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BUILDING JACKET J ro fws+s�aswlr� AfM110NlO aY� CITY OF SALEM No Dom w.d amYq omm In AWN Unow a .MMUlmbem"? YM No Is P"Pb Ulaw In : a.oa�ra.an Awa1 . Y64.m '! 11111111IMq APPUCAIM Palk - Pe1Rlk t0: (Circle whldwm apply Rods POW Infer .btk Sheds POK pApaldftp & ailler: rr� I lennn PUTAW P1L OYr INGWY•OONP. OF BY TO AV=DM AV*M PQ 11110111 TO THE INSPECTOR OF BU LDO ' The undwaiWod hereby epos for a pen* to build a000rditlo d»,followlrq s / 'Orw� am s Ne ofdas OncLL's N�c k�o-1 � Iai3 c� man s o� � 0 60 s �Addnes t Phone 5 S�len1 I la Arol�Ot's Norm / A '�O bi970 Address a Phan Modw ft Nnne 5 n( . 6j J I rJe o n/i( ' is -EnC - Address a Phan Nois.rpmp maNNW nlprnLne Ln , 0 -L'ar mam d-weary (A b�)d r a ' - j brnow.r"0m!rrwt—A) Iq wrabAdit / J09 M Sacwn of AppYonrt o�u�io■I��s MNALTY, ap PoipN11r OF Vxm TO N am P , r 5Us d�d ` 'n illc-"J k I ux +x I nq vice s. Lnc MAILPEWTT� �/,wCX_��,,-hlie 9' k _ I )�',VP _ � � � � . _ _ "'_ � . ,_:S �:�:�r�. a �.n° ,,s�:.,s;.,b.,,Y: � �. . . .. �� � ,r:: � � 4g .°a � ���� �• �'�:�'i �,��',.. e. � ��,. - � .. ... i P� �. ��. PUBLIC PROPERTY DEPARTMENT 120 V"HINeTON VMKST� aRD PL 0CM SIALON MA 01 sn0 TEL(278)7411-44595 WIT.aeo FAX (!741) 740-9e" STANL EY�YW/OVLCZ;JR; — - --- -- -- -- ON DWOM OF DEBRIS AFFIDAVIT In acmdamoe wins the ploviaicmr of UM c 40.M I aclmowlWp fat n a COOMM of Bml&g Permit d .all debris reed tisB from the oomgmcpon acbvity pvazW by this Bns7 'daps Pe®it Ad be disposed of is a peoPerly Hceased soH&waste disposal facility,se dellmed by MM c IM.Si-M. The debris wm be disposed of et -L3 1- Cn R S a 1p rn,= Iacsfam of Fac ft S1gDatlEe of Pit Applkaat OU ASB PRWr CLBA Y) mfa�oa.. Pt)L I J, Aa-h i Name ofPcomit Applicmt Fitm Flame,if Now 4 EX PCi,(4,N/r, A -Addmak City dt Stage - - -- Ilse above statute mpures that debris liom the de molitia% nmovadM rehab or other sherstim�'as odefi byby U cBL S the butid W pcnw arlicensessroto iLdl m 60 locatia m of the Scai y. jaaealCgoa.+ /7faa�fer�osl/, ee...e• . workers' Comyetnss$eiii Iltmretfa Allidntk . . wbti� torledrl iLw s/bolleuis eta / ((// , MoQ k de haabyardy uedstr In pa w and Pimium d Perlsya dM 1 ate an anPwrw Phi wsrkeas' emwow dee cowPis for my si"161 aes wakbe w dtk !tk In �7 lauaaasate . am a aek proprko f and haw " ens werkkti Or me M MIF oiseb- p 1 am a mk ProPAeaara teneral cemraear or Itoraaem+tw (cards ) sett bowkbrsd do ' cemraeaM ILred bckwr who•httw rhti fopewirt� workers' pettoanstntkre Pw�dasf Getwssaw Irtasratate Cmt��ry/► Comrsaw Intttratace Com"willeft Numbeir Conaaaar Isrurancs Conway/ Nttabw () 1 ant a homeowner Psrtorrnint all the aerk my"N' t•nawujow sago a goN of di auawago on as tor►w"d NO as 01fgo a b.aiaaaaaa.f or M M ae.waw, aai I.foOt n a man esu w 4~ p go rasaar aaea fraw 2fA d Mt:t t f 2 aaa MN r aar inaaaia at eaai�a aa.dgo Yvan'boor ,go a 70 a dal aaaaMte w r. tsrr eta STOP WORK ORDER aft to ed f t00.00 a M cadet sat. sin Is • Sf dry of b bl.°�, ADD ������ :iccrscerFcnnnue 6ujj�a eparsn. ant ucenfinj foare Sekeunenr Office - -.?: - - -.cc�r ••e � : SQ4 4Qc spe •r7c OCT-04-2004 12:05 P.02 dull Icrgih w,rdow .._ _. Y I I 1 d I 101 N 1 I - i 1 L � 6 23 ' I ne in" I TOTAL P.02 BOARD OF BUILDING REGULATIONS ~ License: CONSTRUCTION SUPERVISOR Number: CS 068596 sikfidatei 06/21/1957 Expires: 06/21/2006 Tr, no: 28316 Res icted: 00 ROBERTJ KAHL 47 GAY ST N CFIELMSFORD, MA 01863ssioner 15 l? The Commonwealth of Massachusetts r Department of Public Safety Ulf i Massachusetts State Building Code(78051101 Building Permit Application for any Building other than yOn7for Two-Family D ellin (This Section For Official Use Only) Building Permit Number: Date Applied: Buildin O SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for •ch a st ress i of available) 2 %fig GA-N 770 No.and Street City/Town Zip Code Name o Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ I Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peg/p/Pview required? Y s ❑ No ❑ Brief Description of Proposed Work: w+/r+v PA_1 .`d n SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ F B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 - R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB D IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB la' SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Debris Removal:it h Pe rmit:erm : Water Supply: Flood Zone Information: Sewage Disposal: Trench Disposal Site❑ Public 0l Check if outside Flood Zone❑ Indicate municipal - A trench will not be Y Private❑ or indentify Zone: or on site system❑ required❑or french or specify: I- permit is enclosed❑ fv'/i_ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: - - SECTION 9: PROPERTY OWNER ALITHO IZATION f Property Owner 'H Name and Address o � f P tl' G' t- P ��wl S t (11 n /9y Name(Print) N9.and Street City/Town P &� 27 Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip. to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name sjt&-- -7Yr97S� Name of Person Responsible for Construction License No. and Type if Applicable Street.Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION.INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes UF'No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ �•r' Enclose check payable to 6.Total Cost $ C , 7 7 V,,J (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and A ccurate to the best of my knowledge and understanding. Please print,print and sign name Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot# for locations for which a street address is not available) No. and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No 3"', Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No 2' Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) i CITY OF Smarr, NAALSSACHUSETTS BUILDING DEP iRnilINT 3 120 WASHLNrTON STREET,3'FLOOR b Tm (978)745-9595 Rxx(978) 740-9846 ��tgFRf FY DRISCOLL THozius ST.PIERRI3 -MAYOR DIRECTOR OF Pl;BLICPROPERTY/BI:ILDCJG COMMISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers 4pnlicant Information / Please Print Legibly Name(Busiiws&orga[nizzatiorvindividual):�` i /r4 ✓� 12L.i/y/Q� V_ Address: City/State/Zip: Phone N: Are you an employer?Check th"propriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and! 6. El New construction employees(full and/or part-time).' have hind the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. 0l(cutiodeling ship and have no employees These subcontractors have S. 0 Demolition working_for me in any capacity. workers'comp.insurance. 9, ❑Building addition [No worker'comp. insurance S. ❑ We area corporation and its. required) officer have exercised their - 10.❑Electrical repairs or additions 3.❑ tam a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself.[No workers'camp. c. 152,41(4),and we have no 12.0 Roof repair insurance required.)t employees.[No workers' 13.❑Other, comp.insurance required.). Any applicatd that chocks box x l meat also fill out the seciloe below showing their workers'compensation policy miurmatiom I Ltmeownen who submit this affidavit indicating They am doing all work and then hire outside contmctms must submit new,aMdavit indicting rush. :Cuntrostora that cheek this box meet aouhad an additional sheet showing the name of the subiumramni and thahr workers.•comp.policy information. 1 um an employer that is providing worker'compatsadon insurance for my employees: Below Is dre policy and fah site information. Insurance Company Name, Policy N or Self-ins.Lic.N: Expiration Date: ` Job Silt:Address: /YZ c an... � City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 ofthe DIA for insurance coverage verification. I do hereby cerNj run r the p Ins ud pentrides of perjury that the hiforataBon provided above is use and correct it lure: Date; Z�^l P o A; D OJJtch d use only. Do not write in Mix area,to be completed by city or fown oJjleful City ar'rown: Permit/License H Issuing Aulhority(circle one): 1. Bourd of llcalth 2. Building Department J.Cityffown Clerk 4. Electrical btspcctor 5. Plumbing Inspector 6.Other Contact Person: Phanehl: l CITY OF S,UZNf, jbL1ss:kCHUSETTS ©w,yf.{ 120 Vf'-"HvGTGV STREET, 3'�Ft colt v . � T'F-L. (979) 7 5-9595 < .%1JF, L.HY 0213COLL FQ't(979) 7.14- M 6NILAY01 MOAU Sr.PIERM DIRECTOR OF pCoL1C pROPEQTY/svMnLYG COSLN(I5s10.YER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the si-edt edition of the State Building Code, 790 C, ( Debris, and the provisions Of MOL e 40, 3 54; R section l l I.S ©wilding permit hi 1 is issued with the condition that the debris resulting from l 1i, SISQA.1 work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL e The debris will be transported by: .r. (nama uChautcr) The debris will be disposed ot'in : 9-- —_ (name at t�aility) (nhlress or'tacili�j ;ituatt,rr nfpermit applicant Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections) - 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investi ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) "Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant)//-- n Telephone No.- e-mail address Registration Number 4/_ 57 SyhtiS Ro F,��IQ.✓. r oA.7Y.c7 Discipline Expiration Street Address City/Town State Zip Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Discipline Expiration Dat Street Address City/Town State Zi e � � a s7r f q., BUILDINGTO 9 Please be ♦ 1 i1 .t '.y �t 4.{ er of record hereby approval fiv the { {wins {11 •t tial to make appfication for a Wilding permit at the below named prenlises. Ribeiro, Address of Project- Canal SL { 70 Signawre of / .t it r '�'. m>fe8oaa�aas— uEaau¢�nrt aoff @°aaflollu4 Saa6"a�a Buouduaag Regoo0mammao_s aaad Sama ar& 4 Constructioo Supe isor License • : &5 7IM . Er9kankm MOM a�moaea,m�c' uv'T: 20M " s 2G The Commonwealth of Massachliseff ED Department of Public Seflei�PECTIGNA S�ZdiCES Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than PTV%a-FAtr*11,belling w (this Section For Official Use Only) Q Building Permit Number: Date Applied: - Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) , fn l 3E3 Cry" STr s>ati KlLlj u-� V f No.and Street City/Town Zip Code Name of Building(if applicable) _ •-SECTION 2 PROPOSED WORK. - 125 1 ' ry(I�J Edition of MA State de used If w Construction check here❑or check all that apply in the two rows below w Existing Building& Repair Alteration 9 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes V No ❑ Is an Independent Structural Engineeringg Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: C,^ S t weds 2 .9 o-s SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR .. " ".CHANGE IN USE OR OCCUPANCY = Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): .� SECTION 4:BUILDING HEIGFIT AND AREA, - Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F. Fact F-1❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I_4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: + - - SECTION 6.CONSTRUCTION TYPE(Check as applicable) IA ❑ 111 ❑ HA ❑ IIB ❑ HIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: - Private❑ or indentify Zone:-- --- or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ .SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: aOe -IS(— s8q - r390 3 Se.Qz� of:;; SECTION 9: PROPERTY OWNER .. ._ _. Name and Address of Pro erty Owner 6277 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: �1 ge 30S Title Telephone No.(business) Telephone No. (cell) e-m address GD'w If applicable,the property owner hereby authorizes Nam Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this building Penn it application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skipSection 10.1 10.1 Registered Professional Responsible for Construction Control - 11 '" Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 102 General Contractor A'% I iP S V&1- NACCAA I'D Company Name PIANt l , v S LJe/^ AJ+CCN% tt, G S 07a S'13 Name of Person'Responsible for Construction License No. and Type if Applicable / 7 of fi n -5�'- �c�U�'2� 0l-1 S' f Street Address Gty/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.C.152§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents most be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the'gauance of the building permit. Is a signed Affidavit submitted with this application? Yes V No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ ''> Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ Ooo 'ov appropriate municipal factor)_$ 3.Plumbing $ D 4.Mechanical (HVAC) $ D Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ �- (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of owledge and understanding. to 19 h, �� u 6f.0Vte Please t and sign name Title Telephone No. /7 p /i fir, St Street Address • City/Town State Zip Municipal InspeMor to fill out this section upon application approval: "R>vf Name Date L _ ue omuixom<oea o �¢a�uweCld �\ Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistrabon: fjExpiratlow. 129273 TYPe-8/3r2017_ Individual Philip J Vemacchio II11 -�-3-' 3 Philip Vernacchio •` `_,r3:, 17 Clifton St. Revere,MA 02151 `-' .__ Undersecretary �. Massachusetts -Department of Public Safet i .Board of Building Regulations and Standards`.&, Gonstrucfion Supervisor, i r License: CS-072573 .. PEMAJP J VERN�Co �. 17 CLiFf )N ST { Revere M) 0215E J. J iyyr t Expiration t Commissioner 04/27/2016 t CITY OF S.-1I. "NI, XWSACHUSETTS B1:ILDLNG DEPART\1E.NT • 120 WASHINGTON STREET,3'e FLOOR \ TEL. (978) 745-9595 FAX(978) 740-9846 KnIIBFRLEY DRISCOLL MAYOR 'IZ•[ObtAS ST.PfERR6 DtREC[OR OF PUBLIC PROPERTY/BUELDLNG CONMUSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 11 �— , J Please Print Legjbly Name(Busita'ssOrganization/Individual): ?�t 1 IQ 1 vLn n Address: / -2 G City/State/Zip: Phone #: 7 8 Are you an employer?Check the appropriate box: Type of project(required): I.❑ 1 am a employer with-_ 4. ❑ 1 am a general contractor and 1 6. ❑ w construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet ?• Remodeling ship and have no employees These sub-contractors have S. ❑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.❑ 1 am a homeowner doing all work right of exemption per MGL t L❑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' 13 ❑Other comp. insurance required.] •Any applicants that chucks box NI most also fill out the section below showing their work,,,'compensation policy intomtadoa. t I Inmeowoers who submit this affidavit indicting they are doing all work and then him amside emano es mast submit a new affidavit indicating such :Commcton that check this box must attached an additional sheet showing the name of the sub-comractors and their workers'comp,policy infommties. I am an employer that is providing workers'compensadon Ltsurance for my employees. Below is the policy and fob site injormmion. / / Insurance Company Name: /'''^rt t s 1a S e /C' /Uu�Gurta 1� r Policy#or Self-ins.Lic.H: S n .� I�. /02V Cl 6 f O Expiration Date: /'l /i Job Site Address:X City/State/Zip: _,N 4?. .-L. 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 MOL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations ofthe DIA for insurance coverage verification. /da ir=ertify ins andpenalties ofperfury that the information provided above is true and correct SietDate•. v a Phone#: 7 Y3 / 3 S /(� OBicial use only. Do not write in this area,to he completed by city or town officiaL City or Town: PermittLicense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.CityfTown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: JUN/10/2015/WED 04: 56 PM- _ FAX No. _ __ __ P. 001 - - - ® 11 nr� DATB(MWDDWWl '�L-� CERTIFII'oA�E OF LIABILITY INSURANCE 6/10/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIF BELOW-CTHISATE DOES CERTIF CERTIFICATE AFFIRMATIVELY OFNSURAN ERDOESANOT CONSTITUTE EXTEND A CONTRACT BETWEEN COVERAGE AFFORDED THE ISSUINGINSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the POIICy(les)must be andorsscL 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 NAME. T Mary Ann Schraffa Jahn � I iggid Inguran Ge Agency PHONE (617)646-®600 AC Nu_(617)946-8928 399 Winthrop Street E'oaey,7mh2@biggioinaurance.com Winthrop, MA 02152 INSURERS AFFORDING COVERAGE NAIC 1) INSURER w:Flarl swill® Insurance Com an INSURED INSURER SNorGUARD Insurance COIR an Philip T VexnacchiO, III INSURER C: 17 Clifton Street INSURER D: Revere, MA 02151 INSURER B: INSURER F I COVERAGES CERTIFICATE NUMBER•CLI4490OB26 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, POLICY EFF PGLHJYEXP LIMITS �NpR TYPEOPINSURANCE POLICYNUMBER GENERAL UASILIri EACHOC%RRENCE $ 1,0001000 X COMMERCIAL GENERAL LIABILTY PREMISES iE4 22-En'nc.1 1-00,000 A CLAIMS-MADE F7xOCCUR SIPE 50861L L2/15/201012/15/2015 MED EXP An one n $ _51001) PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREOATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO S Z,000,DOD POLICY41 X PRO- LOG $ JgCTCOMBINED IN LE LIMIT AUTOMOBILE LIABILITY E ldmt) BODILY INJURY(Per Person) S 100,000 A ANY AUTO ALL OWNED SCHEDULED A00000074479T 06/18/20150611812016 BODILY INJURY(per saddens) $ 300,000 X AUTOS AUTOS PR PER DAMA X H X NON- IRED AUTOS OWNED Peramdmr $ 100 000 AUTOS S UMBRELLA LIAR L OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION B WORKERS COMPENSATION X ATU- TH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN E.L EACH ACCIDENT $ 1D0 DO OFFICERIMEMBER EXCLUDED.) El NIA 595710 4/3/2014 /3/2015 E.L.OISERSE-EA EMPLOYE $ 100,000 (Mandatory in NHl Ii yyr„desni N"0'Fr /3/2015 /3/2016 E.L.DISEASE-POLICY LIMIT $ 500 000 ' PEBCRIPITON OF OPERATIONS 6elPw DESCRIPTION OFOPERAnONSILOCATIONS(VEHICLES (Anaeh ACORp101,Addltloaal ReMSN850heddla,nmorsepaC ier"uired) veaador #24305 Losre's Companies, Inc. and any and all subsidiaries are named additional insured as respect to General and Automobile Liability CERTIFICATE HOLDER CANCELLATION (781)4S0-3S25 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THIS POLICY PROVISIONS. Lowe'a Companies, Inc_ and any and all subsidiaries AUTHORIZED REPRESENTATIVE P.O. Box 1111 N. Wilkesboro, NC 28656 CI< 1 pb5 JI JJ�r1�`� Commonwealth of Massachuset INSPECTIoNAL SERV Sheet Metal Permit ICES 1015 OCT j3 A Il Date: l7 f� Permit 03 Estimated Job Cost S ago / Permit Fee: Plans Submitted: YES NO t- Plans Reviewed: YES NO Business License # Applicant License # 6 �6 Business Information: Property Owner/Job Location Information: Name: �V 6� — the Name: IV �w5t Shd�° 8!4e QeafL-li LLC Street: 7 fgfY '' street. 436 Canal FD 5 City/Town: QPQpq �R D191� City/Town: StQj2sw� M!R Telephone: 1G,/9 3'�-7 ey Z 3 Telephone: 7 81 5 8 q 5 3 TO Photo I.D. required/ Copy of Photo I.D. attached: YES NO — Staff omi::i J- / NI-1-unrestricted license J-2 / NI-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less Residential: 1-2 family Multi-family_ Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. v over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: 411� Renovation: 1-IVAC _ Metal Watershed Rooting_ Kitchen Exhaust System Metal Chimney/ Vents Air Balancing Provide/detailed description of work to be done: I#I(;L 1tll� 2 MfLu 141C yiJ Q-edoth� Cvlv,e plc r~ INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes Z?"No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy 2( Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit Issued for this application will be In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES_NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑ Master Title ❑ Master-Restricted City/Town Journeyperson Signature of Licensee Pennil# Y ?` ❑Journeyperson-Restricted License Number: gr 7 Cl Fee$_ ❑ Check at www.inass.govld111 Inspector Signature of Permit Approval The Commonwealth ofMassachuse(ta Department oflndnstriauccidents I Congress Street,Suite 100 Boston,MA 02114-2017 UV www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Elechicians/Plumbers. TO BE FILED WITH THE PERMUTING AUTHORU'Y. Aualicaut Information Please Print LedbN Name(Business/Oigapirrtion/b.2ovidual): A+A. H Vd4 C:... f Ac Address: City/state/Zip: 16L) Phone M �76 39- 4 2 3 Are you an employer?Check the appropriate box. ' Type o project(required): 1.❑I am a employer w� .employees(full and%part-tune).' 7. ffNew construction 2�am a sole proFictor or parmership and have no employees wod®g forme in S: 0 Remodeling - my capacity.[No workers'comp.insurance required) 3.Q I am a homeowner doing all work myself.[No workers'comp.insorance tequIred.)t 9. ❑Demolition 4.Ej I s a homeowner and will be hirin contractors to conduct all work on my property. I will 10 Q Building additionsin ensme that all contactors either have workers'compensation insurance w are sole I LE]Electrical repairs or additions proprietors with no employees. 1 5.❑Iam a general connector and I have hired the sub4on6ectors listed on the attached sheet. .❑Plum e repairs or additionsa These subcontmctots have employees and haveworkers'comp msmanceJ 13. ROOF repairs. 6.rl We sce a corporation and its officers have exercised their right of memption per MGL a 14. 1 Other 15Z§I(4),and vro have no employees.[No workers'tmip:insurance regtmed.] -Any applieem that checks boa#1 mast also fill oat the section below showing their conches'a non polity mfmmadon. -- ._. _. . t Homemmers who submit this affidavit indicating they ere doing all work and then hive outside conaactors must submit a new affidavit indicatmg such. ICormac ors that check thisbox must attached an additional shad showing the name of the sub-commotors and state ivtie!ffir or not those entities have employees If the sub-contractors have employees,they must provide their workers'-comp.policy number..,_ I am an employer that to providing workers compensation insarancejor my easployees. BeJow it thepolity and job s#e information. Insurance Company Name: - Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: GSty/Statelzip: 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER aad 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. I do hereby c er the pains ai rallies ojperjary that the injormadon provided love is true and correct Silmature: Date: PhoneM n��8 3 9Z Lf 3 OJlieid use only. Do not write in this area,to be completed by city or town gBicfal City or Town: Permit/Llcense# 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 writtep." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint 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 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 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 firture 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 d(?g license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia .4co t CERTIFICATE OF LIABILITY INSURANCE MW THIS CFItTIFiCATE Isau AS A TTER OF Ge 1a1s cERTIFlCATE DDEs Nor AFFIRAIA TACO ONLY CONFERS NO RIGHT3 uPON TINE CERTIFICATE HOLDER,ells BELOW. THISt TfflGATE OF WSURANCE N07 Y AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES REPRESENTAOR AND THE CERTIFICATE HOt nFsr ONSITITUTE A CONTRACT BETWEEN THE MSUING MURER(S), AUTHol nhe imm and carol aroRrANT: certiecan ow poney,a nolaBr to do ADORIORAL INSURED,uEa bad must ue ertdoraod a sueROGATION IS WANED,su6Jaet to tM cartiTicato l.in(ienuaf eO cerlairl poIkN13 may requite ondoEaetnetlC.A ataNNRen{oa tlISS certificate doss not confer rigtlts ffi FRoollma s. 106 Ditl:m l DrI i�ws/roo f Am RISK SWWOss.N1C6f Fi"jde Eiaeti,FL 33131,407 :500-74"130 :SDO.522-T514 ADP.COI.CA Ri3OO11�A1N3)AFFOI COVERAW NAICi ugsLmm XN3aRgt A: New IIrAPehwo III co 23a41 ADP Tftrp aCOX1O,Bic. M&IRER S: 1n SunN D" kill RNi11RER C: ALTERNATE EMPLOYER �Rabipw�ofms En 181W Ro 9130Mr W AYawt, bl9txMR E: Hul1m,MA 01740 COVERA©e$ i+stRl9tF: CERrifICAT'E NUMBER.1070112 REVISION NUMBER; RMI IS TO CERTIFY THAT S OF INSURANCE USED BELOW NAVE BEEN ISSUED TD THE INSURHIi D AHOyE FOR THE POLICY PERIOD INDICATED. NO7WRfHSIANDRIG ANY REOUR2E6$'NT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT yylT}I KESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE WSURANCE AFFORDED NY THE POLICIES DESCRIBED HEIRESN 19 SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONORIONS OF UCH POLICIES-L SHOWN VE P1EEN RE FA gy PAIo TIT *FanURANCa LIMITS SHOWN ARE AS REOUFSTED. Lin RJR wpn roNl•Ytt Elm LINTS C :YLL O4NbTLLL LNRIt1fY CLA&I ❑ EACH n I RREt g g* s EXn m i L AGGREGAtE l iAn APp�E%PF}e B Y E o POLICY ❑PROJECT❑we GE GATE i PROrn C E AUTONOaiE LABBJIY i ANY ALI E AUTOS cm W BtIDILY RY Pw xcan F NOHOWi® RONLY Y Far 6 NitEDA11T(]e AiBI'fT0.4 E IH19i�LNa RX:" $ LMa c FAf.HUf.Ctmtill i a AEi qN s Cy11E 8 iYORI�OOapygi9h7 W 81 AM,DIVE YIN A X FF ANTE f33 OFFXWRI EIMER EYCXLQEDT NIA WC OS{72828{MA 71113D15 ItIMIe ELL EACH ENT E 2.000,OW Y Lwow EL. E.EA EBX'LOYE E 2.000,000 OESCR OF GPEtA Befow E.i.Pc,eASE-FCk YLaYY Y E,OOp,OW a¢9L4pTNNi OF OP9tI.i101rt4/W I.ATIONS/�RC16P IAC[Mm'181.Aldl5aYd 1pemni�w AEFRICII nw OF UDSO br ATLANi1CR�Rg6RAT�N OFMIOHPN RTC.Pdd�mr ' sldnve A R>FFILGERATY7tI OF HUD50N RrC 8 endl�m�wgplAwl,wiear Rtls Ppj.. R�1eA eR1 Nv01tl i0Y1tt YU a�R5EB0{XIR:% AT{AtITXi CERTIFICATE HDLDER CANCELLATION A al�R Of HWiwl Inc SH AOULD NY OF TIE ABOW q@gcNiS¢D POLICIES OF CANCELLED BEFORE 7He EXPRAUM DATA THEREOF. NOTICE WILL BE DELIVERED RN Hudian,MA 01749 AC40FMAWM 1MTH THE POLICY PROVISIONS. AUTNamaP R�A�ITATN[a ACORD 25(20SUD7) The ACORD i�-2oia ACORD CORPORATION.AN rtja Ee�grlN,a. twaa"d Wgo an MgWUwcd ft S"m of ACORD Ze/T3 39Vd 9IdA3a DIlNVIil7 89ZLZ998LG 5T:ET ST9Z/E1/9T a !T OP lb:19 CERTIFICATE OF LIABILITY INSURANCE p1010912015YI 191Datzals 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 CINU1100110 holder Is an ADDITIONAL INSURED, the pollcy(las) must be endorsed. If SUBROGATION IS WAIVED, sub)act to the terms and eendhlons of tha policy,Certain policies maY require an endorsement. A statamsnt Dn this certificate does not confer rights to the cetNcate holder In fiw of such endoreemen s. P,00WER D Francis Murphy ins Agcy Inc PHDNE -- FAX 50 Main Street Hudson,MA 01749 EiAA1 Dennis F.Murphy 01 x5140 pROp cEn cMgyom&,j,#:ATLAN-j _ INSUR 3 AFFORdNO COVERA3E HAICO INSURED Atlantic Refdg.of Hudson,lnc DISURER A-Selective Insurance Of Amerlw 12672 Michael J.Maguire INSURERS' 9 Bonazzoli Ave unit 26 Hudson,MA 01749 01SURERO' INSURER 0, INSURER e: _� COVERAGES CERTIFICATE NUMBER: 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 :Ed 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.LIMIT$SHOWN MAYHAVE BEEN REDUCED BYPAID CLAMS. IN$R type OFINfiURANCE POUCY EM ��w DMrf6 GENERAL LIABILITY RRENCE ! 1,000, A X COMMERCIAL GENERAL LIABILITY S 183611Tg 1010902015 a ocnmmw 8 100,0 CLAPASI 09 ❑X OCCUR n aao a,een ! 10,00 AbV INJURY S 1,000,GREGATE $ 3,000+ GEN'LAGGREGATE LIMIT APPLLS PER, PRODUCT -COMPIOPA00 E 3,000,00 POLICY X PRO- LOO S AUTOMOagE LNNLrrY COMBINED SINGLE LIMIT 5 1,000,00 (E�acdderE) A ANY A 90e10ti4 10/0912016 10/09/2016 BODILY WURY(Per perteb) S ALL OWNED AUTOS BODILY INJURY(Pm acddeM) 8 X SViEDU1.EDAUT0S PROPERTY DAMAGE X HIRED AUTOS (PER ACCIDENT) 5 X NON-OWNED AUTOS $ UMMELIAUAa I X OCCUR EACH OCCURRENCE $ 1,000,00 A EXCE86 UA9 CLAIMStMADE a 1826870 10/06/2015 1010a12016 AGGREGATE $ 1,OtXl, bebUCTnLE E X RETENTION 8 D $ MDIMPSCOMPEUAWLIN WC STA 0 - ANDPIPLDYQR6`IWNUTY Yrx ANY PROWtIETIXNPARTNER/E%ELY111VE EL EACH ACCIDENT S OFFICERAI in NH)EXCLUDED/ NIA 9 yes. mryiP NH) E1.DISEASE-FA EMPLOYE S d yer,deedi0a un0ar OESCRPTIOIV OF OPERATIONS blow E.L DISEASE-POLICY LIMIT 8 DE6CNPTION OF OPEMn MSI LOCA"ONS l VENWO 99(Aaaeh ACORD 101,AddNORd Rwmft Sdwduk B alPre space is raw" see attached note page CERTIMCATE HOLDER CANCELLATION FMFA1101 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUYIIOR�`�(�//ff��REPRESENTAT�Vjae�rp+ n]�d/11n1- `" . • 'vim' II O 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(20110109) The ACORD dame and logo are registered marl a of ACORD ZO/ZO 39dd 9RJ36 0IlNV-1iV 69LLZ998L6 ST:ET STOZ/6T/OT Tammnnwralt4 of Aasnar4tnrtts W CITY OF SALEM In accordance with the Massachusetts State 13uiIding Code, Section 108. 15, this Jay` CERTIFICATE OF INSPECTION THOMAS FORD SALES INC. is issued to I YJthat I have inspected the premises known as THOMAS FORD located at 0138 CANAL STREET y f in the cit of County of Essex Commonwealth of Massachusetts. The means of egress are sufficient for the following number of persons: BYSTORY "�'"�" zzsxzzzzzzzzzzzzzzz zzzxzzzzzzzzzzzzzzz tory Ca�Vj4y Capacity Story Capacity BY PLACE OF ASSEMBLY OR STRUCTURE Place of Assembly Place of Assembly or Structure Capacity Location or Structure .Capacity Location B—CAR RENTAL/SALES 0135-1998 11/01/1996 00/00/0000 V Certificate Number Date Certificate Issued - Date Certificate Expires Building Off iul The building official shall be notified within (10) days of any changes in the above information. OF SALZ!' 7oR C_ CIZC1.Tr 7: T_ti/5?=LTiOH Date - ('') ree_Reauired S ( ) No Fee Regssired inacnnrdan.a with the orovisions of the Yassachssseru State Building Cade, sec 108. 15. i hereny apply for a Cerrificate of Insaect-os, for the below-named pra@isea located at the iallovsng address: Street & Number Namse o f Pra=ises ?urWe for which Pr=ises is used LiI 1st'r�.ase(s%) or Per3t(s) required for the promises by other Govan+ -Mnral AgcaC+� Q Q CP) W License or Pazair Cly O ~� a sWti�. Certificate to be issued tn: TTI o C'L�-5 ` 7` J C Address: 3 K EM rK 6 l Ower of Record of Building: 5T A Address. � �,a l'. 5( s f Lf IkA- 4l f- 6 LCI Ni c of Present Ealder of Cert'_i:ate: Nie of Agent. _f any-- - Signature of Person to woc= pert__-=rc nom" is issued or hisiber autaor,-ed agent g Date IH5I%IIC=0-IS- Day rina pbane j q7 9aa6o5 f 1. Nike check payable rn: The Clry of Salem 2. Return rhia appliurion virh your cneci to: lasaecrnr of Buildings. C1r9 of Salem Baild,=x Deaarzmear. one sales, Green. sales- :f11- 01970- - PIF3SE HIIIE: 1. Application farm with required fee snot be subritred for each build-lLng or tyrants of parr tbereof r to be car:Lficd_ •ri Applicatlnn o fee asst be ;c=eived beiare the cc_r_ rate will be issu _ ' 0. The building official shalt be notified virhin ran (10) days of any cbamge in the above i=forcarion. CEE =ZCATE t =jvA on nA2E- < < � lo,c� PERIODIC INSPECTION REPORT This form is to be completed each time a Periodic Inspection is made. At the time a new Certificate of Inspection is issued, a notation indicating that the fee has been paid will be made to Application Form prior to the new Certificate of Inspection being issued. Any changes since the last inspection are to be added to the file card of the premises. Street 6 Number 13 C CL'W �T Name of Premises k r) CM '- Certificate to be issued to: ��/tC7W\C�' Address Owner of Record of Building � 3 -}ivUC -e- Address 1u C /VN Purpose for which premises are used Cc Y sa i-2 [e P/VL4n / Changes since last Inspection (required on file card also) L . Bl )S % Y)'e r-e- 1oC(kAC z. 3. 4 5. Date Order Issued: Order Issued To: Address Date Violations Corrected: REMARKS: I have this day inspected the above premises, and the same conforms to the pertinent requirements of the Massachusetts State Building Code and the rules and regulations pursuant thereto. f O - � - 9 9--- UNAA r, a/�1elm Date Building Official Certificate A 13 Date Issued: Date Expires: Recommended Next C� � r) i34t T=utonmrtt1t4 of Attssar4uttrtto CITY/TOWN OF In accordance with the Massachusetts State Building Code, Section 108. 15, this CERTIFICATE OF INSPECTION is issued to . . . . . . . . . .Vl� 5. . . . . J.�7 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I ,fi Yo.a. �--- ✓-� Y Terfitg that III�h77avee inspected the.JJ. . . . . . . . . . . . . . . . . . . . . . . . . . . . .known as. . �Yo.�.S. . .�1~cl located at. . . . . . . . . . . .[3 .& . .� .5T.-.in the. . . . . . . . . . . . .of. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . County of. . . . . . . . . . . . . . . . .Commonwealth of Massachusetts. The means of egress are sufficient for the following number of persons: BY STORY Story Capacity Story Capacity Story Capacity Story Capacity BY PLACE OF ASSEMBLY OR STRUCTURE Place of Assembly Place of Assembly or Structure Capacity Location or Structure Capacity Location - Cir Certificate Number Date Certificate Issued Date Certificate Expires Building 0YjtciUqZ The building official shall be notified within (10) days of any changes in the above information. ( mmunumalt4 jot Ansionr4uUt#o a CITY OF SALEM ^ ., In accordance with the Massachusetts State Building Code, Section 108. 15, this e" CERTIFICATE OF INSPECTION is issued to THOMAS FORD SPL-ES) INC. ][ �J•(/�Prt11 ttlj TI-IOlrl(-1 S FORD that I have inspected the premises known as located at @] ;;jg C(lIVAI_ Sl I- El in the city of Salem County of Essex Commonwealth of Massachusetts. The means of egress are sufficient for the following number of persons: BY STORY X b6sGYK76X "A%%% CaXXXXbY��Sb�j, Capacity Story CaIM pacity Story Ca 3 Xt6 dX GGRrbb'lrS6 (�GS % �sG�G:I;%u�5G�56�55�56 54�sG% 6 BY PLACE OF ASSEMBLY OR STRUCTURE Place of Assembly Place of Assembly or Structure Capacity Location or Structure Capacity Location CHANGE_. OF Uc.3E , f n =Ft t —y ia� �t /Vi 1 / i .—.,qp nts nnri IG-AhIr-v Certificate Number Date Certificate Issued Date Certificate Expires Building Official The building official shall be notified within ( 10) days of any changes in the above informn tion. • � co?e oNNFlir ITT OF unSSAC?P5= -S =�s�? CITY OF SALES APPLICATION FOR CERTIFICATE OF INSPECTION Date //�.24/g7 (>4 Fee :Required S 'VO,&O ( ) No Fee Required In accordance with the provisions of the Massacnusects State Building Code. Sectic 108. 15. I hereov appiy for a Certificate of Inspection for the below-named premises located at the following address:: Street 6 Number /If st Name of Premises %L^.4-r r-A, l/91-9-f �C Purpose for which Premises is used 014le 'M/if -LiWpse( 'o or Permic(s) required for the premises by other Governmental Agencies: LLJ Q License or Permit AAencv o M W W C..7 lfl _...I c W V N a r m w Ce£tlfiC ce to be issued to: -7WU/4.1 c Address: JJ' J, ✓ �� ., 0/5' ,. Owner of Record of Building: i CAw& ST —rtys7 ��A)Tf/Bi1�I�rs47—rlA/P�2/ Address: /V,- CAA/A-L S7— 5G-Ce->k MA-' C)_( '9'-?L) Name of Present Holder of Certificate: Name of Age if F gaacure of Person to waomr are TITLE is issued or his/her author ag t !!�30 _ c/ 7 Date INSTRUCTIONS: Day time phone 97f-yam-ae5l 1. Make cheek payable to: The City of Salem 2. Return chis application with your cheek ta: Inspector of Buildings. City of Salem Building Department. One Salem Green. Salem. MA. 0197O. PLEASE NOTE: 1. Application form with required fee must be submitted for each building or structure of part thereof to be certified. 2. Applicacion 6 fee must be received before the certificate will be issued. 3. The building official shall be notified within ten (10) days of any change in the above information. CERTIFICATE 1 �<lf I'G� 9 EXPI%ATZON DATE:.J_:L_ PERIODIC INSPECTION REPORT This form is to be completed each time a Periodic Inspection is made. At the time a new Certificate of Inspection is issued, a notation indicating that the fee has been paid will be made to Application Form prior to the new Certificate of Inspection being issued. Any changes since the last inspection are to be added to the file card of the premises. Street S Number Name of Premises Certificate to be//ppissued to: /J J�� �r Oq� r�iryt�, Address / 11�/ypu �S/ ovC�Q�?�n //�!(�/�Q ��i j70 Owner of Record off Building 13 C Cd"41 st . VC�CIXJr. Address 13 ( aiv�gi( QA- D Zo () Purpose for which premises are used e'.L' -�- Changes since last Inspection (required on file card also) 1. l�'tQ/✓1.4�- .lN�s C9'L.,�-r�'t.e�"{l� _C�b?li2 ��-2�-n--ci.- � ��°� 2. 3. 4. 5. Date Order Issued: Order Issued To: Address Date Violations Corrected: REMARKS: -------------- I have this day inspected the above premises, and the same conforms to the pertinent requirements of the Massachusetts State Building Code and the rules and regulations pursuant thereto. Da a Building Official Certificate U ��� Date Issued: Date Expires: Recommended Next 0� Inspection: rV(' R (t � P ( ommutattat4 of titansoi stno a CITY OF SALEM W� In accordance with the Massachusetts State Building Code, Section 10 815 this CERTIFICATE OF INSPECTION is issued to TFIOMfaS FORD E3OL EO ILL- I (ffCrfitjj that 1 have inspected the premises known as CRI�If1L. Sl'I�EL"I- in the city of Salem located at 01::38 - County of Essex Commonwealth of Massachusetts. The means of egress are sufficient for the following number of persons: BY STORY Caci '"�''Yr' 7i' �+ Y6A+ Capacity Story Ca patfry #SG16 �o��ggyy,,%�"•G7G Capacity Story Y+: 7+ b767_�5r�',G :G ����d'd°6yG L55:655°,GSb'S76�755 BY PLACE OF ASSEMBLY OR STRUCTURE Place of Assembly Place of Assembly or Structure Capacity Location or Structure Capacity Location CHANGE„ OF USE pli /Vi'I / 'I .-i9Fl fIP f1fY.•tIPC'1M('V Building Official Certificate Number Date Certificate Issued Date Certificate Expires The building official shall be notified within ( 10) days of any changes in the above information. Chi of _'intem, AN 23 3 10ii '91 Bonrb of 'Appeal (3 'Isa � F i LE 4F 'I T Y C L DECISION ON THE REQUEST OF CANAL STREET REALTY—TRUST-FOR-A-----� SIX (6) MONTH EXTENSION ON VARIANCES GRANTED�TO 138 CANAL-STREET Canal Street Realty Trust, through their Counsellor John Serafini Sr. , requested a six (6) month extension on Variances which were granted on January 17, 1990, recorded at the City Clerk 's office on January 24, 1990, the twenty day appeal period having expired on February 13, 1990. After carefully considering this request, the Board of Appeal voted unanimously to grant a six (6) month extension up to and including August 13, 1991 . 7<�O� Richard A. Bencal , Chairman i� JAN ofizlem, Cttssttchuse##s Fig poara of hupud DECISION ON THE PETITION_OF_CANAL STREET REALTY TRUST FOR VARIANCES AT 138"CANAL STREET (I) A hearing on this petition was held January 17, 1990 with the following Board Members present: James Fleming, Chairman; Richard A. Bencal , Vice Chairman; Edward Luzinski , Richard Febonio and Associate Member Peter Dore. Notice of hearing was sent to abutters and others and notices of the hearing were properly published in the Salem Evening News in accordance with Massachusetts General Laws Chapter 40A. Petitioner, owner of the property, requests Variances to allow more than one building on the lot at 138 Canal St. , zoned Industrial , to allow the building to be used and maintained for a Subaru vehicle franchise. The variances requested are for minimum depth of front yard, minimum width of side yard and minimum depth of rear yard and more than one building on one lot. The variances which have been requested may be granted upon a finding of the Board that: a. special conditions and circumstances exist which especially affect the land, building or structure involved and which are not generally affecting other lands, buildings and structures in the same district; b. literal enforcement of the provisions of the Zoning Ordinance would involve substantial hardship, financial or otherwise to the petitioner; c. desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent of the district or the purpose of the Ordinance. The Board of Appeal , after careful consideration of the evidence presented at the hearing, and after viewing the plans that were submitted. makes the following findings of fact: 1 . The property has been used for an auto dealership for many years. 2. No opposition was presented to the plan. 3. If not allowed, the petitioner would lose the Subaru dealership franchise and this would be a severe economic hardship to the petitioner and others. On the basis of the above findings of fact, and on the evidence presented at the hearing, the Board of Appeal concludes as follows: 1 . Special conditions exist which especially affect the subject property but not the district generally; DECISION ON THE PETITION OF CANAL STREET REALTY TRUST FOR VARIANCES AT 138 CANAL STREET, SALEM page two 2. Literal enforcement of the provisions of the Zoning Ordinance would involve substantial hardship to the petitioner; 3. The relief requested can be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent of the district or the purpose of the Ordinance. Therefore, the Zoning Board of Appeal voted unanimously, 5-0, to grant the relief requested, subject to the following conditions : 1 . Petitioner meet all requirements of the Salem Fire Dept. 2. Petitioner obtain a Certificate of Occupancy for the new structure. 3. All construction be done as per existing City and State Building Codes. 4. All construction be done as per the plans and dimensions submitted. VARIANCES GRANTED -RIchard A. Bencal , Vice Chairman A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK from thio dC:i-.:on, if any, sha;i be made pmsuant to Section 17 of t:Ic 61ass. General Chapter 803. and shall be filed ,:,thin 210 daYs r tl jdcre of f,'.:1°. ct ft,ls cecislon in the oltice of the C.tY 208, s cnon 11. the Variance •.i^ h 1. sn r;l toke eit':ct Cat a copy of rhe at the City CIe1 k til It :10 days h :•^ '.ed, or that. if such ,pp--11 M he bcen fl ^n . .: _n :ih;m lssed f honied is rcccrd�d in till : uth Essex . R rlis!;y of Cr_ds an7 adexed under the name yr the owner of rucord or is reeordcd and noted on the owner's Certificate of Titlo. BOARD OF APPEAL