Application Fee
El Conservation Commission Fee
Payment received for what
service? ❑ Planning Board Fee/ ZBA
❑ SRA/DRB Fee
❑ Copies
El Other:
Name Of staff person receiving
payment
Additional Notes
ji
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GORILLA -
47 CANAL STREET 53.179/113 M
SALEM,MA 01970 0256
(978)745-7755
P AYTOTH
DATE
ORDRR OF
�j Eastern Ban DOLLARS 8 =2
n10NIZm glOgp Q 999 �aE
II'000 256u' 1:0 i 130 17961: E'(30500
706R'
—213011—11aziza
original Check and Form: DPCD Finanre — — --
COPY 1: Cl ent
IcOPY 2: AOpI Carlon Fie
E)7/26/2011 08: 38 978-777-9804 JOHN J DOYLE INS PAGE 01/02
Safety Insurance BUSINESSOWNERS DECLARATIONS
AUTO . NOME • SU51NESS ... :. 'P+yRCy';Ferlod ._
P 50.fWrnbet
Safety Insurance Company From Ter s,
°blf7tCB15$oSF"',_ 05/24/2013 05/24/2012
17:01 A.M.51 od Time.1 cw dwd( eemiw
TfatSsactwAi::.i .
Ntatt .Bnaiaesa Daclarationa -
.......................
Named Insurad end Attatfin kdtlrtuta
S Agettt
THE HACK ROOM JOAN J DOYLE INS AGCY, INC.
203 $SSSS ST 85 CONSTITUTION LANE
SALES[ MA 01970 DANWRS MA 01923
Telephone: 978-777-6344 61917
Form of Business: OTHER Type of Business: MENS&BOYS CLOTHING COATS SUITS
DESCRIBED PREMISES
LOC BLDG ADDRESS AUTOMATIC INCREASE
Dal 203 ESSEX ST SALEM MA 01970 4%
riPROPERTY
LOC BLDG COVERAGE VALUATION DEDUCTIBLE LIMIT OF
INSURANCE
001 001 Personal Property Replacement Cost $ 500 < 30, 000
Deductible shown above applies per any one occurrence
BUSINESS INCOME: Actual Loss Sustained Not Exceeding 12 Consecutive Months
LIABILITY AND MEDICAL EXPENSES
Except for Fire Legal Liability. each paid claim for the coverages listed reduces the amount of insurance we provide
during the applicable annual period. Please refer to Paragraph D.4. of the Businessowners Liability Coverage Form.
BUSINESS LIABILITY COVERAGE LIMITS OF INSURANCE
Liability $ 1, 000,000 Per Occurrence
Medical Expenses $ io,eoo Per Person
Fire Legal Liability $ loo,coo Any one Fire/Explosion
ADDITIONAL COVERAGES
Some property coverages are subject to deductibles specified in the policy forms.
Optional Property Coverage Description Limits Of Insurance
LOC BLDG DESCRIBED COVERAGES
Optional Liability Coverage Description Limits of Insurance
CHANGE IN PREMIUM: $ TOTAL PREMIUM: S S80
BPDEC2011
AGENT
07/26/2011 08:38 978-777-9804 JOHN J DOYLE INS PAGE 02/02
+ � Safety Insurance BUSINESSOWNERS DECLARATIONS
AUTO . HOME - BUSINESS
Safety Insurance Company Policy Number F7OrPolicy Periodq�4
HM OOIS809 05/24/2011 05/rai2:o nrn s•. d•m.Nes Business Declaratlona
Ximnee 3risiiird:griil:JldatFn9 4diireas Age
THE BACK ROOM JOHN J DOYLE INSAGCY, INC.
203 ESSEx ST 85 CONSTITUTION LANE
SALEM MA Or979 . DANVSRS MA 01923
Telephone: 978-777-6344 61917
FORMS AND ENDORSEMENTS SCHEDULE
Coverage line Form Number Ed. Date Description
Businessowners aP0417 (01/96) Emp oyment Re ate Pract ces Exclusion
BusineSsowners BP0108 (03/98) Massachusetts Changes
Businessowners BP0439 (01/96) Abuse or, Molestation Exclusion
Businessowners BP0009 (01/97) BUsineSSOwners Common Policy Conditions
Businessowners SB0002 (11/99) Businesaowners Special Prop. COV. Form
Buaineasowners SB0006 (11/99) Businessowners Liability Coverage Form
Businessowners SBO518 (04/07) Asbestos or Other Respirable Dust Excl.
Businessowners IL0003 (04/98) Calculation of Premium
Businessowners SBO517 (04/07) Silica Or silica-Related Dust Excl .
Businessowners SPI004 (04/98) Excl of Certain COMputer-Related Losses
Businessowners SBOS42 (01/08) Excl of Pun. Damages Related to Terr.
Businessowners BP1005 (04/98) Excl-Year 2000 Computer Related Losses
Businessowners SBO514 (05/04) War Liability Exclusion
Bueinessowners SBOS76 (06/07) Limited Funqi, or Bacteria Cov. (Property)
Businessowners SBM001 (06/01) Equipment Breakdown Endorsement
Suainesrowners SBO577 (11/02) Fungi or Bacteria Exclusion
Busi.nessownere STN109 (01/08) NOt1Ce of Terrorism Insurance Coverage
Busi.neeSOwners RP0419 (06/89) Amend-Liquor Liab. Exclusion (Exception)
BUeinessowners SBO534 (11/02) Limited Exclusion of Acts of Terrorism
Premium has been waived for this coverage.
Countersigned By:
BPDEC2011
AGENT
�^�`�` �Q
(�' \
Isv " "
City Of Sal me De
partment of Planning & Community Develo
Check/Cash Receipt and Tracking Form Pment
Please complete form and make two co i
Date Received copes.
Amount Received Wil(
Form Of Payment C-b ^
Check
❑ Cash
Sign Permit Application Fee
❑ Conservation Commission Fee
PaYment received for what
service? C] Planning Board Fee/ ZBq
❑ SRA/DRB Fee
❑ Copies
Other:
Name of staff person receiving
PaYment
Additional Notes ' 'l
�v �S
lc
GORILLA - -- --
47 CANAL STREET 53.179/113 �v
SALEM, MA 01970 0256
(978)745-7755 n ,{
DATE / /plrJ//
pAYi07RE
ORDER OF
EcEastenrnBaDOLLARS 8 :
Yiwu .p a o+ws0y
LL
FOR
-- ADTH IZED SIG
000 25611• 1:0 i i 30 i 7981:
60 0 500 706u•
Original Check and form: DPCO Finance -- —
COPY 1: Client - - --
CopY 2: APPhcahon File
,
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08/31/2011 11:18 978-777-9604 JOHN J DOYLE It,16 PACE 01/01
ACS28D CERTIFICATE OF LIABILITY INSURA f ° t/31/Zoll
jut/31/Zoll
ABODuc (973)777-6344 FAX (976)777-9904 THIS CERTIFICATE ISU 0 AS A MATTER OF INFORMATION
)Oh;-, 3 Doyle Insurance DK ONLY AND CONFERS GHTS UPON THE CERTIFICATE
35 CDOsti tutioR Lane NDLDER.TMS C DOES NOT AMEND,EXTEND OR
Danvers, MA 01923 ALTERNE COVERAt I AqEOR13FI3 BY THE POLICIES BELOW.
INSURERS AFFORDING O GE NAIL f
Nam The Back Row ' S RA Safety Inso ,ifte 39454
203 Essex St INSURER B.
Salem, RA 0197D INSURERC
w9urmt O.
COWBMES
w9LTIER E
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED FAMED ABOVE FOR 'CY PERIOD INDICATED.NOTWITT15TANORNG
ANY FIEDUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTRER DOCUMIENT WITH RESPECT TO WI 4C THIS CERTIFICATE MAY SE t8SUEDUR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE S.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID QAIMS.
TYPE Di IRSURANCE POLICY1We9t POLNn EFiTAw(L XL
POl1CY EPmA LIIBTE
OCNa.L LMlILNT BNA001SR" 05/24/2011 05/24/20 OCLTMR u f 1.000,0
coweERCIAL DENERAL LNBILNY "M`OEroREN.2 f 100 00
cwMB wuE ❑OCGIR MED E P(Aro one pmwI f 10 OO
A ERSOWL1 AV,NJUNT f
NERAL AOOXEOATE S
GEHLACOFMOATEDNII A CSPO¢ VRODUCT9-CCMFAOF AGG f
PO ,per LOC
ADTDYOS EUILW I COMBINO)81NGLE LIMIT S
ANrwMTO I GEA rvjU�AS
KL OYIfED AUTOS BOOLY AIJURY
SrKOLIEDAUT09 (Pw PMrGI) S
NREc AL"08 90omr LwuRr
NMNarvr,EO MTDE IFer AaMNq f
PROD6RTY 04MAGE f
(Ax.cJenil
GARAGE UADILRT Avco DNLT-En AOGDENT f
° Y"� arNEnTNAN EA AGC L
AUTO ONLY; AOO S
=4=51UIBRMULI aRm EACHOORMRENCE f
OCCUR CLAIMS MME AUMI!UTE 3
L
DEDIN.'TIBLE I
RETENTION 5 f
WO OMRS COMFENSATIONANU MA:ETATL'-
aw a.T
BYPL049IS UABLT'
AIN FNOP,OErONTAWNERF-%ECU91E l.L FnCH AOaDENT f
OFyHN CERARE~EXCLUOFD7 EL OEEATE.EAE i
9PECML PROVISIONS Odvw E,�.016EAGE-F`OL,CY LAIR t
OT11pf
DESORPTION OF OPERATIOMc/LOG0.Tg1161 YfANClE91 ESCLU91DN4 ADDED EY ENDTRGENENTJ lPECNL PTIOYRIDNE
I
CERTIFICATE HOLDER CANCELLATION
I
SHOULD ANT OF THE Am01E POUOL38E CANCRJlD mcFORE
EIPIMTIOl1 O1.TE TNEREOY,rMHE D RERWUL AYORTOMAIL
urban Renewal Areas and Salem Redevelopment —DAYS WRITTEN WYn XTXE CERTfiGTE NOLR9l MAMED TONNE EFT, i
Authority and City Of Salem OVTFAILMEMWM&SOCN IINALL IMPOSE NO OBLIGATION OR UAGI.IrT
Washington Street OF urtmiiniagm AQT OR RBWR ATIMM
Salem, NA 01970 AOTNG SEIrtA
ACORD 25(MIJOB) FAX: (97)t)745-7750 WACORO CORPORA ON 198B
Z d 09LL917L8L6 6ugupd 811poo d8Z to LL L£ 6nV