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64 FORRESTER STREET - SIGN PERMIT (2) 64 Forrester Street St. Nicholas Church 64 FORRESTER STREET 71-11 `'IS�- 1039 COMMONWEALTH OF MASSACHUSETTS \1ep: 141 1slock: CITY OF SALEM I nc 0219-202 (''uIlgory: ]SIGN Pcl-mit::. 71-13 BUILDING PERMIT r'mjecl it .1S-2013000371 Irsl- Cost: �i$0.00 rec Charged: 50.00 Lialancc Duc: ':5.01 PERMISSION IS HEREBY GRANTED TO: Ado Const. class: - Contractor: License: Expirti I.ISC GIULip: lllldpc Si_,n l\'nrl.s Lot S,zc(,sq. 11.): 7600 %ening*: R2 Or: St. Nicholas Orthodox Chin rch Units Gained: Applicorzt: V ill;lae Sign works t(nits Lost: A T. 64 hORRL:S'CIR STRICT LN,,sire 11: IS'SI%ED OAt: -7-Inl-2012 AMENDED ON: EXPIRES ON: 27-Dec-If) TO PERFORM TIF_ FOLLOWING WORK: SIGN PliltNIIT AS APPROVED FORST NICIIOL.AS RUSSIAN ORTHODOX CHURCH jbh POST THIS CARD SO ITIS VISIBLE FROM THE STREET 1?lectric Gas PlRmhine Building I'nderground: Iin(Iel ground: Underground: Escacation: Scrvice: Meter Footings: Rangh: Rough: Rough: Foundation: Final: 1,mil: Final: Rough Frame: Fireplaa4(•hinmcy: D.P.W. Fire Health Insulation: \I eters Oil: Final: (Ions,li .Smokc: 71'casu ry: \Vater: ;warm: Assessor timer: Sprinkle, Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF .ANY OF ITS RITZ,S AND REGULATIONS. Signatur . �L ° s Fee Type: Receipt No: Date Paid: C,eck Amount: SIGN IIti'Ee 2(n^I-iRx13$gR,MUST 27-hil-12 s SO 00 — p NT IMPORTA :GINNER OR CONTRAj'I I`pr L ARRANGE POR PERIODIC INSPflCI`IYj'I L CONSTRUCTION. Sk.L CURRENT'dUlI, C,CHAPTER 7 FOR I_LST OF RL-Ot11AFbf1 „ CTI�OM17g. CALL 5�g-615-5647 TO SCHEDULE AN INSPECTION GenTA•ISIW 2012 Des L.auriers Municipal Solutions.Inc. City of Salem Sign Permit Application Worksheet 27-Jun-12 / St. Nicholas Orthodox church 64 Forrester St Zoning(res/non-res) R2 Entrance Corridor(Y/N) N Lot frontage 148 feet Building or tenant frontage 91 feet #of businesses on site 1 Bldng dist from street center 30 feet Multiplier n/a Building and Blade-Si ns maximum area permitted 0.00 sq ft total proposed sign area 0.00 sq ft sign 1 length 0.00 inches height 0.00 inches sign 2 length 0.00 inches height 0.00 inches sign 3 length 0.00 inches height 0.00 inches sign 4 length 0.00 inches height 0.00 inches sign 5 length 0.00 inches height 0.00 inches Freestanding Signs maximum area permitted 20.00 sq ft(per side) maximum#of signs permitted 1 signs maximum height permitted 0.00 ft tall sign 1 proposed sign area 14.22 sq ft length 45.25 inches height 45.25 inches proposed sign height 0.00 ft(approx) sign 2 proposed sign area 0.00 sq ft length 0.00 inches height 0.00 inches proposed sign height ft Application meets guidelines set forth in the Salem Sign Ordinance yes Recommend approval yes cp APPLICATION FOR PERMIT TO ERECT AWA1 rC q 9 /• ..Sl �I NOTE: BUILDING PERMIT MUST BE OBTAINED BEFORE SIGN Is ERECTED N U L012 Location, Ownership and Detail Must Be Correct, Complete, ander PLANNING i Salemam" E7 ill i Date To the Building Inspector. The undersigned hereby applies for a permit to 'Erect, o Alter, o Repair a sign on the following described buildings: Street Address Zoning District o Urban Renewal Area ❑Entrance Corridor �/r ,E. /L�­ C,/'') E#janc District D None Use of Building• Telephone t floor r • floor Address 3 floor Telephone 4 floor E-mail How many businesses are in the building? If a corporate body, name Frontage of responsible officer �I( r ,� Budding S? t•,t so J Fu /,.y, linear feet Construction Sup's License No Applicant s Space(if multi-tenant) N q linear feet Address il' , PhU ell i3e IProperty C�` linear feet Telephone 92S2iI -39�25 Mail Sign Permit to E-mail f,� ,� . j/,N is r r Sign Owner o Sign Erector o Other: signs are • _ ' Sign 1 threeposed Signs(If more than Sign 2 Sinn D Surface o Surface o Surface o Right Angle to Building ❑Ri t Angle to Building o Right Angle to Building �g g o Free Standing D Awning o Awnin o Awning o Portable(A-Frame) - �' o Portable -Frame) a Portable(A-Frame) Other(sp ify) f Ly i in �i Other Is ) f'�xr ❑Other(specify) 4. .,1 Sin Materials 5qn Mate"als Sign Materials I r ///Gn f t��fi, .i4CL % L vlitrnclrt Sign bimensions Sign Dimensiony Sign Dimensions EEsfimated X SI . 2S� J- 71 „ Sign Area Sign Area / � 1J ft 3. ft s ft e standing) ,7 f Sign ght(if free standing) Sign Height(if free standing) f Net Work —4 Signatures Existing Signs I Type Sign Area To Be Removed? Sign Owner D Surface sq it D yes D no C 1�11cr, D Right Angle to Building sq It D yes o no p,Free Standing sq It o yes D no Sign Owner's Authorized Repress tative D Awning sq ft p(yes o no D Other(specify) sq ft o yes o no Property Owner 'CZ e l,r 5 Ift 4-6 de K �., Internal Review Planning&Community Development Department Historical Commission Approval n Buildingftse0ector v oerzaro re. i�g`����`���� 4. • 'a� . . � . .;Y'T N�ARA1C�r Commonwealth of Massachusetts t�eialUsoOnly Department of Fire Services Permit No. �� BOARD OF FIRE PREVENTION REGULATIONS Ov- 11/99]upancy (1 ..e lankChed [Rev. 11/99] eave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All%wk to be performed in accordance with the Messachwats Electrical Code Qv=),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7U V6E 3 , 201-L City or Town of: SALaln mA To the Inspector of Wires: By this application the undersigned glues notice of his or her intention to perform the electrical work described below. Location(Street&Number) (o tf FLyQRE5T&2 67— Ow n e r 7'Owner or Tenant S7—. N[Cii/OG.4S ,pU55/f}N 00e;WgGt'IAl Ch'l//249V Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Woksm 110 Utility Authorization No. r Existing Service 2.OL Amps IZO / 240 Volts Overhead ❑ Undgrd❑ No.of Meters I }fir Lt Volts . Overhead IInd :i ❑ grd❑ Na of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: P.r✓PLf}t (t�Cr7�2tU2 SIGN `�E/)ldlltllCr + PLAC(&6- L46 frr(Otr 2 s[onl r— N Completion of the ollowin table m be xwived b rhe Ins actor o Wires. of Recessed Fixtures No.of CeiL-Susp.(Paddle)Fans a•o of Transformers KVA hof Lig"g Outlets No.of Hot Tubs Generators KVA i of Lighting Futures Swimming Pool ova ❑ - ❑ o. a mergency Lighting _ rod. d. Batte Units r "f ReWtacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones a If Swit�rc es No.of Gas Burners o.o etectaon an 0 InitiatingDevices jN04Rautes No.of Air Cond. Total No.of Alerting Devices Heat Pum umber Tons No.oSelf-Contained No. of Waste Disposers Totals Detection/Alerting Devices No.of Dishwashers Space/AreaHeating KW Local ❑ limclp.41. El Other Connictron No.of Dryers Heating Appliances , ecunty yystems: N(Mf:9evicesorE uivalent No.o afar o.o o.o Heaters KW Signs Ballasts Data Wiring: of Devices or Equivalent No..Hydromassage Bathtubs No.of Motors Total HP a ecommumcations anng: - No.of Devices or E uivalent OTHER: Mach addtnbnal deWl of desired,or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Z BOND ❑ OTHER ❑ (Specify:) Work. Jr °a (Expiation Date) Estimated Value of Electrical C— — (When required by municipal policy.) Work to Start &9$ ,p Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pairs and penalties ofpe�jury,that the information on this application is true and complete FIRM NAME: LUCFFS 6-6EG IC4C SEreIIIC&S /1 LIC.NO.:2057e-�,4 Licensee: C 19157aPht(5�Z G(fCAS Signature LIC.NO.: afapplicable, enter "exempt"in the license number ltne.) Address: Bus.Tel.No: 78/^ -�fQ1rJ OWNER'S INSURANCE AltTel.No.: ve WAIVER: I am aware that the Licensee does not hathe liability insuranc. e coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $bC.00 45.25 - - - - a Saint Nicholas Description : Single Sided Inground Post& Panel Ln Orthodox I ' ' 45.25"x 45.25"Sign Panel constructed of 1" Komacel (PVC) CV Painted with exterior Grade Latex Enamel, Lettering to be V Carved Gilded t O Saturday, Great Vespers 6:oo pm 23k Gold leaf with white drop shadow. d', Sunday , Divine Liturgy io:oo am Panel will attached to 2 -2"steel cross bars with Panel clips or Angle Iron A I)arish ot the Orthodox Church in America All Are Welcome Post are 44 Aluminum Alloy set in ground minimum depth 24 " -28" set Fr Theophan in 6-8" allowable concrete tube and concrete. i r 1 T Customer. St Nicholas Orthodox Church Job No.: 1333 Data, i Company: Order Date:4-13-12 Salesperson:Terry Brown Address:64 Forrester at Sign Dimensions: mate: Village Sign Works 4700 City:salem Stateop:me 01970 31 Turnpike RD Comment,: ." 1 Ipswich MA 01938 :::::.",�,}. ^^^fir�••••�^^^ Phone: 978-356-3256 Contact Terry Browrt .. .m,�. Fax: info@viUagesignworks.com 1! fi I fn 1 J � 1 1 Saint Nicholas Church `. .. Ali Ate%�,tlomC - - Fr fhcophxn Whitfield. Rector � It _-59 979.744.5669 � 1111,AtCAALl71i1®1111 - _ REV.TAE OVNII WHITE IEEO i ,I The Commonwealth of Massachusetts Print Form Department of Industrial Accidents 23 Office of Investigations s I Congress Street, Suite 100 Y Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Alpalicant Information Please Print Le¢ibly Business/Organization Name:; >'�G Address: City/State/Zip: ��54, ,�1, 1144f Clci j S Phone#: Are you an employer? Check the appropriate box: r6� ness Type(required): L❑ I am a employer with employees(full and/ Retail or part-time).* Restaurant/Bar/Eating Establishment 2!-1am a sole proprietor or partnership and have no Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. Non-profit [No workers' comp. insurance required] 1❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 1 of v�tanufacturing no employees.[No workers' comp.insurance required]* I 1 ❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees.[No workers' comp.insurance req.] I 12.❑Other *Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organisation should check box NI. I am as employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic.# Expiration Date: 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 hereb . y,un ains and penalties of perjury that the information provided abov9 is true and correct. Stan re Date. 1_ Phone# Oficial 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.Cityrrown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia AcoRo® CERTIFICATE OF LIABILITY INSURANCE 10DA/13/2011 THIS 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 policy(ies) 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 endorsements). PRODUCER CONTACT Sean Dooley Dooley Insurance Agency, Inc. PHONE (978)356-0581 FA% .(9]91 356-9609 12 Central Street ADDRE'aAll .scan@doole ins.com PO BOX 264 INSURER(S) AFFORDING COVERAGE NAICN Ipswich MA 01938 INSURERAMSA INSURANCE 39454 INSURED INSURER 9: VILLAGE SIGN WORKS INSURERC: 115 DEPOT RD INSURER D: 'SURER E BOXFORD MA 01921 INSURER F: COVERAGES CERTIFICATE NUMBER:CL11101331302 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. WTR TYPE OF INSURANCE D Ue POLICY NUMBERPOUCYYEFF POLICY YY LIMITS GENERAL WIBILITY EACH OCCURRENCE $ 1000000 COMMERCIAL GENERAL LIABILITY PREMISES Ea cum E 50000 A CLAIMS-MAGE �OGCUR 9071C 0/13/11 0/13/12 MED EXP( one n) $ 10000 PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMI AGO S 2000000 POLICY PRD LOC $ AUTOMOBILE LMBLDTY COMBINED SINGLE LIMIT Ea a .dent ANY AUTO BODILY INJURY(Pel person) $ ALL OWNED SCHEDULED INJURY BODILY INJVPer acd0enl AUTOS AUTOS l ) $ NO IAINEO PROPERTY DAMAGE HIRED AUTOS AUTOS $ E UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIM&MADE AGGREGATE E DED RETENTION is WORKERS COMPENSATION YAC STATU- OTH- AND EMPLOYERS'LIABILITY Y I NFR ANY PROPRIETORIPARTNERIEXECU-IIVE OFFICERIMEMBER EXCLUDED] � NIA E l EACH ACCIDENT $ (Mandawry in NH) E.L.DISEASE-EA EMPLOYE $ if Yes,dawi0e=OPERATIONS OF OPERATIONS lmb E .DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Atlach ACORD 101,Additional Remadls Schedule,It mon specs Is mpulnd) MAKING OF SIGNS, CERTIFICATE HOLDER AS ADDITIONAL INSURED i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Saint Nicholas Church 64 Forrester St AUTHORIZED REPRESENTATIVE Salem Ma 01970 I Jay Dooley/SDOOLE .. .- _ . - ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. POPbM 6d with DdfFactory triff vdfs?8fl www..b4fffnTOty e(5M-'--'- a"^." Planning & Community Development City of Salem Department of 9 Check/Cash Receipt and Tracking Form Please complete form and make two copies. Date Received :o 2 6 I Z Amount Received Gu Form of Payment VCheck ❑ Cash Client Information 5 7KnY�0 CASH PAYMENTS: client initials Sign Permit Application Fee Conservation Commission Fee ❑ Planning Board Fee / ZBA Payment received for what F� SRA/DRB Fee service? Copies Other: Name of staff person receiving Lis-, bmak payment Additional Notes E%PLANATION AMOUNT 426 26 ST. NICHOLAS RUSSIAN ORTHODOX CHURCH 64 FORRESTER STREET SALEM,MA01970 53-7116-211: PAY AMOUNT �,� p DOLLARS CHECK OF AMOUNT CHECK DATE TO THE ORDER OF OEBCRIPTION NUMBER People§nlI Band %L-----Bank oecple..coin °004266,1' 1: 21, 117LL621: 21 63225311' Original Check and Form: DPCD Finance Copy 1: C11"nt Copy 2: Application File Estimate #1333 4/13/2012 Prepared For: Prepared By: St Nicholas Orthodox Church Village Sign Works Rev Theophan Whitfield 31 Turnpike RD. Unit 2 64 Forrester St Ipswich, MA 01938 Salem, MA 01970 Phone: 978-7445869 Fax: Phone: 978-356-3256 Fax. Alt. Phone: Alt. Phone: 978-270-3642 E-Mail: fr.theophan.whitfield@gmail.com E-Mail: info@villagesignworks.com Description: 43 x 46 x1"Single Sided V Carved 23k Gold Leaf PVC sign panel,5x5 Wood Post&Caps, Sign Bracket, 2 removeable panels(Liturgy) Estimated time for production: 15 working days Quantity Description Each Total Taxable 1 43 x 46 x1"Single Sided V Carved 23k Gold Leaf PVC sign panel,5x5 2395.00 $2,395.00 Wood Post&Caps, Sign Bracket,2 removeable panels(Liturgy) 1 Install 195.00 $195.00 1 Second Addtlonal Sign 1916.00 $1,916.00 1 Install 195.00 $195.00 1 Spec Sheet Application 75.00 $75.00 Subtotal $4,776.00 Total $4,776.00 Terms: This estimate good for 30 days. 50%deposit due on signing, 50%due on delivery. By my signature,I authorize work to begin and agree to pay the above amount in full according to the terms on this agreement. Signed by Date Amt. Paid Today Page 1 of 2 ��GX\ Q(Xrf��k � �c.{ �orrtS�N � w� r �,�,,�� '�zy'G� oy� i � 5 v � a N c s - • _ r Description:Single Sided Inground Post&Panel 45-9-15 45,25"x 45.25'Sign Panel constructed of 1"Komacel(PVC) Painted with exterior Grade Latex Enamel,Lettering to be V Carved Gilded 23k Gold leaf with white drop shadow. Panel will attached to 2-2'steel cross bars with Panel clips or Angle Iron 1 Post are 4x4 Aluminum Alloy set in ground minimum depth 24"-28'set Lr In 6-8"allowable concrete tube and concrete. CINO'SSS-Unday, Building Sign will be panel clipped to exterior of wall using aluminum panel dip � ,Great VespersStainless steelscrews and L brackets for bottom support. d'I Divine Liturgy,o:oo am 45.25_ ► a � ti N Orthodox Saturday, Great Vespers 6:oo pm d- Sunday, Divine Liturgy,o:oo am A11.4re Welcome F1-;3,ophan Whitfield. Rector Qnbmr=ChulmOh Job M.:1333 Dat: h, Qdw Dat:41312 Sslaep m :Tsnyamwn Mtl_ SIen DMwnabns: EatlmatV1Rage Sig.Wrks 4700qty,aatm 31 T=pikc RDIpswich MA 01938Phone: 9M356-3256 Contact Terry Browny� infoQsilhg<siguworkccom ` "'^—�'••'��