5 BROAD STREET - HISTORICAL - BUILDING JACKET 5 BROAD STREET 0 1
HISTORICAL
llll
No. 153L
HASTINGS. MH
LOS ANGELES-CHICAGO.LOGAN.OH
McGREGOR.TX-LOCUST GROVE.GA
U.S.A.
DECATAM
ENVIRONMENTAL SERVICES
December 27, 2016
Ms. Patricia O'Brien
Salem Park and Recreation
5 Broad Street
Salem, MA. 01970
Dear Ms. O'Brien:
RE: Certified Payroll -Salem Senior Center
As requested, enclosed please find Dec-Tam Corporation's certified payroll report for the week
ending 12/18/2016.
Please let me know if you require any additional information or documentation.
Sincerest regards,
anice Paleo
Chief Administrative Officer
JMP/bb
Enclosure
50 Concord Street,North Reading,MA 01864 • P:978.470.2860 F:978.470.1017 • www.dectam.conn
DEC-TAM CORPORATION Certified Payroll Report 12-27-16 Page 1
System Date: 12-2'/-16
System Timer 11:22 am
For the Period Ending: 12-18-16
Job: 16-03-0781 Salem Park & Recreation
Senior Center
Salem, MA 01970
Lucas Almonte
141 Center Street - Total FWH SWH Other
Lawrence, MA 01843 12-12 12-13 12-14 12-15 12-16 12-17 12-18Total Gross Gross FICA SUI/SDI Deducts Net
030-80-6297 Hispanic Male Mon Tue Wed Thu Fri Sat Sun Hours Rate This Job Per Diem 2,046.75 355.68 72.27 220.35 1,297.63
S - 1 Mold Laborer OT 8.00 8.00 69.369 554.95 50.00 150.82
554.95 50.00
Manrique Medrano
20 Dunfey Street Total FWH SWH Other
Lawrence, MA 01854 12-12 12-13 12-14 12-15 12-16 12-17 12-18Total Gross Gross FICA SUI/SDI Deducts Net
730-20-3953 Hispanic Male Mon Tue Wed Thu Fri Sat Sun Hours Rate This Job Per Diem 2,914.57 670.06 146.68 1,674.87
S - 0 Mold Laborer OT 8.00 8.00 72.821 582.57 .00 222.96
582.57 .00
Ethan Zorrilla
P.O. Box 3153 Total FWH SWH Other
Lawrence, MA 01842 12-12 12-13 12-14 12-15 12-16 12-17 12-18Total Gross Gross FICA SUI/SDI Deducts Net
032-90-4078 Hispanic Male Mon Tue Wed Thu Fri Sat Sun Hours Rate This Job Per Diem 1,587.96 184.01 55.13 131.00 1,146.34
M - 1 Mold Laborer OT 8.00 8.00 67.386 539.09 50.00 121.48
539.09 50.00
Totals for Salem Park & Recreation
12-12-16 12-13-16 12-14-16 12-15-16 12-16-16 12-17-16 12-18-16 Total Gross Total
Monday Tuesday Wednesdy Thursday Friday Saturday Sunday Hours This Job Per Diem Gross Deductions Net
.00 .00 .00 .00 .00 24.00 .00 24.00 1,676.61 100.00 6,549.28 FWH 1,209.75 4,316.84
FICA 495.26
SWH 274.08
SDI .00
Other 351.35
MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM
Company's Name: Address: Phone No.: Payroll No.:
Dec-Tam Corporation 50 Concord Street, North Reading, MA, 01864 (978)470-2860 1 <>0r
Employer's Signature: Title: Contract No: Tax Payer ID Number Work Week Ending:
Chief Administrative Officer 04-2732833 12/18/16
Awarding Authority's Name: Public Works Project Name: Public Works Project Location: Min.Wage Rate Sheet Number
Salem Park & Recreation Salem Senior Center 5 Broad St. Salem, MA.
General/Prime Contractors Name: Subcontractors Name: "Employer"Hourly Fringe Benefit Contributions
Dec-Tam Corporation n/a
B+C+D+E (Ax F
Project Ped employee 0 Hours Hourly Health& ERISA Total Gross
is OSHA Appr. Hours Worked (A) Base Welfare Pension Supp. Hourly wages
Employee Name&Complete Work cenifiea Rate All Other Wage Insurance Plan Unemp. Prev.Wage Tatal Gross Check No.
Address Classification: M % Su. Mo. Tu. We. Th. Fr. Sa. Hours B C D E F Wages H
see attached
Are all apprentice employees identified above currently registered with the MA DLS's Division of Apprentice Standards? YES O NO
For all apprentices performing work during the reporting period,attach a copy of the apprentice identification card issued No apprentices are identified above I x
by the Massachusetts Department of Labor Standards/Division of Apprentice Standards.
NOTE: Pursuant to MGL c. 149,s.2713,every contractor and subcontractor is required to submit a true and accurate copy of their certified weekly payroll records to the awarding
authority by first-class mail or e-mail. In addition,each weekly payroll must be accompanied by a statement of compliance signed by the employer. Failure to comply may result in the
commencement of a criminal action or the issuance of a civil citation. -
11 Dale Received by Awarding Authority
Page 1 of 2 / /
V
WEEKLY PAYROLL RECORDS REPORT
& STATEMENT OF COMPLIANCE
In accordance with Massachusetts General Law c. 149, §27B, a true and accurate record must
be kept of all persons employed on the public works project for which the enclosed rates have been
provided. A Payroll Form is available from the Department of Labor Standards(DLS) at
www.mass.gov/dols/pww and includes all the information required to be kept by law. Every contractor
or subcontractor is required to keep these records and preserve them for a period of three years from
the date of completion of the contract.
On a weekly basis, every contractor and subcontractor is required to submit a certified copy of
their weekly payroll records to the awarding authority;this includes the payroll forms and the
Statement of Compliance form. The certified payroll records must be submitted either by regular mail
or by e-mail to the awarding authority. Once collected,the awarding authority is required to preserve
those records for three years from the date of completion of the project.
Each such contractor and subcontractor shall furnish weekly and within 15 days after
completion of its portion of the work, to the awarding authority directly by first-class mail or e-mail, a
statement, executed by the contractor, subcontractor or by any authorized officer thereof who
supervised the payment of wages,this form, accompanied by their payroll:
STATEMENT OF COMPLIANCE
December 2$2016
1, Janice Paleo Chief Administrative Officer
(Name of signatory party) (Title)
do hereby state:
That I pay or supervise the payment of the persons employed by
Dec-Tam Corporation on the Salem Senior Center
(Contractor,subcontractor or public body) (Building or project)
and that all mechanics and apprentices, teamsters, chauffeurs and laborers employed on
said project have been paid in accordance with wages determined under the provisions of
sections twenty-six and twenty-seven of chapter one hundred and forty nine of the
General Laws.
Signature_ 0—t—L
Title Chief Administrative Officer
05/14
69 BRIDGE STREET
DEDHAM, MA 02026
FFAx 781 .251 .09.0040.251 .LI Errvirohmental PHONE 1 .251 90040
.0901
November 23, 2016
Michael Lutrzykowski
City of Salem
120 Washington St. 3`d floor
Salem, MA 01970
RE: Waste Disposal Manifest
Salem Senior Center
5 Broad St. Salem, MA
FLI Project# 16-1240
Dear Sir/Madame:
Please find enclosed the original waste disposal manifest for the asbestos removal at the above
referenced location.
Should you have any questions regarding this letter or project, please do not hesitate to contact us
at(781) 251-0040. FLI appreciates the opportunity to provide our services.
Sincerely,
FLI Environ tal, Inc.
Stephen Shea
Sr. Manager
SERVICE TRANSPORT GROUP, INC. 3 1 47
58 PYLES LANE NEW CASTLE DE 19720 PHONE (877)999-9559
q}s 'r?WASTESHIPMENTRECORD a,
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CC Speci Friable or, on-Friable No. Type
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IF Non-Friable(check one):❑Category 1 ❑Category II
6. Special Handling Instructions 24-hour emergency spill response no.800-424-9300
7. Generator Certification: 9
This is to certify.that the above-named materials are.properly classified„described,-packaged,marked and labeled and are in proper condition for transport by highway
_ according to the applicable regulations of the Department of Transportation,US E.P.A.,and any other state government agency.I certify that the foregoing is true and correct
to the best of my knowledge.If the waste shipment is not as I stated,I accept the RETURN of the COMPLETE LOAD to the generator's"s`ervice location at the generator's
expense.
Printed/Typed Name &Title Signature }' ��+ Date
David F . Wealoh vice Pres, tt/� �t /v 1`!�!6v
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Company Name & Address Signature: Telephone No.
Service Transport Group, Inc. 877-999-9559
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Printed Nam :
W 58.Pyles Lane Date:
F New Castle, DE 19,720 Title:
j 11. Discrepancy Indication Space:
Q 12. Waste Disposal Site Owner or Operator's Certification (Receipt of above Waste except as noted in 11)
N Waste Disposal Site (Check One) STG USE ONLY Date:
O Signature: F 1
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Permit No. 100277 Permit No. P0104984 Title:
WHITE Generator•GREEN-S T G.•YELLOW-Contrador•PINK-Landfill•GOLD-Pick Up Receipt
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yA••::•..1�4 n. .�{ "�SA.FBPFV EP �.
69 BRIDGE STREET
DEDHAM, MA 02026
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PURCHASE ORDER
Fiscal Year 2017 Page COMMUNITY DEVELOPMENT
Purchase (978)745-9595 EXT 5692
Order # 04002788-01 120 WASHINGTON STREET 3rd FI
SALEM, MA 01970
FLI ENVIRONMENTAL INC COMMUNITY DEVELOPMENT
(978)745-9595 EXT 5692
69 BRIDGE STREET 120 WASHINGTON STREET 3rd FI
DEDHAM, MA 02026 SALEM, MA
01970
Vendor Phone Number Vendor Fax Number Re uislton.Number I Delivery Reference
00003046
Date Ordered Vendor Number I Date Required I Freight.Method/Terms Departmerit/LWbation
09/14/16 029424 1 09/13/16 COMMUNITY DEVELOP
Item# Descri tion/Part.No. Unit/Qty Cost-Each Extended Price
001 1.00 37800.00000 37, 800.00
EACH
Asbestos Abatement Project - Salem
Senior Center, 5 Broad Street, Salem
MA 'PREVAILINNG WAGES REQUIRED
UTILIZING MA 1160001 9/2/16 MA1.
BUILDING"
PO Total 37,800.00
***** General Ledger Summary Section *****
Account Amount
25513-5713 37,800.00
i
CITY RECORDS INDICATE
CITY OF SALEM ARE PRESENT IN THE BUDGETFICIENT ACCOUNT UNENCUMBERED FUNDS
y
I PURCHASING DEPARTMENT AVPan� •
120 Washington Street oveo av (�//�G/t^/"-, mNU.�."AV/Lf
SALEM, MASSACHUSETTS 01970
TEL(978) 745-9595 FAX (978) 744-5918 Whitney C. Haskell
SALES TAX EXEMPTION#E-046-001-413 CITY P sing A ant
(NOT VALID WITHOUT CITY PURCHASING AGENT'S SIGNATUREI
Baystate Building& Remodeling Inc.
po box 725
Salem, MA 01970
(978)741-1700 .
tommy@baystatebuilding.com / t
http:/ANww.baystatebuilding.com /
ESTIMATE
ADDRESS ESTIMATE# 1178
City of Salem Massachusetts DATE 07/21/2016
93 Washington St EXPIRATION DATE 08/21/2016
Salem, MA 01970
ACTIVITY AMOUNT
EMERGENCY SERVICE: SALEM SENIOR CENTER 5 BROAD ST SALEM, MA 01970
Services 4,475.00
CLEAN, CUT, PACK AND FILL ALL OPENINGS IN MASONRY AROUND PERIMETER AT
GROUND LEVEL TO STOP RODENTS FROM ENTERING BUILDING.
APPLY NEW MDO PLYWOOD PAINTED WHITE TO WINDOW OPENINGS AS NEEDED
INSTALL NEW ICE AND WATER SHIELD TO REAR BULKHEADS
PRICE INCLUDES PREVAILING WAGE LABOR, MATERIALS AND DEBRIS REMOVAL
- -- - - - --- ...__' - ---- - _._ -.._......... ...... ....... - .. ...-
We Build"SOLID"Customers! TOTAL $4,475.00
Accepted By Accepted Date
We Build"SOLID"Customersl
SALEM SHEET METAL INC.
P.O.Box 310
8 Waite Street
Salem,MA o1g7o
May 13,2016
City Of Salem
Council on Ageing
5 Broad Street
Salem,Ma 01970
TELEPHONE:
(978)744-0924
Proposed Work: Salem Sheetmetal Inc.proposes to furnish all the materials and perform all labor
necessary to complete: Copper/Slate repair:
Repair Detail:
1. Seal front right side gutter with Gycole tripolymer 2 cotes.
2. Repair snow fence,copper ice panels.
3. Replace missing/damaged slate to top dormer area.
4. Reconnect copper ridge cap flashing.
5. Clean debris.
6. Furnish 60' man lift.
Total S 4,875.00
All work to be performed in accordance with the drawings and specifications submitted for the work and
will be completed in a substantial workmanlike manner.Any alteration or deviation from the above
specifications involving extra costs will be executed only upon written order,and will become an extra
charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond
our control. Owner to carry fire,tornado and other necessary insurance upon above work. Workman's
Compensation and Public Liability Insurance on the above work to be taken out by Salem sheet metal Inc.
Respectfully Submitted,
R L Petit
.a
TELEPHONE:(979)744-300
FAX: (978)744-mz
6/13/2016
Jane,
Pursuant to the roof work performed in May of 2016 regarding obtaining a Minority and Women
Business and section 3 contractor interested in bidding the 5 Broad Street project the following results
were achieved.
Section 3—Only one (1)-firm D.P Carney Construction, Inc. of Springfield, Massachusetts was the only
Roofer that was found on the Section 3 look up on line, Daniel Carney stated he would look at it but did
not have a lift to view project.
The remaining businesses Erinna Construction Services(Mr. Ramon A. Erinna)of Haverhill,
Massachusetts, Boggs Properties, LLC of Dorchester,American Green Business Service
of Dedham, Massachusetts, Anthony Desmond Contracting, LLC of Quincy, Massachusetts declined due
to non-building operations in their company,distance of project or size of project.
As of this electronic transmittal, no bids have been returned from the two companies who received the
plans for review.
Any questions please contact me.
Respectfully,
Michael E. Lutrzykowski
r�
z
95
SALEM SHEET METAL INC.
P.O.Box3io
8 Waite Street
Salem,MA("970
Invoice
July 8,2016
City Of Salem
Council on Ageing
5 Broad Street
Salem,Ma 01970
TELEPHONE:
(978)744-0924
Repair Detail:
1. Seal front right side gutter with Gycole tripolymer 2 cotes.
2. Repair snow fence,copper ice panels.
3. Replace missing/damaged slate to top dormer area.
4. Reconnect copper ridge cap flashing.
5. Clean debris.
6. Fumish 60'man lift.
Total$4,875.00
7FLEPH N&(978)744
FAX (978)744-m2
Payroll Register Salem Sheet Metal Inc Check Date: 05/24/201(1 1 1e
Company(3797) Process: 2016052401 1
Period: 05/08/2016 to 05/14/2016
Dept.: /1 11
Gomez, Code Earning Hours Rate Amount Code Tax Status Taxable Amount Code Deduction Amount Type Reg
Obdulio E Reg Regular 8.00 65.0000 520.00 FITW Federal Income T M-3 520.00-12 19 Chk Date 05/24/2016
Emp Id 6 MA Massachusetts SIM-3 520.00 18.28 Batch W
Rate 30.0000 MED Medicare 520.00 7.54 Net 449.75
SS OASD1 520.00 32.24 Dir Dep 449.75
Chk Amt 0.00
Total Eammgs 8.00 520.00 Total Taxes 70.25 Total Deductions 0.00 ChkNcr# 3060
Gomez-Matul, Code Earning Hours Rate Amount Code Tax Status Taxable Amount Code Deduction Amount Type Reg
Cipriano M Reg Regular 8.00 45.0000 360.00 FITW Federal Income T M-2 360.00 3.98 Chk Date 05/24/2016
Emp Id 10 MA Massachusetts SL M-2 360.00 11.66 Batch W
Rate 20.0000 MED Medicare 360.00 5.22 Net 316.82
SS OASDI 360.00 22.32 Dir Dep 316.82
Chk Amt 0.00
Total Eamrngs 8.00 360.00 Total Taxes 43.18 Total Deductions 0.00 Chk(Vcr# 3061
Matul, CodeEaming Hours Rate Amount Code Tax Slams Taxable Amount Code Deduction Amount Type Reg
Balletic, Reg Regular 8.00 65.0000 520.00 FITW Federal Income T M-3 520,00 12.19 OS Phone Ded 15 00 Chk Date 05/242016
Emp Id 2 MA Massachusetts Si M-3 520.00 18.28 Batch W
Rate 30.0000 MED Medicare 520.00 T53 Net 434.76
SS OASDI 520.00 32.24 Dir Dep 434.76
Chk Arm 0.00
Total Earn
ings8.00 520.00 Total Taxes 70.24 Total Deductions 15.00 ChkNcr# 3062
Dept.:.(100) 100 Total
df
Employees 3 Code Earning Hours Rate AmountCode Tax Taxable Amount Code Deduction Amount Checks 0
Female 0 Reg Regular 24.00 1400.00 FITW Federal Income T 1400.00 28.36 05 Phone Ded 15.00 Vouchers 3
Male 2 MA Massachusetts SI 1400.00 48.22 Net 1201.33
Chks&Vchrs 3 MED Medicare 1400.00 20.29 Dir Dep 1201.33
Female 0 SS OASDI 1400.00 86.80 Chk Amt 0.00
Male 2
Total Earoiugs 24.00 1400.00 Total Taxes 183.67 Total Deductions 15.00
Report Total _-
n
Employees 3 Code Earning Hours Rate Amount Code Tax Taxable Amount Code Deduction Amount Checks 0
Female 0 Reg Regular 24.00 1400.00 FITW Federal Income T 1400.00 28.36 05 Phone Ded-15,00 Vouchers 3
Male 2 MA Massachusetts SI 1400.00 48.22 Net 1201.33
Chks&Whirs 3 MED Medicare 1400.00 20.29 Dir De
Female 0 1201.33
Male 2 SS OASDI 1400.00 86.80 Chk Amt 0.00
Total Earnings 24.00 1400.00 Total Taxes 183.67 Total Deductions 15.00
HaWers Payroll Services Run Date: 07/13/16 Dept. (100)100
Filing scams and exemptions display current data,not data at the time of the payroll. Run Time: 1146 AM
Employee Gomez to Maul
FLI Environmental
69 BRIDGE STREET
DEDHAM, MA 02026
PHONE 781 .251 .0040
FAx 781 .251 .0901
September 7, 2016
Mr. Mike Lutrzykowski
City of Salem
One Salem Green
Salem, MA 01970
RE: Asbestos Abatement Project
Salem Senior Center, 5 Broad Street, Salem, MA
FLI Proposal# 16-143a
Dear Mr. Lutrzykowski:
FLI Environmental,Inc. (FLI) is pleased to submit the following technical and cost
proposal to provide you with Asbestos Abatement and Project Management Services at the
above referenced site. FLI is a Massachusetts Certified Asbestos Analytical Service and
employs individuals licensed by the Commonwealth as Asbestos Inspectors, Designers and
Project Monitors. FLI has conducted a walkthrough of the area to review the existing
conditions. Scope and pricing is based on the abatement plan prepared by FLI
Environmental, Inc. dated August 30, 2016. The proposal shall outline the technical
approach and services for properly removing Asbestos Containing Materials and providing
compliance oversight and air monitoring necessary for proper project completion.
I. SCOPE OF SERVICES:
A. Project Management:
1. FLI shall provide an experienced State licensed Asbestos Project Designer acting
as a project manager to oversee the abatement project for regulatory compliance.
2. At the completion of the project, FLI's Project Manager will prepare a summary
letter report outlining the progress of the project and final air sampling
procedures and sample analysis results which occurred during the abatement
project. All project forms, including daily logs and checklists will be included.
B. Abatement of Asbestos Containing Materials:
1. FLI will contract with a Massachusetts Licensed Asbestos Abatement Contractor
to perform the work. Licensed Asbestos Abatement personnel will conduct all
abatement activities. The Abatement Contractor will provide an experienced
Project Manager to oversee all aspects of the abatement work.
2. The Abatement Contractor will provide an experienced, State Licensed Asbestos
Abatement Project Supervisor acting as the on-site foreman for the project.
Salem Senior Center FLI Proposal# 16-143a
5 Broad St.,Salem,MA Page 2
3. Access to the work areas will be limited and will be posted with warning signs at
all potential entry points.
4. Workers will remove identified asbestos containing materials according to
applicable regulations.
5. All waste will be properly packaged and transported to an approved landfill and
tracked using a waste shipment record.
6. All work practices and engineering controls outlined in the Massachusetts
Regulations regarding Asbestos will be met or exceeded during the abatement
phase of this project.
C. Project Monitoring:
1. FLI shall provide one EPA-AEERA accredited Asbestos Project Monitor to
conduct inspections during preparation and removal work. The exact time,
schedule, and hours utilized will be determined by the final project schedule.
2. FLI's monitor(s)will inspect the Contractor's work for compliance with project
specifications and applicable regulations. FLI shall maintain daily inspection
logs, checklists and reports of activities while on-site during the course of the
asbestos abatement operations.
3. Upon completion of each abatement phase, FLI's Project Monitor will perforin a
visual inspection of the abatement area(s) to ensure that all work is complete and
that the work site is free of dust and debris. Final clearance air samples will be
collected and analyzed after each area passes the visual inspection. Containment
areas will be dismantled and engineering controls removed after the air samples
pass the clearance criteria.
D. Scope of Work:
Removal and disposal of non-ACM debris/stored items
remaining in the area
Boiler Room
Abatement of approximately 70 LF Pipe&Header Insulation
Abatement of approximately 40 SF Tank Insulation
Removal and disposal of non-ACM cardboard and other
"Cardboard Room" debris/stored items remaining in the area
Abatement of approximately 1,000 SF Floor Tile&Mastic
Vault Abatement of approximately 15 LF Pipe Insulation
Maintenance Area Abatement of approximately 45 LF Pipe Insulation
Removal and disposal of non-ACM debris/stored items
Storage Room(adjacent to remaining in the area(large TV and copier to remain)
Maintenance Area)
Abatement of approximately 25 LF Pipe Insulation
Salem Senior Center FLI Proposal# 16-143a
5 Broad St.,Salem,MA Page 3
1I. PROPOSED SCHEDULE
A. Notification will be made to the Commonwealth of Massachusetts upon receipt of a signed
Notice to Proceed or signature approval outlined below. There is a 10 working day
notification period required by MassDEP and DLS prior to starting abatement activities;
work will be scheduled as soon as possible thereafter.
B. Work will be scheduled during first shift working hours and will be coordinated with
the owner to accommodate accessibility and scheduling issues.
C. The project is anticipated to take up to ten (10)work shifts to complete and is
tentatively scheduled to begin in September, 2016.
D. The final comprehensive monitoring report and Project Manager summary will be
completed within one week of abatement project completion.
III. FEE SCHEDULE:
A. The work shall be invoiced using the rates listed below. The rates quoted include
portal to portal hours from FLI's Dedham office and are inclusive of expenses.
B. Totals listed below are for the completion of the project from start to finish and
include: abatement and disposal of Asbestos Containing Materials noted above
including, labor, material,permits, equipment and insurance; providing compliance
oversight and air monitoring. No additional amounts will be billed without specific
authorization from client.
1. Asbestos Abatement $33,330.00
2. Project Management& Compliance Oversight $4,400.00
TOTAL $37,730.00
IV. TERMS:
A. An invoice for the total amount due will be sent upon completion of the abatement
and submittal of the final report. Payment is due in full upon receipt of invoice.
FLI shall schedule the work upon receipt of a signed contract or signature approval
outlined below.
B. All rates listed above are applicable for work performed within an 8-hour shift
during first shift working hours(between 6:00 a.m. to 5:00 p.m.), Monday—Friday.
C. The client or owner must remove all furniture, equipment and moveable stored items
that are to be retained from the work areas prior to commencement of the project.
D. Water and Electricity must be available at the site at no additional cost.
Salem Senior Center FLI Proposal#16-143a
.5 Broad St.,Salem,MA Page 4
E. The rates listed herein shall be valid for this project for a period of thirty(30) days.
Should you have any questions regarding this proposal, please do not hesitate to contact us
at(781)251-0040. FLI appreciates the opportunity to provide our services to you and we
look forward to working together on this project.
Sincerely,
FLI Environmental,Inc.
David MacDonald
President
Approval for FLI Proposal#16-143a by City of Salem and Notice to Proceed:
Signature Date
Print Name and Title Purchase Order Number
t 69 BRIDGE STREET
R'PFLI
DEDHAM, MA 02026
PHONE 781 .251 .0040 Environmental FAX 781.251 .0901
May 1,2016
City of Salem
5 Broad Street
Salem,Massachusetts 01746
RE: Inspection for Asbestos Containing Materials at
Salem Senior Center, 5 Broad Street, Salem,MA
FLI Project#: 16-1240
Dear Mr. Silva
FLI Environmental, Inc.performed an inspection for asbestos containing materials(ACMs)at the
property located at the address noted above. This report outlines the initial visual survey, sample
collection and summary of analytical results provided by FLI.
Inspection Summary:
"4
Asbestos Inspector: Richard Bowen
License#: A1061044
Date of Inspection: April 6,2016
Total Materials Sampled: 5
Samples Analyzed At: Asbestos Identification Laboratory, Inc.
NIST/NVLAP Certification#: 200919-0
MassDLS Lab Certification#: AA000208
Scope and Approach:
FLI provided a state licensed and EPA AHERA accredited asbestos inspector to perform an inspection of
the subject area(s). The purpose of the inspection was to identify and sample building materials suspected
to contain asbestos. Suspect materials include thermal system insulation,fireproofing, soundproofing,
plasters, skimcoating, spray-applied or trowel applied finishes, ceiling& floor tiles, sheet flooring,
caulking,glazing,mastics, adhesives, cement board products, roofing materials and numerous other
products. Materials having the same function/application, similar color,texture or other observed similar
characteristics were grouped together and sampled as one homogeneous material. A minimum of 2
samples of each homogenous material were collected.
Homogeneous materials determined to be non-suspect by the inspector(if observed), include concrete
floors,wood flooring/joists, concrete block, black/brown vinyl flexible duct connectors,fiberglass
insulation, armaflex(neoprene) insulation,rubber, plastic, ceramic tile, glass and metal.
Salem Senior Center,5 Broad Street, Salem,MA
Asbestos Inspection
May 1,2016
Page 2
If present, areas within walls, drywall encased columns and above ceilings were inspected where possible
in accessible representative locations. However, each individual enclosed area was not inspected.
Accessible areas beneath such surfaces were examined and sampled, and material quantities were
estimated based on these observations.
Bulk Sampling:
Bulk samples were collected in a random manner and submitted via chain of custody to the analytical
laboratory. The samples were analyzed by Polarized Light Microscopy per EPA Method 600/R-93-116,
July 1993. The detection limit of the EPA recommended method is one percent asbestos by weight.
Materials containing greater than one percent asbestos are treated as asbestos-containing as required by
the EPA. The laboratory is accredited by the National Institute of Standards and Technologies
NIST/NVLAP Program and licensed by the Massachusetts Department of Labor Standards(DLS)for
asbestos analysis in bulk materials.
Asbestos Containing Materials:
Any homogeneous material having at least one(1)sample analyzed to contain greater that one percent
(1%)asbestos is categorized as an asbestos containing material. A summary of materials determined to
contain asbestos is provided in Appendix A including approximate location(s)of the material and
estimated quantities. Laboratory Analytical Data Sheets for each sample analyzed are included in
Appendix C.
Non-Asbestos Containing Materials:
Homogeneous materials where each sample analyzed was determined not to contain asbestos are
categorized as non-asbestos. A summary of non-asbestos materials is provided in Appendix B.
Laboratory Analytical Data Sheets for each sample analyzed are included in Appendix C.
Remarks and Limitations:
I. Additional unforeseen suspect materials may be present beneath surfaces(multiple layers)or
within chases or crawlspace areas that were unknown at the time of the inspection but may be
discovered during demolition,renovation or maintenance activities. Any additional suspect
materials not identified in this report that become exposed during building renovation,maintenance
or demolition should be sampled and analyzed for asbestos content prior to disturbing.
2. Each identified asbestos containing material must be removed by a licensed asbestos abatement
contractor prior to being disturbed by building maintenance,renovation or demolition activities.
3. This report is not meant to be used as an asbestos abatement plan or abatement specification.
Material quantities and locations are estimates and approximations and should not be used to obtain
pricing from contractors. FLI recommends contracting for abatement after an abatement
specification is prepared by a licensed Asbestos Project Designer.
Should you have any questions or need additional information, please contact our office at(781)251-
0040. Thank you for the opportunity to provide you with our services and we look forward to working
together in the future.
S�1` Salem Senior Center,5 Broad Street,Salem,MA
it lFLfEnvironmentalAsbestos Inspection
May 1,2016
page 3
APPENDIX A
Asbestos Containing Materials Summary Table :r
Material Location Estimated ~Sample#('s)
Quantltv
Black Floor Tile Basement,"Cardboard Room" 500 SF 1240-04A,B
Black Mastic Associated with o4 Basement,"Cardboard Room" 500 SF 1240-05A,B
o;ttot . Salem Senior Center,5 Broad Street,Salem,MA
I oFO Environmental Asbestos Inspection
May 1,2016
page 4
APPENDIX B
Suspect Materials Found Not to Contain Asbestos
♦\ - _ 'f. ^
Sample#('s) Material Sample Location A Sample Location B Sample Location C
1240-01 Tan 12"x 12"Floor Tile 2nd Floor, Large Room 0 0
1240-02 Beige 12"x 12"Floor 3rd Floor,Large Room 0 0
Tile
1240-03A,8 Yellow Mastic
Associated with 01,02 2nd Floor,Large Room 3rd Floor,Large Room 0
Asbestos Identification Laboratory Batch: 13150
165 New Boston St., Ste 271
Woburn, MA 1
781-932-96002-9600 KV nW V
Web:www.asbestosiden6ficationlab.com
Email:mikemanningCasbestosidentificationlab.com Lab Code: 200919-0
May 03, 2016
Rick Bowen Project Number:16-1240
FLI Environmental Project Name:Salem Senior Center-5 Broad Street,
69 Bridge Street Salem, MA
Dedham, MA 02026
Date Sampled: 2016-04-06
Work Received: 2016-05-02
Analysis Method: BULK PLM ANALYSIS EPA/600/R-93/116
Dear Rick Bowen,
Asbestos Identification Laboratory has completed the analysys of the samples from your office for the above referenced project
The information and analysis contained in this report have been generated using the EPA /600/R-93/116 Method for the
Determination of Asbestos in Bulk Building Materials. Materials or products that contain more than 1% of any kind or
combination of asbestos are considered an asbestos containing building material as determined by the EPA. This Polarized
Light Microscope (PLM) technique may be performed either by visual estimation or point counting. Point counting provides a
determination of the area percentage of asbestos in a sample. If the asbestos is estimated to be less than 10% by visual
estimation of friable material, the determination may be repeated using the point counting technique. The results of the point
counting supersede visual PLM results. Results in this report only relate to the items tested. This report may not be used by
the customer to claim product endorsement by NVLAP or any other U.S. Government Agency.
Laboratory results represent the analysis of samples as submitted by the customer. Information regarding sample location,
description, area, volume, etc., was provided by the customer.Asbestos Identification Laboratory is not responsible for sample
collection activities or analytical method limitations. Unless notified in writing to return samples, Asbestos Identification
Laboratory discards customer samples atter 30 days. This report shall not be reproduced, except in full, without the written
consent of Asbestos Identification Laboratory.
• NVLAP Lab Code:200919-0
• Massachusetts Certification License:AA000208
• State of Connecticut,Department of Public Health Approved Environmental Laboratory Registration Number:PH-0142
• State of Maine,Department of Environmental Protection Asbestos Analytical Laboratory License Number:LB-0078(Bulk)LA-0087(Air)
• State of Rhode Island and Providence Plantations Department of Health Certification:AAL-121
Thank
you
,Rick
nBowen for your business.
/irir�ae�
Michael Manning
Owner/Director
May 03, 2016
Rick Bowen Project Number:16-1240
FLI Environmental Project Name:Salem Senior Center-5 Broad Street,
69 Bridge Street Salem, MA
Dedham, MA 02026
Date Sampled: 2016-04-06
Work Received: 2016-05-02
Analysis Method: BULK PLM ANALYSIS EPA/600/R-93/116
FleldID Material Location Color Non-Asbestos% Asbestos%
Lab1D
1240-01 Tan 12x12 Floor Tile 2nd Floor, Large Room tan Non-Fibrous 100 None Detected
142813
1240.02 Beige 12x12 Floor Tile 3rd Floor Large Room black Non-Fibrous loo None Detected
142814
1240-03A Yellow Mastic Associated 2nd Floor, Large Room yellow Cellulose 2 None Detected
with 01,02 Non-Fibrous 98
142815
1240-03B Yellow Mastic Associated 3rd Floor Large Room yellow Cellulose 2 None Detected
with 01,02 Non-Fibrous 98
142816
1240-04A Black Floor Tile Basement, "Cardboard black Non-Fibrous 98 Detected
Room" Chrysotile 2
142817
1240-04B Black Floor Tile Basement, "Cardboard black Non-Fibrous 98 Detected
Room" Chrysotile 2
142818
1240-05A Black Mastic Associated Basement, "Cardboard black Non-Fibrous 90 Detected
with 04 Room" Chrysotile 10
142819
1240-056 Black Mastic Associated Basement, "Cardboard black Non-Fibrous 95 Detected
with 04 Room" Chrysotile 5
142820
Tuesday 03 May 2016 End of Report Page 1 of 1
Analyzed by: Batch: 13150
/ CHAIN OF CUSTODY Page_ of
Client:_ v 1 EPA16W/R-93/116 Turnaround Time Sample Method
Address: Asbestos Identification Lab Less 3Hre Bulk
Project Site 8
166 New Boston St. Same Day aSoil
Phone/email address: Suite 227 Next Day [D1Nipe
Woburn, MA 01801
(781)932-9600 Day 1:313olnt Count
Contact C www.asbestosidentlflc#6o b.com Stop on let Positive? Yes/No
Relinquish by/date: A Date Sampled: tom(/ Notify Method: E aiWer i
Received by/da (�,� ` C _� Anayzed B '
/ BATCH# \ v \`C 11 1 Rev f2/f5
#of Samples Received/. \ LLLIII���.../// Date:
Temp in Celclus= Stereo Scope Optical Properties RI Non-Asbestos Percen a(%)
c
c o
O Field ID/ fa
o ff (Client a c $ E o
m
Reference) Material/Location IM
o a3d w u
J Q L C L N o
o _o E r Asbestos .8 m d mC
od o ar o
= Minerals
M g cr x CA 0
Material Chrysotile
r11Amoefte
N Crocidolite
NN Location Tremollte
Anthophylita 10
Actinolite
Material Chrysotile
_ Amosits
Croddolite
CJ Location Tremolite
AMhophyllte
Actinolite
Material Chrysotlle
d 3 Amoslte
('� rocldolRe
Location `� reni
Arithophyllte
Actinolite
69 Bridge Street.Dedham.AAA.02028 (781)251-0040 fax(781)251-0901
ASBESTOS BULK SAMPLE CHAIN OF CUSTODY RECORD
*KFEnvironmental
FLI Project#: 16-1240
Client: City of Salem Date: 4/6/2016
Site: Salem Senior Center, 5 Broad Street, Salem, MA Sampled by: Richard Bowen
License#: A1061044
Asbestos Analysis Positive
Sample#(s) Material Location A Location B Location C PLM TEM c n (yin)
1240-01 Tan 12"x 12"Floor Tile 2nd Floor, Large Room x
1240-02 Beige 12"x 12"Floor Tile 3rd Floor, Large Room x
1240-03A,8 Yellow Mastic Associated with 2nd Floor,Large Room 3rd Floor,Large Room x
01,02
1240.04A,B Black Floor Tile Basement,"Cardboard Room" Basement,"Cardboard Room" x
1240-05A,6 Black Mastic Associated with o4 Basement,"Cardboard Room" Basement,"Cardboard Room" X
Turnaround: Rush 24-Hr 48-Hr
Relinquished by:
ZeflTim 3-Dey -Day 5-Day
Received by:
Datertime Date Needed
Relinquished by:
Date/Time
Received by:
DateTme
Page 4 of�,
vQ':coNat,�O
CITY OF SAELM
DEPARTMEN ] OF PL. ANNIN ( i AND
COMNILINITY DEVI_L.0Pi\IE. N I
Kimberley Driscoll
MAN-OH
Ll) bV'\>;nN1,W\ N i:i i i • i i-1119711
LYNN GO I NIN DtM AN.AICP I I L 978-010 5685 . I;AX: 078-7-lo-0404
MEMORANDUM
To: Mayor Kimberley Driscoll
City Council
Cc: Cheryl LaPointe, City Clerk
Beth Rennard, City Solicitor
Re: Surplus recommendation—5 Broad Street
Date: February 10, 2009
We recommend that the City-owned parcel and structure thereon at 5 Broad Street,
Assessor's Map 25, Parcel 546, be declared surplus property as it is no longer needed for
any municipal use.
We conducted a survey of all Department Heads to determine if there was any potential
municipal use and did not receive any interest in the parcel or building.
Thomas St. 151erre Duncan
Director of Inspectional Services City Planner
(Public Properties)
��t _ _
5 ��rl� .
Since 1873 ?.
EMBREE V,2 *IITE INC.
ELEVATORS-MACHINISTS 26-30 FARRAR ST. LYNN, MA 01901
CITY OF SALEM
ATTN: PURCHASING, LIZ
ONE SALEM GREEN
SALEM, MA. 01970 Feb. 15, 1996
RE: PASSENGER ELEVATOR @ SALEM COUNCIL ON AGING
Dear Liz:
During a recent service of the elevator @ 5 Broad St.
Salem, our service department made the following
recommendations:
Elevator #258-P-15
* We will furnish and install a modern infra-red
door detector in replacement of the safety edge,
the advantages of this State of art door
protection is the door will automatically
reopen/retract without any contact with the
doors, this not only protects the passengers but,
it also protects all the doors.
Price: $1,345. 00
Time out of service: approx. 4 hours
* We will furnish and install a hydraulic tank
heater because when the hydraulic oil is cold
the elevator may not level properly until it
warms up, this may cause a tripping hazard,
this usually happens in the morning when the
elevator has not been used throughout the
night
Price: $345.00
Time out of service: this will not effect
service
Please sign and fax/return one copy of this quote
if you wish for us to proceed with these repairs, we will
call to schedule work arrangements.
Authorized by
Date P.O.#
Attention to this matter will unsure safe and proper
operation of your elevator equipment.
Sincerely,
pneph Comley
General Manager
617/593-3604 • 617/598-5553
1-800-424-5554 • FAX 617-599-6720
Since 1873
EMBREE & WHITE INC.
ELEVATORS-MACHINISTS 26-30 FARRAR ST. LYNN, MA 01901
CITY OF SALEM
ATTN: PURCHASING, LIZ
ONE SALEM GREEN
SALEM, MA. 01970 Feb. 15, 1996
RE: PASSENGER ELEVATOR @ SALEM COUNCIL ON AGING
Dear Liz:
During a recent service of the elevator @ 5 Broad St.
Salem, our service department made the following
recommendations:
Elevator #258-P-15
* We will furnish and install a modern infra-red
door detector in replacement of the safety edge,
the advantages of this State of art door
protection is the door will automatically
reopen/retract without any contact with the
doors, this not only protects the passengers but,
it also protects all the doors.
Price: $1, 345.00
, Time out of service: approx. 4 hours
* We will furnish and install a hydraulic tank
heater because when the hydraulic oil is cold
the elevator may not level properly until it
warms up, this may cause a tripping hazard,
this usually happens in the morning when the
elevator has not been used throughout the
night
Price: $345.00
Time out of service: this will not effect
service
Please sign and fax/return one copy of this quote
if you wish for us to proceed with these repairs, we will
call to schedule work arrangements.
Authorized by
Date P.O.#
Attention to this matter will unsure safe and proper
operation of your elevator equipment.
Sincerely,
epOnComley
General Manag
er
617/593-3604 9 617/598-5553
1-800-424-5554 • FAX 617-599-6720
r
"d
PATRICIA
Actmg Director
«�a.a
In Your Reply
Refer to He
%I/edf./V WWeupfaiL, ���cca6% 0265 90A-0165
November 22, 1989
C
n frr
William H. Munroe s,e, C4M
Director of Public Property = '
1 Salem Green
r"
Salem, MA 01970 ;n� _� -
Dear Mr. Munroe: N
On November 13, 1989, the Salem Council on Aging on 5 Broadstreet'w'as surveyed
to determine the exposure risk of occupants and workers-to-asbestos. This
survey was conducted through a Legislative mandate because medical evidence
suggests that individuals exposed to asbestos fibers may be vulnerable to
environmentally induced cancers. This report should be used as an overview of
the location and condition of asbestos-containing material. All
recome-ndations are based on the condition of the material at the time of the
survey. Bulk samples taken on the survey were analyzed by polarized light
microscopy with dispersion staining. The results of the analyses and
recOnmendations follow. Note that where asbestos was in good condition, no
sample was taken. Our Division feels that cutting into a well wrapped covering
creates an unnecessary exposure risk. Coverings are assumed to be asbestos
until proven otherwise. If these coverings become damaged or it becomes
necessary to cut into these coverings, a sample should first be sent in to our
office for analysis.
Background
Asbestos is a known human carcinogen. There is no evidence of a threshold
exposure level at which the risk of cancer is not increased. While it is
difficult to quantify the precise risk posed by exposure to asbestos,
unnecessary exposure must be avoided. Generally speaking, with increased
exposure or prolonged exposure, the risk of an asbestos related disease
increases.
Asbestos exposure can be estimated in two ways. First, by measuring the
asbestos fibers in the air and secondly, by visually inspecting the ACM.
However, air monitoring data reflects only current airborne asbestos levels and
Provides no information about future exposures. Air monitoring can be
misleading, showing low airborne asbestos levels in an environment where severe
damage to. ACM is obvious. Airborne asbestos levels may be low even where fiber
release is significant if fibers have settled out of the air and there is
Salem Council on Aging
90A-0165
Page 2
little activity in the area while sampling is taking place. Different
circumstances can produce much higher levels of airborne asbestos on days when
the asbestos fiber concentrations are not measured. The U.S.E.P.A. does not
recommend air monitoring for initial assessment of exposure potential.
Visual inspection is the preferred approach to exposure assessment. It is
based on the premise that certain observable factors/diaracteristics of the ACM
and the building environment are good indicators of current or future fiber
release episodes and resulting exposure levels.
The actual potential for exposure depends on many factors, including: (1) the
asbestos content of the material; (2) the friability of the material, i.e., its
tendency to crumble; (3) the amount of physical deterioration present; (4)
activity/movement in the building; (5) physical placement of the material in
relationship to the HVAC system; (6) percent composition of asbestos; (7)
occupancy duration; and (8) the exposure and accessibility of the material.
These factors may act singly or in combination to produce environmental
contamination.
The following is an evaluation of these factors/characteristics as observed on
the first visit. Response actions were formulated on the basis of the
following assessments.
Under the current Federal and State regulations the initiation of response
actions including repair, encapsulation or removal of asbestos in most cases is
voluntary. Once initiated, then all of notifications, procedures, practices,
and disposal of asbestos are highly regulated.
Morris Martineau acanied the D.O.H. representative during this survey.
Results of samples taken during the survey were as follows:
Lab No. Building Name Description Results Percent
90B-0503 Council on Aging Boiler froom, spray-on Fiberglass 75
5 Broadstreet, Salem fireproof ceiling Gypsum 20
Cellulose 5
90B-0504 Council on Aging Boiler room, elbow Chrysotile 70
5 Broadstreet, Salem joint Binder 15
Cellulose 15
90B-0505 Council on Aging Boiler room, header Chrysotile 60
5 Broadstreet, Salem insulation off boiler Fiberglass 10
Cellulose 10
Binder 20
90B-0506 Council on Aging Boiler room, high Chrysotile 60
5 Broadstreet, Salem horizontal pipe cover Fiberglass 10
Cellulose 10
Binder 20
Salem Council of Aging
90A-0165
Page 3
Lab No. Building Name Description Results percent
90B-0507 Council on Aging Domestic hot water Chrysotile 65
5 Broadstreet, Salem tank casing (old unit) Gypsum binder 35
90B-0508 Council on Aging Exhaust Stack, inner Calcite binder 70
5 Broadstreet, Salem block insulation Synthetic fiber 20
Cellulose 10
90B-0509 Council on Aging Boiler exhaust stack Gypsum 65
5 Broadstreet, Salem outer skin coat Fiberglass 30
Sand 5
90B-0510 Council on Aging Ceiling tile 21x2' Fiberglass 90
5 Broadstreet, Salem off of black stairway Binder 5
Paint 5
Observations/RecomTendations
Asbestos containing building material (ACBM) can be divided into the following
three categories:
1. Surfacing ACBM - spray on decorative, acoustical, fireproof
2. Thermal ACBM - coverings that prevent heat transfer-pipe, boiler,
tank, duct
3. Miscellaneous ACBM - all other types, e.g., floor tile, ceiling tile,
etc.
Response Actions were recommended on the basis of the following assessments:
Condition
- physical state of ACBM
- undamaged or damaged, e.g. , water, humidity, physical
- nonfriable or friable (able to be cnmibled with hand pressure)
Disturbance factors
- accessibility
- vibration
- air erosion
Air flow
- air plenum - the space between a permanent and suspended
ceiling used to transport air
- air shaft - a vertical air plenum
- elevator shaft - piston action of elevator moves air between
floors
Salem Council on Aging
90A-0165
Page 4
General Irnentory
This three story brick building has an oil fired radiator heating system.
Asbestos containing pipe and joint covers in fair to poor condition were found
in the boiler room and basement. vinyl based floor tiles, which may contain
asbestos, were observed on all floors. One suspended ceiling tile was tested
and was non-asbestos and the plaster walls were undamaged and not tested.
Spray-on ACBM
Fireproof material found on the boiler room ceiling was analyzed and confirmed
to be a non-asbestos material. No other spray-on was observed in this
structure.
Thermal ACBM
The heating system was an oil-fired steel jacketed boiler, insulated with
fiberglass. The new domestic hot water heater was also steel jacketed with
fiberglass insulation below. The old hot water storage tank has a packed
plaster/asbestos insulation casing. The casing was old and friable and in poor
condition, in that a large section of casing was missing near the tank bottom.
The tank was no longer in service so future damage is unlikely. The tank and
asbestos casing should be removed and disposed of as asbestos containing waste
as soon as fiscally practical. The pipes associated with the new hot water
tank were fiberglass with PVC covered joints, however the high horizontal
straight runs of pipe covering that start from the boiler header are asbestos
containing (see samples 0504, 0505, and 0506) . These coverings have
significant contact damage and are friable. These coverings appeared beyond
repair and must be removed as soon as possible. The pipe covering in the
basement outside of the boiler room has spot contact damage which must be
repaired as soon as possible to an undamaged state. Disturbance of the thermal
acbm by vibration, air erosion, and fiber spread by air flaw in the basement
was considered minimal. The asbestos containing thermal insulation should be
labeled to prevent accidental disturbance.
The exhaust stack skim coat and underlying block insulation (0508 and 0509)
were tested and found to be non-asbestos containing.
All other pipe coverings observed on the upper floors were fiberglass.
Miscellaneous ACEM
Polyvinyl chloride based floor tiles in very good condition were observed on
the first and second floors. No samples were taken however prior to any
renovation or removal of these floor tiles, samples should be sent to a
certified testing lab for analysis.
Between 1950 to present some manufacturers of polyvinyl chloride floor tiles
have added up to 21% asbestos to their product. Under normal use conditions
the floor tiles are not considered friable, and pose no exposure risk to
occupants and workers.
Salem Council of Aging
90A-0165
Page 5
However, any removal or renovation operation which involve sanding, sawing,
scraping, chipping, blasting, drilling or pulverizing of otherwise non-friable
asbestos containing materials will release asbestos fibers and are subject to
the provisions of the state asbestos regulation 453 CMR 6.00 "The Removal,
Containment or Encapsulation of Asbestos".
Exemptions from 453 CMR 6.00 may be granted on a case by case basis by the
Commissioner if the work operations involving non-friable asbestos containing
material can be performed without production of asbestos dust. For example, if
the vinyl asbestos floor tiles (VATS) can be removed intact without sanding the
underlying mastic.
For more information refer to the enclosed policy statement No. 8842.
A mixture of two foot by four foot and two by two foot suspended ceiling tiles
were observed in the first and second floor offices, bathrooms, cafeteria and
bingo hall. A sample of one (0510) tile was analyzed and no asbestos was
detected.
The third floor had new looking plaster walls and ceilings in excellent
condition. No samples of wall plaster were taken in this building. Damaged
plaster is often sampled because prior to 1973, some joint compounds and
wallboards contained asbestos. Prior to any further renovation which would
entail wall removal, samples should be sent to our office or an accredited lab
for analysis.
Until the acm pipe and tank covering can be scheduled for removal and/or
repair, an operations and maintenance program should be developed.
An operations and maintenance program should include periodic surveillance of
the asbestos Containing material (acm) for damage as well as training of
maintenance staff.
The EPA recommends including in an 0&M program instruction in minimizing
disturbance by staff.
For example staff should be instructed:
1. Not to drill holes in acm.
2. Not to hang plants or pictures on structures covered with asbestos-
containing materials.
3. Not to sand asbestos-containing floor tiles.
4. Not to damage asbestos-containing materials while moving furniture or other
objects.
5. Not to install curtains, drapes, or dividers in such a way that they damage
asbestos-containing materials.
Salem Council of Aging
90A-0165
Page 6
6. Not to dust floor, ceilings, molding or other surfaces in asbestos-
contaminated environments with a dry brush or sweep with a dry broom.
7. Not to use an ordinary vacuum to clean up asbestos-containing debris.
S. Not to remove ceiling tiles below asbestos-containing materials without
wearing the proper respiratory protections, clearing the area of other
people, and observing removal waste disposal procedures.
9. Not to remove ventilation system filters dry.
10. Not to shake ventilation system filters.
Regulations
All asbestos related work done in buildings should be conducted in conformance
with relevant regulations. -The following regulations may in part or in whole
be applicable to future asbestos projects in your facilities:
- Massachusetts Rerntation 453 CMR 6.00: sets work place standards,
notification requirements, and licensing, certification, and training
requirements for persons involved in asbestos abatement work. Work place
standards and notification requirements became effective October 30, 1987.
Licensing and certification requirements will become effective May 2, 1988.
Any worker who may disturb asbestos material during the normal course of
his/her duties, and whose job itself is not principally that of asbestos
abatement, must receive two days of appropriate asbestos associated project
worker training by October 30, 1988.
- O.S.H.A. Asbestos Standard 1926.58: sets work practice standards for the
construction industry.
- O.S.H.A. 1910 134 Respiratory Protection: sets requirements for a minimal
acceptable program and permissible practice and is referenced to in the
Mass. Regulation 453 CMR 6.00. 1910.134 also requires before issuance of
respiratory protection, that the worker must be evaluated by a local
physician and the physician's determination given that the worker will be
Physically able to perform the work and use the equipment.
- USEPA National Standard for Hazardous Air Pollutants (NFSHAPS) : NESHAPS
requires the removal of asbestos materials (greater than 260 linear feet or
160 square feet) prior to the commencement of any renovation or demolition
work in a building if that work would disturb the asbestos material or
preclude access to the material for removal later. (See also Mass. DEQE
regulations.)
- USEPA "Worker Protection Rule": prescribes stringent work practices to be
followed by state, county, and municipal employees protected under this
rule. The amended Final Rule was published in the Federal Register on
February 25, 1987.
Salem Council of Aging
90A-0165
Page 7
- Massachusetts Chanter 111F (Riot to Know): Be sure to inform all
contractors or maintenance personnel who are on site to perform maintenance
activities of the presence and locations of asbestos containing materials
(ACM) if there is the potential that the activities will disturb the ACM.
Conclusion/Recommendations Summary
1. The spray-on in boiler room and the boiler exhaust casing is not asbestos
containing and no response action is required.
2. The defunct hot water tanks casing is significantly damaged asbestos
containing material. It should be removed as soon as practical by a
licensed abatement contractor.
3. The hien horizontal pipe coverings and elbow joints on plumbing from the
upper header to the end of the boiler room wall were significantly damaged
and should be removed as soon as practical. The same pipes outside the
boiler room have spot damage that should be repaired and labeled as
asbestos containing.
4. At least one or two municipal plumbers or HVAC workers should be trained as
asbestos associated project workers and provided with the necessary
equipment for <3 square/linear feet of asbestos associated work. Refer to
453 CMR 6.00.
5. Prior to any floor tile major renovation ( ! 3 square feet) samples of tile
should be analyzed by a certified asbestos analytical service. D.O.H.
cannot analyze VAT tiles adequately.
It is important to note that the mere presence of asbestos may not create a
health hazard. The exposure risk is dependent on many factors including
accessibility, friability, percent composition and presence in the air plenum.
If the proper precautions and procedures as noted above are followed, the
exposure risk to occupants and building workers can be minimized.
Please notify this office in writing of planned or completed abatement projects
which were recrnmnended in this report so we can update our files as necessary.
If you have any questions regarding this report, please call this office at
9617) 969-7177.
2ur
Y.Pennesi
Environmental Engineer
Approved:
tricia circone
Acting Director
AP/cj
TULI Of itttlem, Massac4usctts
public PropertU Department
+Nuilbing Bepartment
lone t4ntem Green
500-745-9595 Ext. 300
Leo E. Tremblay
Director of Public Property
Inspector of Building
Zoning Enforcement Officer
SPECIFICATIONS
Coastal Storm Damage
Repair of Roof
Council on Aging, 5 Broad St. , Salem
Replace all missing and loose copper flashing
Replace all missing and damaged slate shingles
Do all necessary patching around roof penetration
Repair and replace all missing facia and soffit boards
Back prime and paint all wood that is being replaced
Use only galvanized nails at wood work
STARTUAIS
NHN
CONSULTING
June 23, 1997 ENGINEERS
City of Salem
Planning Department
One Salem Green
Salem, MA 01970
Attention: Kathy Winn
Assistant Community Development Director
Reference: 5 Broad Street
First Floor Alterations
Dear Kathy:
We have reviewed the feasibility of removing selected interior walls at the first floor of the
Council on Aging building at 5 Broad Street. These are as shown on sketch "SK-1",
attached. We have inspected of the structure above and below the first floor, and have
done a limited amount of exploratory demolition to expose the existing framing system,
and have structurally analyzed representative members.
The following information is based a compilation of the results of our investigation and
analysis, and upon assumptions which we have made regarding existing material
strengths.
Overall Building Construction and Condition:
The existing building at 5 Broad Street is as former three story, turn-of-the-century school
building with wood joist and timber beam interior floor framing supported on a mix of cast
iron an timber columns, brick piers, and wood stud and brick bearing walls. The roof is
framed of deep timber through trusses with the 3rd floor supported by the bottom chord
and suspended by hangers from the top chord panel points.
The building is arranged in three sections: an east section which nearly comprises half of
the structure, and similarly sized west section which are divided by a much narrower
central core bay which contains the stairways. In this report we will call these the "east
section", the "stair bay", and the "west section".
All framing is symmetrical about the central stair core of the building, with joists running
parallel to Broad Street. The joists of each half of the second floor are supported at the
P.O. Box 8560 • Salem,Massachusetts 01971
(508) 745-6817 • Voice / Fax
5 Broad Street Alterations June 23, 1997
City of Salem,MA Structures North
exterior end wall, at a beam and column line approximately 12 feet in from the end wall,
and a wood stud bearing wail on each side of the stair core. The first floor joist framing is
supported by the outside walls, two interior framing lines in both the west section and east
section, and by the framing lines which support the walls of the stair bay.
The exterior bearing walls are of multi-wythe brick construction resting on a stone
foundation below the first floor elevation. Alterations have been undertaken in structure
over the years which most obviously include lowering the basement floor elevation in the
workshop below the east section, and adding an elevator in the east section along the stair
bay. The basement floor work also included adding a steel beam and steel pipe columns
below the eastern-most interior bearing line, adding a ramp, and probably underpinning
some of the exterior foundations.
Most of the structural members which we observed were in relatively good condition, with
the exception of some punkiness in a few of the first floor members exposed over the
basement.
Considering the age, condition, and looks of the structure, we have assumed that the wood
beam and joist framing is Dense Southern Pine or Dense or Close Grained Douglas Fir
with an allowable bending stresses in the range of 1,500 to 2,000 psi. We have assumed
that the brick bearing walls have the equivalent of an early "Grade A" brick with lime-sand
mortar, having an allowable compressive stress of at least 100 psi on the gross area.
Based some of the codes which were in effect in the first half of this century, smaller
classrooms (less than 900 sf area) were designed to support 50 pounds per square foot
(psf), larger classrooms, open plan areas, and lecture halls supported 100 psf, and
corridors supported 75 psf. Partition loads were counted as no less than 2 psf per vertical
foot floor to floor height.
East Section and Proposed Modifications:
The east section of the building has an open plan at the second and third floors and is
partitioned into smaller rooms at the first floor and basement. The second floor is used as
a function area. Activities include ballroom dancing, meals, and bingo. It is desired that
the open plan area and associated activities be moved down to the first floor by clearing
out all of the interior walls to the east of the stair bay. By the former code as well as the
current code, the present occupancy of the second floor would be considered 100 psf and
that of the first floor would be considered 50 psf plus about 20 psf for partitions.
In our investigation, we found that the walls which need to be removed are framed as non-
load bearing interior partitions, with the top plates touching only bottom of the ceiling
strapping, and a gap of varying width between the top wall plate and the bottoms of the
Page 2
5 Broad Street Alterations June 23, 1997
City of Salem,NIA Structures North
second floor joists. We dynamically loaded the second floor (two people jumping up and
down simultaneously) and observed the gap width oscillating between 3/4" and 1/4" with
the loading, demonstrating the lack of direct support provided by the first floor walls. I also
observed a horizontal crack in the plaster along the tops of the walls where it flexes when
the ceilings move up and down with respect to the tops of the walls.
In looking at the second floor one can see raised areas over the first floor walls which are
parallel to the joist framing. This is due to the fact that, the strapping and plaster provide
enough support for the isolated joists under which the walls run parallel fir them to have
deflected less than the surrounding framing. We found that the second floor is framed of
full 2x10 joists @15" for a 12 foot span and full 3x13'/2 joists @ 15' for an excessive 32
foot span if we discount the first floor walls.
In structurally analyzing the second floor joists and beams, we found the framing of the 32
foot span and the supporting beam were up to 30% to 40% overstressed for a 100 psf live
load and a 20 psf dead load. Fortunately, the joists of the 12 foot span were found to be
acceptable. If one considers the possibility that the second floor may have originally been
designed to contain partitioned classrooms, the live load would have been 50 psf and the
dead load would have been 20 psf plus approximately 20 psf in partitions. A present load
of 100+20=120 psf is 33% greater than a former classroom load of 50+20+20=90 psf,
falling into the 30% to 40% overstress range. It therefore seems likely that the second floor
was originally framed as a classroom space.
Without the first floor walls, the second floor would deflect nearly 3" at full loading and
would be unacceptably overstressed. Even though these walls were not framed to be load
supporting and we believe they provide a secondary means of support at full loading.
During a fast dance, for example, the gap between the wall and the floor probably opens
and closes as the floor "bottoms out' to the beat of the music and dancers above. The
load is then shifted to the first floor, which also was not designed to take this added load
but is usually not fully occupied when dancing is going on above. It is therefore important
that a direct method of support be provided for the second floor, whether the walls are
removed at the first floor or not.
Based upon our measurements of the first floor framing in the basement of the west
section of the building, and assuming this is as symmetrically framed as the other levels
have been found to be, the first floor joists should be sufficient to support a 100 psf live
load and a 20 psf dead load at this level. As previously noted, some modifications have
been undertaken beneath east half and the members were not completely accessible for
our inspection. We can only assume that these were constructed to the full capacity of the
supported framing. The columns appear to be more than sufficiently sized.
We have developed two schemes for the removal of the interior walls at the first floor. The
Page 3
5 Broad Street Alterations June 23, 1997
City of Salem, MA Structures North
first involves the retention of three columns at the interior bearing line toward the east wall,
and the second involves the same but with the removal of the middle column (please see
sketches SKS-2 & 3 and SKS-4 & 5, respectively).
The structural work would consist of internally adding structural steel beams and posts in
sections beneath the second floor while the walls are in place. This work would also
include strengthening the existing columns where necessary, supplementing the existing
bearing wall along the stair bay with two new columns, and adding some shallow concrete
footings or reinforcing those already in place. Following installation of the internal framing,
the walls would then be demolished without any additional shoring or bracing required. We
estimate that the heaviest piece of steel would be 20 feet long and would weigh not more
than 800 lbs.
West Section and Proposed Modifications:
In examining the west section, we noted that all of the partitions which you have planned
to remove are only of partially clad, light frame construction, running between the finished
first floor and the underside of the plaster ceiling above. We have noted that the spaces
above are being used as offices, for which the design live load is equivalent to the original
classroom occupancy for which the structure was presumable designed. We were able
to locate columns, dropped beam locations, and framing orientations which directly
correspond to those which we measured in the east section. It is therefore our conclusion
that the light partitions may be removed without any supplementary reinforcement.
As the first floor is framed sufficiently to support a 100 psf live load, the kitchen may be
expanded as may be required as the blanket live load for kitchen use is no greater than
100 psf. Depending upon the sizes and weights of the some of the isolated pieces of
equipment, they might require adjustable posts being placed directly beneath their
supporting members if their weight approach several thousand pounds. These loads
should be evaluated on a case-by-case basis.
Budgetary Estimated of Construction Costs:
The following is our budgetary estimate of the structural cost of adding the necessary steel
framing and foundation work for the elimination of the interior walls with three columns and
two columns respectively. Included is an allowance for finish repairs at the basement level
which are only directly related to the structural modifications themselves. All other finish
work is rolled into the subsequent budget estimate for the interior renovation and finish
work. The interior renovation estimate includes allowances for electrical and mechanical
work but does not include any kitchen fit-out work as this would be a specialty to the project
and at the City's direct discretion. Kitchen related costs would include special finishes,
ventilation, fire prevention, plumbing, and equipment and would be considered additive to
Page 4
5 Broad Street Alterations June 23, 1997
City of Salem, MA Structures North
the costs which we have provided.
Structural Work with Three Interior Columns:
Item Low End Estimate High End Estimate
Structural steel beam and column $15,500.00 $20,000.00
fabrication and installation.
Jack, remove and replace existing $1,500.00 $2,000.00
timber column with new steel column.
Retrofit existing columns at first floor. $3,400.00 $5,000.00
New footing and footing reinforcement. $1,500.00 $2,200.00
Finish repairs at basement. $500.00 $1,500.00
Fireproofing encasements around steel. $1,250.00 $1,300.00
Total with three interior columns: $23,650.00 $32,000.00
Structural Work with Two Interior Columns:
Item Low End Estimate High End Estimate
Structural steel beam and column $18,500.00 $23,000.00
fabrication and installation.
Retrofit existing columns at first floor, $6,000.00 $8,200.00
basement.
New footings and footing reinforcement. $3,500.00 $4,500.00
Finish repairs at basement. $1,500.00 $2,500.00
Fireproofing encasements around steel. $1,500.00 $2,000.00
Total with three interior columns: $30,000.00 $40,200.00
It is assumed that there will be a stage or service area at the east end of the function
space, so that depending upon the layout, two or three interior columns may or may not
be a problem. Total eleimination of all columns may cost in the range of an additional
$30,000.00 to $50,000 and has therefore not been considered a viable option.
Page 5
5 Broad Street Alterations June 23, 1997
City of Salem,MA Structures North
Interior Renovation and Finish Work at First F/oor
Item Low End Estimate High End Estimate
Partition and ceiling demolition. $12,500.00 $15,000.00
Allowance for electrical re-routing from $5,000.00 $12,500.00
partition demolition.
New partitions. $6,500.00 $12,500.00
New suspended ceiling system. $7,000.00 $10,000.00
New flooring. $9,500.00 $13,500.00
New finish carpentry. $10,000.00 $25,000.00
Electrical fit-out, alarm, lighting. $12,500.00 $27,000.00
Heating and ventilating allowance. $5,000.00 $15,000.00
Total finish work: $68,000.00 $130,500.00
Total Project Budget:
To summarize the preceding, we estimate that if the project goes well, existing conditions
are as assumed, and if the architectural finishes are minimized and a third column is
accepted, the project cost not including kitchen fit-out, general contractor's mark-up, or
design fees can be as low as $91,650.00. If the contingencies are used, existing
conditions are not favorable, the middle column is removed, and more upgraded interior
finishes are selected, the project cost not including kitchen fit-out, general contractor's
mark-up, or design fees may approach $170,700.00. Given the 40% range in cost, it is
clear that the final total will be dependent upon existing conditions which have not been
fully exposed and upon selections and decisions made by the designers.
As I understand the city will be acting as the general contractor on the project, no general
contractor's overhead and profit have been taken. This can run between 20% and 30%
of the project total, depending upon the job. Designer fees will run between 5% and 10%
of the specified work, depending upon the breakdown between in-house and outside
design work, and the nature of the work being specified.
I hope that the preceding is helpful to you in planning these valuable improvements for the
Council on Aging. Please contact me if you have any questions of if we may be of further
service.
Page 6
5 Broad Street Alterations June 23, 1997
City of Salem, NIA Structures North
Please see the attached sketches for your reference.
Warmest Regards,
n M. Wathne, PE, President
Structures North Consulting Engineers, Inc.
Page 7
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The Commonwealth of Massachusetts
g� Board of Bud SA
ding Regulations and Standards ALEM
L OF
Mlassachusetls StatitRialding Code, 780 C'MI§
' Revised_7vlar 3011 '
Building Permit Application To Construct,Repair, Renovate.Or Demolish
One-or Two-Famili,Dwelling
This Section For Official Use Only
10 _-Building YermitNumber: "lJa£e Applied: c,
1 It
Building Official(Print Nar:e) Signature I but,
( SECTION 1:SITE INFOP24ATION
1.1 Property Addres : -L-1 Assessors:Map:&-Parcel:Numbers
� e3�S'CTP.df
l L lals this an accepted street?yes no Map Number Parcel Number
1.3.-ZoningInformation: - 1.4 Property Dimensions: -
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
bob 1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: Outside Flood Zone? Municipal ❑ On site disposal system
Check if yes❑
SECTION.2: PROPERTY OWNERSHIP'
2.1 Ownerr of Record:
Name(Print] City,State,ZIP
No.mid Street Tetepbanc Email Address
tCEf"iTi)1�T3.11E.�'+f'.R11'i'ItaN-i3!FPRilPfICI� F'ORX1-drbe kaltIlan AN.
New Construction❑ Existing Building❑ - Owner-Owupied ❑ Repairs(s) ❑ -Altendion(s) ❑ Addition.-❑-
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
BriefDescription of Proposed WorkZ: eS f
Bloc1 Sf- s� 'P .fn
SECTION&ESTIMATED CONS17RUCTION COSTS
Item Estimated Costs Official Use Only
: .-a or andMate€ials
_ 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
- 2:Electrical - $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing _ $ ;� 2. Other.Fees: $
4.Mechanical (HVAC) $ List:
5.3tleclianical (ire $
Su ression Total All Fees: $
/ t�-- Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �OJ dD ❑Paid in Full ❑ Outstanding Balance Due:
SE-NO -ro M%3"-Ay rna501%3"- A
� r CA
SECTION 5: COINSTRUCTIONSERVICES
5.1 Construction Supervisor License(CS)JL) 0 J'
License Number Expiration Date
Name of�C. Hokicr
ww`�r�S / . List CSL Tvpe(see below)
No.sand Street r 'i'ypc Description
�,� ! 1 el 2 U Unrestricted(Buildings up ng cu.R)
� r/ ( R Rcstdctcdi&2Fami1 Dwelling
Cityll'own,State,ZIP M Mmonry
RC Roofing Covering
WS Window and Sitting
SF Solid Fuel Burning Appliances
291 01r3o9v I Insulation
Telephone Email address D Demolition
- 5.2 Registered Home/I�m,provement Contractor(HIC) j( 1?126'll�
Lf"JY3Y Czrt Pxi�-�(OPP (_.CTI luc CReDg((istralion t�Fmnbor Expiration Date III
- HIC CQmpany�>oS C Registr t Name
N— J�jtreptl; � x(L!5`a a_ �q Email address
Ci /Town,/State,ZIP [ Telephone
SFC N 6:1XrORKER S'ry MPUX8,,AT-JON-1N%I:TRANCE.AYFIDAVFI(M-G,i,,.=s,15z.¢25(40))
Workers Compensation Insurance affidavit 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
Signed Affidavit Attached? Yes .......... No........._'❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTIOR APPLIES FOR BIALMN.G PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf, in.all matters relative to work.authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
&ECTION 711 OWJgERt tIRAUTHOR.IZiMAGFAT_MCLARATTON
By Ernenng my name below,I hereby attcst.under the pwrisand penalties of perjury that all of the information
contained in this a plication is true and accurate to the best of my knowledge and understanding.
Print 0hvn.e.'s or Authorized s Name(Electronic Signature) Date
NOTES:
l. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
{riot registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under MG.L.c.142A.. Other important information on the HIC Program.can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When.substantial-work is planned,:provide the informn.tionbelow:
Total floor area(sq.ft.) {including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
- Number of bathrooms Number of haWbaths
Type of heating system Number of-decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
i
Office of Consumer Affairs and Business Regulation
10 Park Plaza -Suite 5.170
Boston, Massachusetts 021.16
Home Improvement Contractor Registration
Registration: 169898
Type: Corporation
$iT Expiration: 8/16/2017 Tr# 26988d
MURRAY MASONRY & MORE, CORPt}RAT t
BRENDAN MURRAY
P.O. BOX 8454
SALEM, MA 01971
'Update Address and return card.mark reason for change.
- Address E]Renewal ❑ Employment Lost Card
SCA 1 0 2OM-05/11 -
&iH �,»�,r<.,enrr�ofc tea ,�«m
frice of Goasumer Affairs&Business Regulation - License.or.registration.vaBd for individut..uss only
6ZME 1MPROYEMEN7;:o TRACTOR before the expiration date. if found return to:
tration- 189g98 Type: Office of Consumer Affairs and Business Regulation
IRS& 10 Park Plaza-Suite 5170
fxpiratlon 8116=17, Corporation Bostoa,141A 0211E
MURRAY MASONRY&MORE:CORPORATION
BRENDAN MURRAY _ r�
10 REAR JEFFERSON STREETS
V)1ItM,MA 01970 Underseeretary Not valid withou a are
F
PURCHASE ORDER
Fiscal Year 2015 page 1 PLANNING DEPARTMENT
(978)745-9595 EXT 5W2
E�iuchase _Q 44 -n0,0 i20 WASHINGTON STREET 3RD FL
Order SALEM, MA D1970
M YMASONRY AND MORE CORP. fqANNINGDEPARTMENT
100R LYYN STREET (978)T45 9595 EXT-5697
SUITE#1 120 WASHINGTON STREET 3RD FL
PEABODY,AAA O'I98i"3 SALEM.MA
01970
„ -
00008267
06112/15 030803 06/12/15 PLANNING
•4' "'- -: :-__ ,: " .. _, ,Rita:w: .. ....,-.z :,e+-�,asp _ 'FA
ORT(;TNAT.
001 1.00 6500:00000 6,500.00
EACH
RESTORATION OF BROWNSTOM FACADE
PO Total 6,500.00
***** General Ledger Summary Section ***++
Account Amount
25513-5713 6,500.00
,
CITY OF SALEM CITY paEs°ENTTSxiv"r°HEBU ACCOUNT.UNENCUMBERED FUNDS
PURCHASING DEPARTMENT
120 WwftvM Street .
SALEM,�TTSOTM nsr�v>:oar � -- .Whimsy C. HaskeO
TEL 1978)7459595 FAX I978I 744-5918 Furchae,�q ,tOENT�S SKiNAitlPE1
SALES TAX EXEMPTION&E-046.0oj 4t a"3 {NOT VAUD WOUT CITY
7'heLommonweafthofM,assachusetts - - - - - - - - -
- Department of IndustritalAccidents
Offlee oflnvestigations
a a 1 Congress Street, Suite 1,00
Boston, MA 02114-2017
ytzuuv rttlts�gov/tli�
Workers' Compensation Insurance-Affidavit: Builders/Contractors/Electricians/Plumbers-
Applicant Information Please Print Legibly
Name (sts;nessiorganization/Indivi'dual): Murray Masonry and More, Corp.
Address: P. O. Box 8454
City/State/Zip: Salem, MA 01971 Phone #:978-594-1138
Are you an employer? Check the appropriate box: Type of project{required):
1:M I am a employer with 4. 1,am a general contractor and I 6. ❑New 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. 7. Remodeling
slip and have no employees These sub-contractors have g. Q Demolition
working for me in any capacity. employees and have workers' 9 ❑,Building addition
[No workers' comp. insurance comp.insurance.:
required.] 5. E] We are a corporation and its I0.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
Myself,]No workers' comp. right of exemption per MGL 12,Q.Roof repairs
insurance required.] t c. 152, §1(4),and we have no L�e� L� ��
emptoyees. .[No workers' 13�Other Cj C6
comp. insurance required.]
'Any applicant that checks-box#t must also fill outthe section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees: If thesub-contractors have.empiovecs;thcy must provide their workers'comp:policy number:
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name:Acadia Insurance Company
Policy#or Self-ins. Liz. #:WCA 51 7 1 61 2-1 0 Expiration Date:10/03/2015
Job Site Address: 5 Broad Street City/State/Zip:Salem,MA 01970
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 hereby certify under the ains and penalties of perjury that the information providedd}above is trueand correct.
Si ature: Date:
Phone# 978578-0940
Official 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:City/Town-Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person: Phone#:
{
Salem Historical Commission
120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
0 Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: 5 Broad Street
Name of Record Owner: City of Salem
Description of Work Proposed:
Restore brownstone fagade over the front entry.
Dated: June 10 2015 SALEM HISTORICAL COMMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.