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63 JEFFERSON AVE - BUILDING INSPECTION (8) b y (at�- 6,ccc,Aff The Commonwealth of Massachusetts Department of Public Safety \Lusar h iurtls tithe ISuilding Code(781)C%I R) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: _ Date:Applied: -__ I Building Official: SECFION 1: L CATION(Please indicates Block ##and Lot#for to O lions for which a street address is not available) Nu.and Street City /roan Lip Code Name of Building(if applicable) SECTION 2: PROPOSED WORK Fdillon of MA Stine Code used If New Cunstruetiun check here❑or check all that apply in the nvo roars below --- I?xislinf; ISuilding❑ Repair❑ Alteration ❑ Addition❑ DentolitionX(Please fill uut,unl Nobntit APpcndiX I) Change of Use ❑ 1 Changeof Occupancy ❑ Other ❑ Specify: _-- Are building plans and/or construction dill:uments being supplied as part of this penuit application? ties N, No ❑ -- Is an Independent Structural Engineering Peer Review nsluire I? ICP Yes ❑ No ❑ - Brief De si ri atom of Pro used Turk:" I T - SECTI ONIPLETE"11HIS SE ION IF EXIST[ UILDI G UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY - Check here if an Existing Building Investigation and Evaluation is enclosed(Sue 780 CkIR 34) ❑ Existing Use Group(s): __. Proposed Use SECTION 4:BUILDING IIEIGIIT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) a Total Area(.sy.ft,)and Total Height(ft.) SECrtON 5:USE GROUP(Check as app Iicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ AJ ❑ A4❑ A-5❑ 8: Business E: Educational ❑ F: Facto F-I ❑ F2❑ FL• Hi h Hazard H-1 ❑ H 2❑ 11.1 ❑ 1-1-4❑ 11-5❑ 1: Institutional 1.1 ❑ 1-2❑ 1-1❑ I-1❑ Ni: Mercantile❑ R: Residential R-I❑ R-'_❑ R-1❑ R-I❑ S: Storage S-I ❑ S-2❑ U: Utility❑ _ Special Use❑and please describe below: Special Use SECTION 6:C ONS'TRUCrION TYPE(Check as applicable) IA0 IB ❑ IIA ❑ IIB ❑ IIIA ❑ 11113 ❑ I IV ❑ 1 VA ❑ VIA ❑ SECTION 7:SITE INFORMATION(refer to 781)CNIR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trenchr1rennih Debris Disposal al: Public❑ Check it outside Flood Zone 0 Indicate ncnnicipal 0 A trenchl,ill not be Licensed Disposal Site❑ rcyuiredT or trench or Np ily: I'mate❑ Or indcntih Zane: — or on site Nv stern ❑ . permit is enc lased❑ Ii.hiln+aJ right-utnvfy9 Ilamrds to Air Navigation: Not :\pl+local+Ie a9 Is titrurttvc wilhinairpo it a�'l+roe:h droa? Is tltvir rcairw:+nnl+IvlrJ.' or C,.n.ont to Budd enclo.rd 0 \cs❑ ur NOV Yes❑ .No Cl SFCI'ION 8:CONI'EN"r OF CFRIIFIC,X I F OF OCCUPANCY I:,hiwn ut Code, -.. C'ee C;raup(.): \po of Construt ovh: Uu up.utt I„uJ per I tenor _ I An•. the buildint;c„main .in�prinklcr tie.lrm? . . tit+rcial �tIptilah"lls. _ _ _ f SECTION 9: 1'I(OPIiR'IY O1VNIfR P:UI'if0tilZA"IIUN N.unc.uul Address It Properly Uwncr Mime(1 nt) Not and Strevi City/'rows Zip Property Owner Contact Informaliol r a�a-8 ,1aJiO hu i Cam I isle telephone No. (business) Telephone No. (cull) c-mail address If applicable, Ihu proprrl owner hereby wlhorizes Nance Street Address City/town State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit a p plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If buildin is less than.35,0W cu.ft.of enclosed s pace and or not under Construction Control then check here D and ski Section 10.1 10.1 Re ister¢d Professional Responsible for Construction Control Na a(Re gtstmcnt) ,. Telephone No, e-mail address Registration Number Street Address City Town State Zip Discipline Expiration Date 10.2 General Contractor Lowy me l A el 1 �3 Name of erson esponsible for Cut suuction License No. and Tv pe if Ap I cable Y ! -gym Street Address Ci /Town State Zip --a .�h�l q 1 q S �n�h�o► 6 �qa 1C�(�- Tole phone No. business Telephone No. cell a-i ofl address SECTION 11:lR 4:F.1.I,"-,'t t o\IPI \),:v It?\ IN',I11:.\.NCI .\I I II"W11 M.G.L.c. 152. 25C 6 A Workers'Compensation Insurance Affidavit from the\lA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is.I signed Affidavit submitted with this a lication? Yes O No ❑ SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and \1aterials) Total Construction Cost((rum Item 6)=5— I. Building 5 Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical 5 appropriate municipal factor)=5 3. Plumbing - S 4. .\lechaniad (FIVAC) 5 Note: \finintiva=5_—(contact municipality) I 5. .Viw4awrirett Other D�O S C.X/O Enclose chunk payable to _ B. rolal Cost 5 (contact municipality)and write check nmuber here SECFION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By coloring my name below. I hercbv most under the pains and penalties of perjury that All of the III to Mod t ion Contained in this .application is Irtie and dCc1Jra1v to the best of my knowledge end understanding. t I'Irase print dud sign name fills Ta ph,aae No. Date ';1rnTt :\ddresS City,'finyn to Zip i ( Municipal Inspector to fill out this section upon application approval: -. - ',iv1 N',altae I late i CITY of SAI EM, NLISSACHUSETTS t BUILDING DEPARTatE.NT 120 %V.iSHLNGTON STREET, )tie FLOOR TEL 978 745-9595 F.tix(979) 140-9844 ;v�LpF RL FY DRISCOLL ') A.11,Y01 THOSW ST.PtERAS DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO\L\IISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electric(ans/Plumbers \imlicant Information ..V;1117t:111a.Cilia+4t)f�anllallefLlmllvldll.lf): Please Print LLeaib!l V lyyp I pri/ { n+ Address: City/St3te/Zip:—U,1 1 V�Sj MCI(c one M C)C)W I IAJI/-1 Are you an employer?Check the appropriate box: Type of project(required): 1.0 t am a employer with 4. Q I am a general contractor and 1 6. ❑Now construction anlployces(full and/o part-time). have hired the sub-cantractars 2.❑ I am a sole proprietor I r- listed on the attached shcct. t 7. ❑Remodeling ,hip and have no employees These sub-contmetors have 9. [C�Demolition working for me in any capacity. warkers'camp.insurance. 9. ❑ Building addition INo workers'.comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions ),❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or udditians myself.(No workers*sump. c. 152, 91(4).and we have no 12.❑ Roof repair insurance required.) t employees. (No workers' Il.❑Other trump,insurance rcyuircJ.J •Wiry uppli.am dot ducks bat el mall also fill uul Iht soUioe bit Ww showing their trmkan'comptntadun policy inflimution. I h.neuwlura who,ul mil this atBdavit indicating they wt doing ail work and than him outride wntracicim mtnl submit a new antdasil indioling tuck =Cmlrxwo that Owl;Ibis box mall aaxhud ja uldidurvtf.hart showing the name of the rufsauniruWn and Chair workers'wmp,pulley Infonnauaq. l urn an employer that is provfdMir Ivorkers'comptritrarlon lirruruner far my employers Below/s the policy and Job rile h1fot'll"don. ( l'�'-I asurmtco Company Name:_ 11ulicy 4 or Self itts. JLic. 4: Expiration Dale: '2 Job Silo Address: 63 Cityislatetzip: \ttacb a copy of the workers'compensation pulley declaration page(showing the policy number and expiration data). F.6lum to secure coverage as required under Section 23A of bIGL c. 152 can lead to the imposition of criminal penalties of a rinc up to il,500.00 andlur one-year imprisnnmcnt,as well as civil penalties in the form of a STOP WORK ORDER and aline of lip to S250.00 a Jay]gainst lilt vlolamr. He 7dvided that a copy of Ihtl]tatelnl'nt may Ix:forwarded to ilia Of lice of Invczligmiune,Ii rile DIA far o insurance cverage verification. /du her c•ntijy a rr the poi mid penoltlex afgetiury that the irifernrallon provided above it true tried curves .i , I Data: 21z�/ Z PFII ,h (Z�C7 /— 2��/ U/ficiol rue only. Do not write in dbir area,to br completed by city of town n/filial City or Tutvn: -_ __. Pcrmitil lcente 4 I++oink \ulhurily (circle one): 1. hoard of llcallh 2. Iluildln�Department .I. Clerk J. F.leetric.11 In+pectnr i, Phlnthln4Impeetur 0. thirst -- -- Office�t ego atioo.a r HOME IMPROVEMENT CONTRACTOR w Registration162103 Type: Expiration 1/1412 0 1 3 Individual 1 KIDERSON r i' € - LLt �r SEAN ANDERSON �, « ,+,i 81 GERTUDE ST. ., LYNN,MA 01902 r t' Undersecretary i . , 11ass:rehusctts- Department of public Safct3 { Board of Building Hc_ulations and Standards �}J Construction Supervises License License: CS 99866 SEAN ANDERSON 1 81 GERTRUDE STREET LYNN. MA 01902 1 i Expiration: 10/26/2013. E ('anmi.�ionrr Tra: 4283 i s, CITY OF SM-ENrl INL,SS.ICHUSETTS JLLMLNG 0 E P.1 AT.%LLN r 120 %V-u-4LVGTON STRE$'t', Jw RccR rM (978) 748.959f KIMBEALraY ORLSCOLL F.Vt(978) 740.9846 ,tiG1YOlt MO.�W ST.PMAtts DIA=TOtL OP PL BLIC PROPEtaTY/BCR,pLYG COSL1l(SSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) fn ucordance with the sixth edition otthe State Building Code, 780 CMR section I Debris, and the provisions of MGL o 40, S 34; Building Permit it is issued with the condition that the debris resulting from 111, S I JOA. this work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c The debris will be transported by: The debris wiill be disposed of in in;M- o ,Y) .. f,ddrtff oer-,C j'jy) u4nuum o(permit �pphc�nf Big A's Home Improvement Lynn, Ma 01902 81 Gertrude Street (857)891-2589 Licensed and Insured CSL 99866 2/28/2012 63 Jefferson Ave. Salem,Ma Demo description: Front: -Remove electrical wiring completely in section of the building that had been on fire. -Remove all office walls and ceilings. -Remove all misc.Debris. -Remove all flooring down to concrete. Back: Remove all ceilings. Remove all flooring. Clean walls Bathroom to remain (fixtures and walls to be cleaned.) Total 28,000.00 Disposal of debris will be put in 40 yard roll off dumpsters,suppled by Graham Waste. Total for demo and dispoal rrr. .., Ott'ice�t` m=, At air rsAUsiness ega ah HOME IMPROVEMENT CONTRACTOR -+ Registration/:�x162103 Type: Expiration 1114/2013 Individual - I. I S AN ANDERSON; ' ' SEAN ANDERSON 6t v 41 - 81 GERTUDE ST. LYNN,MA 01902 Undersecretary i i * Massachusetts -Department of Public Safer;%' 4�t Roartl of Building Remilations and Standards i f Construction Supervisor License License: CS 99866 S i SEAN ANDERSON 81 GERTRUDE STREET LYNN, MA 01902 ! i � I i .Expiration: 10/26/2013. V ,ti i t'onm�issiuuel' Trp: 4283 1( - a / ' ® OATE(MMIDIYYYYY) Av o CERTIFICATE OF LIABILITY INSURANCE 2 29i12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERnRCATE HOLDER THIS CER71FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADD171ONA_ INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen PRODUCER CONTACT NAME; Divirgilio Insurance Agency PNDNE (781 592-5220 RAX - (781) 598-5957 270 Broadway ADoaL. al@divir ilioinsurance.com P.O. Box 8065 INSURE S AFFOAOING COVERAGE NAICA Lynn, MA 01904 INSURER A:Patrons Mutual Insurance ,INSURED INSURER B: SEAN ANDERSON IPSURERC; BIG A'S HCME IMPROVEMENT INSURER D: 81 GERTRUDE ST INSURER E: LYNN, MA 01902 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 DESMBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SU POUOYEFP P W LIMITS LTR TYPEOFINSURANCE POUCYNUWER MIDDAY MN/DDVYYY A GENERAL LIABIUTY CTROO10445 5/23/11. 5/23/12 EACH OCCURRENCE S 500.000 DAMAGE TOREN ED g SO OOO COMMERCIAL GENERAL LIABILITY IwF CLAIMS-MADE OCCUR MEOW IAnyona palm) S $ 000 PERSONALS ADV INJURY 3 500,000 GENERAL AGGREGATE S 1,000,000 GEN'L AGGREGATE LMITAPPUIES PER PRODUCTS-COMPIOP ADD S 1,000,000 POLICY PRO- LOC INGLELIMB $ AUTOMOBILE LIABILITY eeceiomrt S ANY AVID BODILY INJURY(Pa Penton) S ALLOWNED SCHEDULED BODILY INJURY(Per weidoM) S AUTOS AUTOS PROPERTY DAMAGE NON-0YRJEO er PE. S HIREDAUTOS _AUTOS b UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCE55 UAB CLAIMSMADE AGGREGATE S DED RETENTION 8 S VIORKSM COMPENSATION WC STATU• OPR H AND EMPLOYERS•LIABILITY YIN MiU ANY PROPRIETDRIPARTNERIEXECUTNE NIA E.L.EACH ACQ OEM (Mandatory N„)EXCLUDED? EL.DISEASE-EA EMPLOYE Ityyees dwalbe under EL.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS bN . IESCRIPDON OF OPERATIONS i LOCATIONS I VFM CLES (A IWh ACORD ID1,AdeSonel Reeerb Sdml&e,II more space Is Mqu MCI) Carpentry RE: 63 Jefferson Ave Salem MA 01970 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED D1 Salem, MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE 1 Josephine Salamanca ©1988 2010 AC D ORP O TION. Alf rights reserved. AnnOn ee rOM AIDCM The AR MI.1 ne,.,e end Innn em renia/a�nd mer4a nF ACIIRD � � � OB0O � OQ � 0 (3 CPO n1g11CraA ITo—G 6/62l//_U1Z O : 0*: UJ AM YA(JG Z/UU/_ rdLA OVZVVI' ACORD. CERTIFICATE OF LIABILITY INSURANCE O=Oi2012 PHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAIE HOLDER. THIS CERTIFICATE DOES NOT AFFIRF(IATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF IASURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:O the cegltleMe holder is an ADDITIONAL INSURED,the pohcy(ies)must be endorsed. It SUBROGATION IS WAIVED,subject to the terms and conditions of the poky,ceMan policies may require and endmsemerd. A slelemenL on this certificate does not center rights to the care licate holder in lieu o1 such andorsemengs). PRODUCER CONTACT NAME: PHONE FAX DTVIRGI1.10 INS AGENNUY (AIC,No,Ed): FAX (AIC,No): CO HON SU(.? EMAIL ADDRESS: PRODUCER LYNN.MA W914 CUSTOMER ID P. i1\•SS INSURER(S)AFFORDING COVERAGE NAICIT INSURED INSURER A: TRANFLFJ:Srrn;trr A5.S1G\7,1E•]T INSURER B: ASDERSOY SHAN URA BIG A HOME NPRON TME\1' INSURER Ce INSURER D: SI (Wit:I RUN,SI INSURERE: LYNN.MA Ul IX)2 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 1S TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTfATHSTANDING ANY REOMREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W MCH THIS CERTIFICATE MAY BE ISSUED ORMAYPERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERON 19 SUBJECT TO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UTATS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDLSUBR - POUCYEFFOATE POUCYEXPDATE TYPE OF INSURANCE POLICYNUMBER (MMAD.YVYY) (MM.DU.YVYY) UMITS LTB NSR WvD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S CIA SAS MA BE OCCUR PREMISFS(Ea nrrurrmwn) MED EXP(Airy ano person) 5 PERSONALAY.ADV INJURY S GENT AGGREGATE LIT-11'/APPLIES PER GENERAL AGGREGATE S POLICY PROJECT LOC PRODUCTS COFR'.OPAGG 5 AUTOMOBILE LIABILITY COMBINED SINGLE S ANYAUTO LIMIT(Ea amadan) ALL OWNED AUTO, BODILY INJURY S SCHEDULE AUTOS IPry ls!rarnq HIRED AUTOS BODILY 1111URY 5 (Pm ozulmn) NONOWNEDAUTOb PROPERTY DAMAGE 5 1per Ws slmvj UPASRELLA LNB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS MADE AGGREGATE 5 DEDUCTIBLE S RETENTION S 5 "IC STNVIOI�YIIYUS OILIER WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YN UB lAIGPZI A III fD13201U 1n:132hl I E L EACH ACCIDENT S 100,000 Atv vHOPFRII(%bPGHHI-u FIX017Yr Y EL DISEASE EA EMPLOYEE 5 100.000 CTTICErs VLNGLrf LX"rim IY IMender.,m NH) E L DISEASE POLICY LIMIT S 500,000 1'r, 1::1.. 1. IRh IPWIOI<ti(IPFRATRhS-- DESCRIPTION OF OPERATIONS,LOCATIONS,VEHICLESIRESTRICTIONS:SPECIAL ITEMS Tliti RFPL\C'L'S.t1l TN2b 1R I I'R1 U7C,CIL'ISSUED I V T fit(FR'I IFIf ATP 1[1IT.DrU An 1XITINn WORKERS CoNIT'l l IN 11RAOF. TILE WORKERS I V\DTCSAI II IN 011I1.1 LIVES 1LJL PRI AIDE I UVERAI:P W IR Al7JERArS SEAS. CERTIFICATE HOLDER CANCELLATION HUGII OT SEN SHOULD ANY OF THE ABOVE DESCRIDEO POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN (0 AYFURSON A%'(: ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE SALE'.\1.MA DI0-0 Charles J Clark ACORD 25(2009/09) 19W2009 ACORD CORPORATION. All rights reserved. CID � � O �UO � Op 0 0- - C) ,q) S'eL� 63 JFFR�RSON AVENUE 695-12 COMMONWEALTH OF MASSACHUSETTS Map F 24 ' wu CITY OF SALEM Lot. 0210 T Category it INTERIOR DEMO O Permlt# 695 12 . •Jk •r"- BUILDING PERMIT Project# '" JS-2012-001903 Est Cost $28,000 00 .xv Fee Charged: $213.00 Balance Due:';; $.00 PERMISSION IS HEREBY GRANTED TO: Const. Class:" Contractor: License: Expires: Use Group: s "m ?_...;;,The Kaat Service Group Inc LotSuksq.'ft) 42393.0276 I 7, ,i. ' ,„Owner: HUGH REALTY TRUST, KERR HUGH TR Units Gamed:'" r `I' lej Applicant: The Kaat Service Group Inc Units Lost: AT: 63 JEFFERSON AVENUE Dig Safe#:fiu ISSUED ON. 29-Feb-2012 AMENDED ON. EXPIRES ON: 29-Ju1-2012 TO PERFORM THE FOLLOWING WORK: REMOVAL OF ALL OFFICE DEBRIS,REMOVAL OF ALL OFFICE WALLS,AND ALL CEILING TILES,REMOVAL OF HVAC SYSTEM, REMOVAL OF FLOORING (THIS PERMIT IS ONLY FOR INSIDE DEMO ONLY)jbh POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: Underground: Underground: Excavation: Service: Meter: Footings: Rough: Rough: Rough: Foundation: Final: Final: Final: Rough Frame: Fireplace/Chimney: D.P.W. Fire Health Insulation: Meter: Oil: Final: House# Smoke: Water: Alarm: Assessor Treasury: Sewer: Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: BUILDING REC-2012-002092 29-Feb-12 1892 $213.00 GeoTMSO 2012 Des Lauriers Municipal Solutions,Inc. l� 03/14/2012 NED 9: 53 FAX Farquhar and Black 2002/002 A CERTIFICATE OF LIABILITY INSURANCE /141 012"' 3/14/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW- THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the Cenlficate holder is an ADDITIONAL INSURED,the policAies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and condition$of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s. PRODUCER CONTACT NAME Christopher Kennedy Farquhar & Black Insurance Agency, Inc. Salk (781)599-2200 (FAX Not_(781)591-29A0 85 Exchange Street Suite 101 ADORE :Chris@FandBinaurance.cam Wy CUSTOMER CUSTOMER IOUD0034588 _ MA 01901-1475 INWRER(S)AFFORDING COVERAGE NAIL# INSURED INSURERA:Pemn-America Insurance Co. INSURER a: The Kaat Services Group, Inc. INSuaeaG: 20 Morris Street INsuRER D: _ _INSURER E: Revere MA 023.53. INSURERF: COVERAGES CERTIFICATE NUMBER:Towa of Salem REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POIGOCDYEFFTFO C Eit" - -_ LIMITS ILTR TYPE OF INSURANCE AD POLICYNOYBER I GENERAL DABILm' i ._EACH OCCURRENCE LIMITS 1,DDD,DDD IX COMMERGAL GENERAL Lueu.ITY PREMISES(a _ A. Ea oavmnee), E 50,000 ,CLAIMS-MADE ,x OCCUR PEC6B4627S-2 p/12/2011 I1L2/2012 i mEo n won) S 5,000 I � i .... PERSONAL&ADV1WURY ,$ 11000,000 J .. GENERAL AGGREGATE S 2,000,006 GEML AGGREGATE UNIT APPLIES PER j PRODUCTS•COMPpPAGG $ 1,000,000 X I POLICY PRO I LOC E AUTOMOBILELIABILIIY :COMBINED SINGLE UMn IANY AUTO - AMOWNEDAUTOS BODILY 'URY(Per penm) S SCHEDULED AUTOS BODILY IN/URY(Pw KWen0 S PROPERTY MMAGE S HIRED AUTO$ (Pw Atti]ml) NON-OWNED AUTOS 1$ S UMBRELLA LIAa ' OCCUR EACH OCL'l1FRENCG $ _ EXCESS 11AB H ClAIMS-MADE AGGREGATE I$ DEDUCTIBLE S RETENTION S WORKERS COMPENSATION WC E% STATU- AND EMPLOYER R YIN O TN• ANY PROPRIEOTW OFFICERIMEMIXJC _ NIA E.L.EACH_ACCIO rr S (Mandatory In NH) N EL DISEASE,EA EMPLOYE $ des be under — Co. EL DISEPSE-PO,ICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ANAeh ACORO 101.AddiftIci Rwnaft WWII ,Nmme apace Is requm) Workers Compensation Inaurance Coverage is wrLtten with Liberty mutual Ins"aace Coverage o££octivo 3/12/2012/3/12/13. Liberty Mutual will iasua certificate directly to you shortly. CERTIFICATE HOLDER CANCELLATION (978)740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington Street Salem, MA 01970 AUTHORIZED REPRESEmATNE Flaria.n Cruz ACORD 25(2009/09) 01988-2009 ACORD CORPORATION. All rights reserved. INS025(woeoo) The ACORD name and logo are registered marks of ACORD ' USETTS �- �ru .DRIVERSLICEN B jjj�� y_' E , 50254102 � ,4 11 21 2013 11 21-� , ...6.11k tali �X CUBS PEEL 'TIMOTHY�G ti� �� •': � '' �t 32 FAIHVIEW AVE sv Iv. '�+01996 a 131 tY67 x'" wt �!he t 03/14/2012 WED 9! 53 FAX Farquhar and Black E001/002 serving einsurance needs dssof the North More Farquhar&Hlack since1864 85 Exchange Street Insurance Agency Smite101Lynn,MA Q1 901 (761)599-2200 FAX(781)581.3940 I From the Desk of Marian Cruz j marian _fandbinsurance.com Date: March 14, 2012 Fax: 978-740-9846 Attention: Michael E Lutrzykowski/Assistant Building Inspector Company: Town of Salem Please find 2 pages including the cover sheet. If you do not receive all the pages, please contact me at extension 102. Thank you! RE: The Kaat Services Group Inc. Certificate of Insurance Property Location: 63 Jefferson St, Salem MA Enclosed please find the certificate of Liability you have requested for the above insured. If you have any questions, give our office a call, fax or email. Thank you! 911ai&n Cruz Marianp Fandbinsurance.com Farquhar&Black Insurance Agency,Inc. 85 Exchange Street,Suite 101 Lynn, MA 01901 This transmission contains information that may be confidential or privileged, and is intended only for the recipient identified above. If you received this transmission in error,please notify the sender immediately,delete all copies,and be aware that any disclosure,copying, distribution or use of the contents of this transmission is strictly prohibited. Also,for your protection,coverage cannot be bound or changed via voice mail, email, fax, or online via the agency's website,and is not effective until confirmed directly with a licensed agent. 3/15/2012 6:23:00 AM PST (GMT-8) FROM: 100005-TO: 19787409846 Page: 2 of 2 CERTIFICATE OF LIABILITY INSURANCE F °A 3MMM 51201Yrr) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the cerLificat , hdlder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. H SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,Certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s . PRODUCER FARQUHAR& BLACK INSURANCE AGENCY CONTACT NAME: 85 EXCHANGE ST STE 101 PHONE Nu ac Nn: 7 581-3940 LYNN, MAO1901 - E-MAIL ADDRESS: INSURER(9 AFFORDING COVERAGE NAIC# INSURER A Liharty Mutual Insurance INSURED INSURER B THE KAAT SERVICES GROUP INC 20 MORRIS STREET INSURERC: REVERE MA 02151 NSURERD: INSURER E: MSURER F: COVERAGES CERTIFICATE NUMBER: 12603052 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICYEFF POLICYEXP LIMITS LTR SR VND POLICY NUMBER MMIDD/YYYY MM/DDM'YY GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES e.arnnndl $ CLAIMS-MADE OCCUR MED EXP(My one pars.) $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ POLICY PRO LOC $ INGLE LIMIT AUTOMOBILE LIABILITY a amid.t $ ANY AUTO BODILY INJURY(Par person) $ ALL OWNED SCHEDULED BODILY INJURY(Perecddenl) AUTOS AUTOSNON-C pp $ HIRED AUTOS AUTSVJNED PPe acdadalt AMAGE $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS41ADE AGGREGATE $ DED RETENTION$ $ 1 Is A wORReas coMPENSA'non WC5-31S-381142-012 3/12/2012 3/12/2013 WC STATU OETI- AND EMPLOYERS'LIABILITY YIN I TORYLIMRS ANY PFOPRIETORIPARTNElVEXECUTNE E.L.EACH ACCIDENT $ 500000 OFFICERIMEMBER EXCLUDED? H/A (Mandator,in NH) E.L.DISEASE-EA EMPLOYEE $ 500000 If,, deacrbe under DESCRIPTION OF OPERATIONStebw E.L.DISEASE-POLICY LIMIT I$ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Mach AC ORD 101,Additional Remmka Schedule,H more ape as is required) Workers Compensation insurance coverage applies only to the workers compensation laws of the state of MA. RE 63 JEFFERSON STREET - SALEM. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: MICHAEL E. LUTRZYKOWSKI ACCORDANCE WITH THE POLICY PROVISIONS. 93 WASHINGTON STREET SALEM MA 01970 AWHORRED REPRESENTATIVE Jeff Eldridge ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD CzT Do 1260302 CLINTThiS Celt i fiCate5 Conte L9EandC SupeY edes ALL PrevLOUSLYL esauedS cent Lf Lcates. AM Page 1 O£ 1 3/15/2012 6:28:00 AM PST (GMT-8) FROM: 100005-TO: 19787409846 Page: 1 of 2 'From:. is FARQUHAR & BLACK INSURANCE AGENCY 85 EXCHANGE ST STE 101 LYNN, MAD1901 FAX DOCUMENT Certificate of Insurance Delivery by scertsonllne TM (781)599-2200 (781)581-3940 From: Anne Chandler Subject: ACORD 25(05/10)Certificate of Liability:THE KAAT y SERVICES GROUP INC TOWN OF SALEM ATTN: MICHAEL E. LUTRZYKOWSKIt Date: 3/15/2012 93 WASHINGTON STREET SALEM MA 01970 Delivery Via: FAX 19787409846 E No. of Pages: 2 This document was created by eCertsONLINE. The attached or linked document(s) contain certification of insurance coverage for the insured named in the sub ect above. Your company Is listed as the organization requesting receipt of these document's. If this document is sent via e-mail, you must click on the link below. The linked document is in a pdf format, and you must have Adobe Acrobat Reader installed on your system. To download the Adobe Reader for free, visit www.Adobe.com. If you have any questions regarding the content of this message, you should contact the Producer/ Agency listed on the attached/linked documents. THIS MESSAGE IS INTENDED FOR THE USE OF THE INDIWDUAL OR ENTRY TO WHICH R e ADDRESSED AND MAY CONTAIN INFORMATION THAT O PRMLEGED,CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDERAPPLICABIE LAW.IF THE READER OFTHE MESSAGE a NOT THE INTENDED RECIPIENT,OR THE EMPLOYEE ORAGENT RESPONSIBLE FOR OELNERNG THE MESSAGE T07HE INTENDED RECIPIENT,YOU ARE HEREBYNOTIFIEO THAT ANY DISSEMINATION,DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBPED.IF YOU HAVE RECEIVED THE COMMUNICATION IN ERROR,PLEASE NOTIFY US IMEDIATELY SYTELEPH ONE,AND RETURN THE ORIGINAL MESSAGE TO US AT THE ABOVE ADDRESS VIA REGULAR POSTAL SERWCE. ©2002 Certificate of Insurance Delivered by ecertsonllne TM Insurance Visions,Inc.All rights reserved.