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33 NEW DERBY ST - BUILDING INSPECTION (2) Q� The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than aOne-or Two-F 4'1y in (Phis Section For Official Use Only) Building Permit Number: Date Applied: Build' SECTION 1:LOCATION(Please' dicate Block#and Lot#for locations for which a street ad rs not a aila e) 7 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2 PROPOSED WORK Edition of MA State Code used B New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No AN Is an Independent Structural Engineerin Peer Review require es ❑ NoI /J Brief Description of Pro Wo G.� 1- —. �f / `0 C (�( 6 :'+Pf-21 ;f- 11)frCKd n—r SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A 4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F.- Factory F-1❑ F2❑ 111. Hi Hazazd H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ 1-2❑ I-3❑ 1-4❑ M. Mercantile❑ R: Residential R-1❑ R-2❑ R$❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ H110 III D IIIB ❑ I IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ Private❑ i or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA IQstoric Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: Ir- � �� SECTION 9- PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner r�10A( �, �� z��0, AV Name(Print) No.and Street City/Town Zip Prpp�rty Owner Contact Information: l�l� fll�� fihn/� PIUMALa k— k1 �eI GGG Title Telephone No.(business) Telephone No. (cell) e-mail If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on theproperty ro owner's behalf,in all matters relative to work authorized by this building emit application SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) !f building is less than 35,000 ca.ft.of enclosed spam and or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Res onsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor A - Company e Sd� e--�a��h Name oPperson Responsible for Construction tense No. and Type if p cable /�Os,raSfarS 6f- Un �� 0 IT 7d, Street Address/ City/Town she Zip Telephone No.(business) Telephone No. cell —�—� e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152_§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents most be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes 0 No O SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate t best of my knowledge and understanding. ,ro Rele r4j . n Ve Please print and sign name / Title Tet honep e No. D l /�, v re, g PO e/S 0- Un+ /13 SS (ram-. I— Of ??� Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date CITY OF SM.EM, T&LUSACHUSETTS BUU Dk\G DEP iRTNI UNT • 120 WASIMNGTON STREET,3"FLOOR Dj TEi.. (978)745-9595 PAX(978) 740-9846 K1JfBERLEY DRISCOLL MAYOR THoaus ST.Pw-M DIRECTOR OF PUBLIC PROPERTY/BUUMLNG COMMSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A_ The debris will be transported by: E�,kt ,Srtv,�lts (name of hauler) The debris will be disposed of in : �/C- 54 c (name of facility) Q ot (address of facility) sk ature of per t applicant l.1 1 date JcbisvlLJx i CITY OF &UX-N4 N'LXSSACHLSE= BUILDING DEPARTNmN-T ' d• 120 W asHiNGTON STREET,3'a FLOOR dj w TEL (978)745-9595 FAX(978)740-9946 KIJBERLEY DRISCOLL MAYOR DIRECTOR ST.PIF1tRE DIRECTOR OF PUBLIC PROPERTY/BL'IIDNG C015IISStONER Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Letzribly Name(easiness,orgatlization/1nJividual): FIT fL ' 7 Address: vt—G �S C4, v Id City/State/Zip: M 4, 0 1910 Phone N: Aar�e you an employer?Check the appropriate box: Type of project(required): 1.t—1 am a employer with 3 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contracmrs 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7• &Remodeling ship and have no employees These sub-contractom have R. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y P tY• 9. [-]Building addition required,] workers'comp.insurance S. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] Officers have exercised then 3.❑ 1 am a homeowner doing all work right of exemption per MGL t LEI Plumbing repairs d additions myself.[No workers'comp. c 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees.[No workers' 13.❑Other comp.insurance required.] •Any applicut that checks box 91 mtW also ,It.1 the section below&owing their wmketa'notnpcntauoo policy infomtatioa 'I Inmeowoas who submit this affidavit indicating they ate doing ail work and then hire oaaide mntm,,, room submit a new affidavit indicting such :Cmurswnt that check this box mtut attached on additiond short showing die tunes,ofam osb.ew uacfine yet their workrn•comp,policy m(amnion. lam an employer that ar provid g workers'compensadan In mneejor my employees. Below Is the policy and jab silo information. / �— Insurance Company Name: t/ n Policy H or Self-ins.Lie.N: Expiration Date- '25 Job Site Address: - ' i City/State/Zip: t Attach a copy of the workers'compensation po ry declaration page(showing the policy number and espiration 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby cntl ° I a l.e s and penalties ojperjury that the information provided above i true and cored Sienalure• /� Date: �I Phone,#: —1 7�V -31-7�S7Cg _ OJfcid use only. Do not write in this areas to be completed by city or town of WaL City or Town: PermitflJccuse f! 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 if• A`� - CERTIFICATE OF LIABILITY INSURANCE 11/o i 011 PRODUCER (978) 745-5905 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ALLAN INSURANCE AGENCY INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 63 1/2 Jefferson Av€hue 2nd Floor ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. BOX 511 SALEM MA 01970-0511 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Maxum Indemnity Company INSURER B:Atlantic Charter Elite Remodeling & Demo Inc. _ INSURERG One Couregous Ct. #113 INSURER D: Salem I MA 01970- INSURER E: COVERAGES 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 OFSUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY NUMBER POLICVEFFECTIVE POLICYEXPIRATION DATE IMMIDDIYYYY) DATE IMMIDD[YYYY] LIMITS GENERALLIABILITY / / / / EACH OCCURRENCE $ 1 000 000 DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY / / / / 'PREMISES 4Ea occurrence $ 50,000 A CLAIMS MADE 1XI OCCUR DC0006338-07 03/25/2011 03/25/2012 MED EXP(Any one Parson) $ 5,000 / / / / PERSONAL B ADV INJURY $ 11000,000 / If / / GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS-COMP/OP AGG $ 2,000 000 POLICY PRO LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT $ ANY AUTO / / ./. / (Ea accident) ALL OWNED AUTOS / / / / BODILY INJURY $ SCHEDULED AUTOS / / / / (Per Person) HIRED AUTOS / / / / BODILY INJURY $ NON-OWNED AUTOS / / / / (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY / / / / AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE / / / / AGGREGATE $ DEDUCTIBLE / / / / $ RETENTION $ $ WORKERS COMPENSATION / / / / X WCYT�IU-. OR AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN CV00946700 01/29/2011 01/29/2012 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? �Y $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,tlescribe under SPECIAL PROVISIONS bel" E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER If DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION RCG LLC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$O SHALL 120 Washington St. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUT RI D REPR TATIC. w� Salem MA 01970- 4 ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200901) The ACORD name and logo are registered marks of ACORD ELITE REMODELING & DEMO, Inc. 1 Courageous Ct Unit 113 Salem MA 01970 Cell 978-317-5388 Fax 339-440-5489 A g, November 7, 2011 Proposal submitted to: Job Location: RCG LLC 33 New Derby St 120 Washington St Salem MA 01970 Salem MA 01970 Elite_Remodeling_& Demo,_Inc. hereb f�subEr t specifications and estimates_for : The removal of all rotted/weathered signage and exterior storefront and installation and painting of new exterior storefront. Labor skilled 16hrs @$45/hr $720 General laborer 20 hrs @ $25/hr $500 Dump fees .7tn @$140/tn $98 Scaffolding $100 Materials Lumber, paint etc $850 Permit $25 Total Proposed total price: 2293 6 Any alteration or derivation from above specifications involving extra With payment to made upo costs will he executed only upon written or verbal order,and will n comp 7(, I become an extra charge over and above the estimate.All agreements LJ contingent upon strikes,accidents our delays beyond our control. Workers comp and general liability insurance held by Elite Remodeling&Demo,Inc.. Submitted by Elite Remodelin e Note_This-pr<Eosal ma be withdrawn by us if_ t acce tamed within 30 days Acceptance of P osa The above prices,specifications and conditions are satisfactory and are h ceple Y are authorized to do the work specified. Payments will be made as outlined above. / Signature Date !� 1 Signature Web Nww.elit servicesonline.corn - E-mail eliteservicesremoval@gmail.com i 1 . �lassachusetts- Dcpartmcnt of publicS:tfeO Bo:ud of Building Rc_ulations and:Standards Construction Supervisor License License: CS 102155 Restricted to: 00. STEPHEN GORDON 7 COX COURT BEVERLY, MA 01915 Expiration: 11/27/2012 Tr#: 102155