13 HOLLY ST - BUILDING INSPECTION (3) a the Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
� OFSALEM
Massachusetts State Building Code, 730 CMR, 7"'edition Hrt�ia�edAom unary
Building Permit Application "ro Construct, Repair, Renovate Or Demolish a /. '008
One-or Two-Family Duelling
This Section For Official Use Only
Building Permit Num, er: Date Applied:
Signature:
Building Commissioner/Ins or of Buildings Dale
SECTION 1: SITE INFORMATION
1.1 Pro{ye Addge�s� v 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? s Municipal❑ On site disposal stem ❑
Public❑ Private❑ Check if yes❑ p P y
yg �
p �! //SEECC,TION �2: PROPERTY OWNERSHIP'
/
2 r n e
-`/O S "�'//`1 7 /�/' A104e
e(Pn t i Address for Service:
�J &I
�nat e 'relephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑J Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specit'y:
Brief Description of Proposed Work':
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlcial Use Only
(Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Cheek No. Check Amount: Cash Amount:
6. Total Project Cost: �17 ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
AI/- X�Z/�mea I.i�•ense Numher I:.spi tinn ate
me nt l.•SI.-I , der Gi- /' 93 �
List C'SL f)�pe(see below)
Ad Tr Description o
Il Unrestricted(tip to 35,000 Cu. Ft.) Of
R Restricted 1&2 Family Uwellin
'gnalure /, M .Mason Only
�Ze 7V 7�/ 7 RC Residential Roofing Co%crin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
U Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) /
HIC Comp• y Nmne r IIC is a amy Regis�Number
Address S'� EABo��z41a!
Lspir Ion Dat
Signatur Tdep ne
ECTION . ORKERS' COMPENSAT N INSURANCE AF IDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the lssuan5c of the building permit.
Signed Affidavit Attached? Yes .......... Nu...........0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. ZYIS AAlnmon as Owner of the subject property hereby
authorize / a AAA to act on my behalf, in all matters
relative to work authorized by this building permit application.
S'i%a�r'e or Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, ,&ZWAL_4�Z4Zg&,N—TAqd1A1 &3VIas Owner o Authorized Agen ereby declare
that the statements and information on the foregoing application are true and accurate, o e es of my knowledge and
behalf.
Print Na
Sig re r or anznd Agent Date
Si med under the pains and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will trot have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.). Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalt%baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"
,
110 VI 12 2UIU 11 : 44 HP LRSERJET FR% Page 3
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CONTRACTOR WORK ORDER
107trtservatfon swwces fi MUP Printed: 111121 10
Judy JOSEPH&IRIS KAMON Phone(eve): (781) 910-66M I
A&M General Contracting 13 HOLLY ST Phone(day): (781) 910-6606 I
2 Tulip St SALEM MA 01970 4654 O Site ID: S1o000864404 j
Salem, Me 01970
Completion Deadline:
Ell I
Worts order:A&M 20101112
ASL Attic Slope Dense Pack 6" 140 2.01999 282.7999
AS-,Attic Slope Danse Pack 6" 210 2.01999 424.1999
KWL Polyisocyanurate T' 192 2.75999 529.9199 .
6mm.PolyVB crawispace 40 0.74000 29,50000
AR Attic Slopes Int Dense Pack 6" 210 2.03999 428.3909
KFL Enclosed Kneewall Floor 4" Cellulose 598 1.18999 699.6599
BEDROOM Hatch: Poyisocyanurate 2" 6 31 155
KFL Kneewall Floor Dense Pack 6" 140 1.92999 270.1999
KFL Open Kneewall Floor&"Cellulose 315 1.16999 368.5499
OTHER Wall Ins. Interior 3"Cellulose 192 1.78999 339.8399
Total for Work Order A&M_20101112: $3,528.17
i
Asbestos Possible Asbestos Containing Material Observed
FOUND IN INTERIOR WALL AND KWF 0 DIAGNOSTIC
K&T Wiring Knob and Tube Wiring Noted Eteddelan Letter on File
HOME HAS HAD HISTORy ON FHW PIPING. AIR SEALERS SCHEDULED SAME DAY DECLINED TO SET UP BLOWER
i
DOOR License#39641E
Moisture Existing Minor Concema/Conditions
SMALL DIRT CRAWL IN BASEMENT
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Cnnawrvatinn Rervinww r�rnun-4n Wanhinntnn Strawt-Wan ihnmunh MA n1fiR1 -Ann-dRn-7479 i
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tic cuiu 11 : w-r HV LHSERJET FAX page 2
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CERTIFICATE OF COMPLETION
i
(Conservation Services Grasp
JOSEPH&IRIS KAMON Phone(eve): (781)910-6606
13 HOLLY ST Phone(day): (781) 910-6606
SALEM MA 01970 4654 E-Mail:
SUM: S10000854464
I.
Contract ID: 810000864464-2712010C Sub-contractor Work Order* A&M_2010111
I
ASL Attic Slope Dense Pack 6" 140
ASL Attic Slope Dense Pack 6" 210
KWL Polyisocyanurate Z' 192
_ 6mm PolyVB crawlspace 40
ASI Attic Slopes lint Dense Pack 6" 210
KFL _ Enclosed Kneewall Floor 4"Cellulose 598
BEDROOM Hatch: Pol isoc anurate 2" 5
KFL Kneewall Floor Dense Pack 6" 140
KFL Open Kneewall Flow 6" Cellulose 315
OTHER Wall ins. Interior 3" Cellulose 192
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PLEASE NOTE:The Inspection of the house is for the purpose of finding CUSTOMER AUTHORIZATION OF CERTIFIED WORK !
out whether the CorNmdor completed the work,
1 confirm thi t the measures listed above have been completed to p y -
CUSTOMER SHOULD NOT RELY ON THE INSPECTION FOR satisfaction. I have recehred a copy of the Certificate of Completion
ASSURANCE THAT THE CONTRACTOR'S WORK NECESSARILY hereby authorise the veterans of any final payments to the Contract i I
COMPLIES WITH ALL LAWS AND STANDARDS RELATED TO understand that this Authorization of Completed Work does not In by
SAFETY. manner void any warranties provided to me by the Contractor.
It was the Contractor's sole responsibility to assure that the measures
were installed properly and safety. In addition, this Post-Installation
Inspection does not replace hrepactione by licensed Inspectors where
required by state or local law. It Is the duty of the Customer to obtain
such required Inspections.
Inspector's Signature Customers's Signature
Date Date
Cnru;nrvafinn SPnAr'AA Crrmn-4n Waehinnfnn StrAat-Wacfhnrnunh MA ni sft1 Rnn-4An-7477
HV LHSENJEI FHX page q
MassSAVE Planview Diagram
Customer 16AAAOA Home Phone
Address_ boll / S-( Work Phone
Town SQl t<ry\ Cell Phone ( )
Any limitations for access by large truck? NO A YES_If yes,describe
Any specific directions or landmarks? NO hr _YES ,N yes,describe
Energy Speclallst spec'ed job: Cell PFwne#
File reviewed by . Office# 508-836.9800 ext CellNOUS #
yo'# rrSLeQ�9't+t46ilo¢ D.Q.(r"Cellalase- 14�A Z"(�olilzao (2x3`kanao��11�
pio* APt.a Sleprs biais� P l� Cdltlett IgZlp ;pti.�iRteR w�11�t1.re.yyh
I gtol{t Att'.� Slats? bdwsca&Cca- L#"C`lteto1F4- 2"Pot.l tso w znE" mr.)
-CM CocleaaeSt V-. F -,t CU Ads-0- � �$' Y W Nlka& .o S - Z"idl frro
31� DPsa r,aF t."uAtolos'e- P
140 ctdr a.1 t." O r /D .401* 60,Arh ;Pal $_ �srrtE
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3"Crtt.rbS�-fvA) ls�j „a— i..,wn Pay.(
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nslae�•1�.�.� L 1 l
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3 t� �rl.aoRECs K-WF �
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Existing Conditions -- X=Access ❑ =Vents Note inside square: R-roof, S=soffit, G=gable,
RV=ridge vent, bS=continuous soffit, CDE=contnuous dd edge, T= turbine
Install - O= New Access: Note in circle: C=ceiling,W=wall, 5 -sheathing Temp unless noted otherwise
p =Vents Note in triangle: R=-W roof, S=soffit, G=gable, M= 12"mushroom, ST= 12"Stack(flat rood
R;:9i35ct.0'wl 5.03
From:Kristin Harris FaxID: Page 2 of 3 Date:11222010 01:39 PM Page:2 of 3
OP ID: KZ
CERTIFICATE OF LIABILITY INSURANCE DA 11/22110
FCERTnIFICATE
RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
ENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.ANT: If the certificate holder Is an ADDITIONAL INSURED, the poNcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
s and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
te holder In Ileu of such endorsement(s)- 781-224-5700 CONTACT
LLC WWW.Mazonson.com NAME 781-224-5777 PHONE.
q
701 Edgewater Drive A/C No 9E
Suite 230 ADDRESS:
Wakefield, MA 01880-6236 cuCOU RJohn Scan' IDcA&MGE-1
INSURED INSVRER(S)AFFORDING COVERAGE NAICt
A&M General Contracting,Inc. wsURERA:Peerless Insurance Co
Norman Dube INSURER a:ACE-USA
119R Foster Street
Peabody,MA 01960 INSURER C:
INSURER D' -
INSURER E:
NSURER F:
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
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,
E%CIUSIONs AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.NSR
LTR TYPE OF INSURANCE 1 R WW POLICY NUMBER MM�DREYVY MMIDD PO Y/TWY LIMITS
GENERAL-LIABILITY
EACH OCCURRENCE $ 1.000,000
A X COMMERCIAL GENERAL LKSILITv CBP8756795 03/20/10 03/20/11 PREMISES E�$ 100.000
CLAIMS-MADEIXJ OCCUR MED ExP(Any one person) $ 5,000
PERSONAL F ADV NMPY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'POLICY X LIMIT APPLIES PER: PPODUCTS-COMP,OPAGG $ 2,000,000
_ POLICY X PECT LOC $
AUTOMOBILE LIABILRY
comaNED SINGLE LIMB $
A ANY AUTO BA8757895 03/20/10 03/20111 COMB 1,000,000
ED)
ALL OWNED AUTOS BODILY IN,ARY(Perperson) $
X SCHEDULEDAUTOS BODILY NXRV(Pereaadenl) $
X HIRED AUTOS PROPERTY DAMAGE $�
X NON-OWNEDAUTOS $
A
U LA LIAR X OCCUR EACH OCCURRENCE $ S,DD0,000
A EXCE%CE5 S LIAR CLAIMS-MADE
DEDUCTIBLE
CUS758895 03/20/10 03120/11 AGGREGATE g 5,000,DDD
X RETENTION $ 10,000
WORKERS COMPENSATION $
AND EMPLOYERS'LIA91UTY X TJRTT MITS DTR
B ANY PRORNETORI EXCLUDED'
Y/N C.46275251 03/20110 03/20/11 E L EACH ACCIDENT $ 500,000
OFFICERI,in NH)
FXCLUDED� NIA
IMentlstory In NH)
If yes 0esmbe un0er EL DISEASE-EA EM(1DYE $ SOO,OOD
DESCRIPTION OF OPERATIONS belmv EL DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATONS/VEHICLES lq"uh AC ORD 101.ACEklonal Remarks$I h.dWe.It mon space is nqulretll
CERTIFICATE HOLDER CANCELLATION
SALEM-2
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
=Washington
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City
ACCORDANCE WITH THEPOLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009l09) The ACORD name and logo are registered marks of ACORD
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I w::M:1'Y:11t I It ul 1.
12^�WASHING JON SrxELT • SALEM. MAMACI It il.I IIJ197.
fla.:978.715-9595 • h.tx. 978.740•9s46
Yorkers' Compensation Insurance Af sdavit: Builders/Contrac torsi Electrici ans/Plumbers
%o )licant Information Please Print Le ihly
V it lTit: (Buenlcss/OrganbatinN I ndty iduuB:
:Wdress:�9
City,Starci/.ip..4��VWA0//Q 6 0 Phone"':
:\re s1 u as employer!Check the appropriate box: 'Type of project(required):
1.IJG I am a employer with .2 6 4. ❑ I mn a general coulractor and 1 6. ❑ New construction
employees(full and/or part-time). have hired the sub-contractors 7. ❑ Remodeling
2.❑ I ant a sole proprietor or partner- listed on the attached sheet.
ship and have no ernpluyccs - These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
No workers' comp. insurance 5. [1 We are a corporation and its exercised their
required.] O 10.❑ Electrical repairs or additions
officers have
3.❑ 1 ❑ni a homeowner doing all work right of exemption per NIGL I LEI Plumbing repairs or additions
myself. INo workers'comp. c. 152,§1(4),and we have no 12.❑,,_,�uuf repaiirrs N' Al
insurance required.] t employees. INo workers' 13.02Other�N��.��N%%�
comp. insurance required.]
•any,ipplicaca dtYt chucks boa It[ must alas fill caul the aecli oil Wow allowing Iheir worked cumpensWiwt put icy intianumion
'I lumw,wnen whu.stdtmil this affidavit indiuuing Ihuy ate doing all work and ducn him outside cuturxton,must submit a new al'rdavis indic tin8 etch.
d"emricu r that check this box must attached an additional sleet showing me classic of the submonlrwtons and their wuAoem'comp.policy information.
/am an employer that Lr proi4ding workers'compensation i isurance jar my entp/ayees. Beaty is the pa/icy and Job site
;n ararut;an �� u S'A
hsuranccQmlpmry Vame: qq '// r / .... . .__.-.---.----_-----
policy 4 ur Sclf--ins. Lic.t1: i, "��Y Fi '-7 .S /. -.--- Expiration Date: A/�r `7 A (�
Job Site -lddress:� (J C'ity,State/Zip'44,2 -/l/l yx el/ /t�
Attach as copy of Bte workers' compensation policy declaration pale(showing;the policy nonber and expiration date).
Failure to secure coverage as required under Section 25A ul'JIGL 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 fine
of till to i250.00 it Jay against llte violator. He advised that a copy of this statement may be forwarded to the Office of
Invrsngaunns of thu UTA for miurance coverage %cJhcation.
/r/a hereby certify r I• if rains and net rjury that file informution provided aboves true Zancorrect.
O,/iciut ase only. I)u not write is this area, to be curap/eted by city or tolva o„ viaL _
I
Cily or Town: _- - Pcnnit/Licvnxe 0._ -
Issuing.\uthurily (circle one):
I. Board of fit
2. Building Department 3. Cityi Ibwn Clerk 4. Llectrical Inspector 5. Plumbing; Inspector
6. Other
0.11tacl l'crsow _ .. Phone q:
Information and Instructions
,,\lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation fix their employees.
Pursuant to this aatute, an rmplurrr is defined as"...every person in the service of another under any contract of hire,
cypress or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
,d the tbreguing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of in 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,cunstruction 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."
`IGL 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."
Additiunully, hIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract f'or 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 tine affidavit for you to till 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 ns.a reference number. In addition,an applicant
ilea[must submit multiple pennit/liceise applications in any given year,need only submit one affidavit indicating current
policy infomation(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 future 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. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I lic 01fice ul investigations would like to thank you in advance for your cooperation'and should you have:any questions,
picas du not hesitate to give us a call
The D.:p:utment's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
ifCvi>cd 5-26-05 www.mass.gov/dia
✓/gyp, 1707/SI)tIY)L[!/66�U1 Of�.. `C(I'WLC/I IIVc'.(n
�f''11��,,Office of Consumer Affairs&Business Regulation
i I�j HOME IMPROVEMENT CONTRACTOR
Registration: 141124
_Expiration: 1/12/2012 -
y , Type: Supplement Card
A+M GENERAL CONTRACTING INC.
MICHAEL FITZGERALD
a 5 SOUTH RIDGE CIRCLE
LYNN,MA 01904 Undersecretary
+- \l:{..;trhu.rtt. - Dcp:u-nncnt ni Publii FAO\
VVBoard of Buildin_ Re uLuion, and ,c{ndard.
3 ,:onstruction Sup4}visor Specialty License
License: CS SL 99933 _
Restncted to: RF WS,DM,IC
MICHAEL FITZGERALD
9 WINCHEST COURT
GLOUCESTER, MA 01930
�s i1J� Cxv,,anon: 6/19/2012
t ..mmi..n,arr Tr- 99933