28 NORMAN ST - BUILDING INSPECTION (5) 1
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F , The Commonwealth of Massachusetts
I Department of Public Safety
ot
„✓ \lassachux•tts State Building Code(780 C\IR)Sevanlh Edition
City of Salem
Building Permit Application for any Building other than a I-or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Budding Inspector:
SECTION 1:LOCATION (Please indicate Block N and Lot 11 for locations for which a street address is not available)
28 NUrrl'lan J-tee-! (Salem 0/9q0 Whf'-1-e Heh P60-fi'y
No. and Street City /Town _ Zip C.wie Name of Building(if applicable)
SECTION 2:PROPOSED WORK
—/ If New Construction check here❑'or check all that apply in the two rows below
Existing Building t3' Repair❑ Alteration Gck Additiun❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ -- UfBe� ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 6 No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Pru used Work:
.Q 1wily- er-olw✓l� Ci)rwe/f" Q I Alli de 14EK) _ ,-j yj�, D
� - E1e M v
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use Group(s): o ! e Proposed Use Group(s): Q0V
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) / 14,50 9 / 21.3o 9
Total Area(sq.ft.)and Total Height(ft.) I Zr3 D q 9 D// Zr 3U�I 9 Orr
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B! Business ❑ E: Educational ❑
F: Facto F-1 ❑ ^F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
L• Institutional 1-1 ❑ I-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3 M R-4❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ 1100 IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION !refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public ❑ Check if outside Pluod Znne❑ Indicate municipal ❑ A trench will not be Llcen,ed Disposal Site
required ❑or trench or 1puafa':
I'n rate❑ ar uidenldc Zone:_ or tonate.r.trm ❑ permit is enclosed ❑ _
Railroad right-of-way: Hazards to Air Navigation: ll:\ Ih�n�n. (�,•mnu��om 14...I... ('n r•.:
\.q .\pphca6le ❑ I.strui(mv..ilhm airpnrt appro..ch area.' 1, their re%iew comiplvivd'
r l Im,rnt u, Build end""ad ❑ )v, ❑ ,-r No.❑ 1'r, ❑ \o ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I.Jun ui "I C,aly -..__ L.c fk pc•1n C Occupant I ood par l-Inirt
) n� lh.•bwl.hnp amlau..ut`;pnnF,lrr��•lam'' spacial ?upulattun,
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Prupert\' wrier
Pp7 )7�[.t.o L" o Ta✓a ,Qoc(c( /�a!alb Ul9 rep
.Name(Print) No.and Street Cih./Town Lip
I per) llpp'nrr Contact Information:
1 tt, Curd 617- _-_-
Title Telephone No. (business) Telephone No. (cell) e-mad address
If at,plicable the ,ropeov owner hereby autoze
C CL) Skee O l ot3
. 'ame Street Address City/Town State Zip
to act on the l,ropert% ow nets behalf, in all matters rvlali%e to work authorized by this building permit a p >licatiun.
SECTION III:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,L1Lx)cu. tt.at emlo.ad s pace and/or nut undor Con>truction Cuntrul than check here 0 and.kip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Wavre )0630ti 54-7-957- 9(01� w�ohnson0 w'a} ch. Cdrn 31510
Name(Registrant) Telephone No. a-ma it addresses Registration Number
19 /VcNfhOreeleyeStfeeb 1241a+tAe COG
Street Address— City/Town State Zip Discipline Expiration Date
10.2 General Contractor
l-oo+ (9'eoe(al �'a✓lirac�ors
Compan Name: 1
I iv
�1te of Prr n Resyt PP Apr Construction ��L N f t 4 r No. and Type ife7licabl��`U�
r'11t NP Son l 'f a f-p
treet Address City/Town State p
(cU _�. 3o7Z __ I ruf 1<A@ Va Xtesf C-6Zi,4I
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit.
Is a signed Affidavit submitted with this application? Yes the
O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor U U 6U . 00
and Materials) Total Construction Cost(from Item 6) =$ t
1. Building $ 20 O. 00 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ L L't o>, O 0 appropriate municipal factor)_$
3. Plumbing $ co U 0, 00
4. Mechanical (HVACI $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ —
Enclose check payable to
6.Total Cost $ 300 00.eO (contact municipality)and write check number here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name b law, I here st under the) ins and penalties of perjury that all of the information contaij1h,,,
applicahan is true andlkr ,cau a bee of me knu vie ge and understanding.
brids� —
Oru�t�/ � 1.� 33v�Tolc p •\'oHAY-,titrvcl Wdre, City;Tot n ate GpMunicipal Inspector to fill out this section upon application approval: \ame /
CITY OF S,,u.ENtii, NWSACHUSETTS
BuILDIING DEPARTMENT
• ' 120 WASHINGTON STREET, Yo FLOOR
' TEL. (978) 745-9595
FAX(978) 740-9846
KIMBFRt RY DRISCOLL
MAYOR THoe.I.�s ST.PiERRH
DIRECTOR OF PUBLIC PROPERTY/Bt1T.DING CONDMIO iER
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:
,l i a0&){ wasf-e 3q5 ee s" o6.
(name of hauler)
The debris will be disposed of in
eabodl� 'MaS4/
(name of facility)
306Q)-rf-e , �A
(address of facility)
si e o ermit applicant
date
Jcbri�at7�p6
i CITY OF S.UEm. iXLxSSACHUSETrs
BUILDING DEPAR-r.%C&iT
• P 130 W.ksmNGTON STREET, 3�FLOOR
TEI.. (978) 745-9595
IF.,AX(978) 740-98"
KI),{BERLEY DRISCOLL
'I [s\
MAYOR tiObs ST.PIE1tRH
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CONWISSIONER
CONSTRUCTION CONTROL DOCUMENT
Project'Title: -7,�Q,J Date: 1o.11allc�
Project Location: -zs1
Scope of Project:
_V5 � ;���I
In accordance with SECTION 116.0-t 16.4.2 of the 6th edition of the Massachusetts State Building Code :
I n ws ( Mass. Registration Number 2,1310
being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised
the preparation of all design plans, computations and specifications concerning:
Entire Project [ ] Architectural [ ] Structural [ ] Mechanical
[ J Fire Protection [ ] Electrical [ ] Other(specify)
for the above named project and that to the best of my knowledge,such plans, computations and specifications meet
the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all
applicable laws for the proposed project.
Furthermore, I understand and AGREE that I shall perform the necessary professional services and be present on
the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the
documents approved by the building permit and shall be responsible for the following as specified in section
116.2.2:
1. Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for the building permit, and approval for the conformance to the design
concept.
2. Review and approval of the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine, in general, if the work is being performed in
a manner consistent with the construction documents.
I shall submit periodically, in a form acceptable to the build' @M ss report together with pertinent
comments. Upon completion of the work, I shall submit fi t r45 nal report as to the
satisfactory completion and readiness of the project for oc
� 10
Signature and Seal of registered professional: °' Y\NE
TM &F �t7
�O�
r r 19 North Greeley Street,Palatine,Illinois 60067.5025
Telephone:1.847.359.9616 Fax:1.847.359.9641
Attn: City of Salem
Building Department
120 Washington Street
3rd Floor
Salem, MA 01970
Re: 7-Eleven
28 Norman Street
Salem, MA 01970
Date: October 12`h, 2010
I, Warren Johnson, as the licensed architect for this project, am acting as the engineer as well. I
have prepared, or caused to be prepared under my direct supervision, the engineering plans and
specifications and stat that, to the best of my knowledge and belief and to the extend of my
contractual obligati a re in compliance with the Massachusetts Code.
Thank you \2��a o`'
4� Q �A
313'
Warr nci ILL! ,Is
W ren hn cts �/
m0E:L:gvn
October 1,2010
Mr. Pat DeLeo
30 Tara Road
Peabody, MA 01960
Re: Store#34411 - Conversion of White Hen to 7-Eleven
28 Norman Street
Salem, MA
Dear Mr. DeLeo:
As you know, we are in the process of converting most White Hen locations to 7-Eleven
stores. This conversion will require some non-structural alterations to the interiors of the
existing stores. The alteration will consist mainly of new equipment,wall treatments,
some new flooring and minor electrical and plumbing work.
All work will be done in compliance with the terms and conditions as set forth in the
Lease and all local zoning and building codes and will be performed by licensed and
insured contractors.
Since we are required to obtain the Landlord's signature to apply for permits and obtain
necessary approvals, we are requesting your consent to make the above alterations and
ask that you indicate your consent by signing in the space provided below and return to
me at your earliest convenience by e-mail to William.Flanagan@7-1 Lcom or fax at 609-
860-5079.
Should the work planned for your location require any structural alterations, we will
contact you separately for that approval. if you have any specific questions about the
work to be performed, I can be reached directly at 609-860-5049.
S' ly,
' B' Flanagan c e/
Property Manager dlord Consent and Approval
�QSg-uctJ�C � Tf
.Nanfe
7-Eleven,Inc.
Real Estate&Development/1075 Cranbury South River Road/Jamesburg,NJ 08831
800-453-3711/Fax No:609-860-5079
License
a F, 73653
LINDSEY V RUTKA
17 NELSON ST
EAST HARTFORD, CT 06108
i
10/21/2012
4126
The Commonwealth of Massachusetts PnritFormr
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):VAN HORST GENERAL CONTRACTORS
Address:17 NELSON STREET
City/State/Zip:EAST HARTFORD, CT 06108 Phone #:(860) 289-3072
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑✓ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.❑ 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.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
Any applicant that checks box#1 must also fill out the 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 a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers' comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:ACE
Policy#or Self-ins. Lic. #:C4579149A Expiration Date:9/1/2011
Job Site Address:28 NORMAN 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 certi IF e gains an hies of&!2uLp that the in ormadon provided above is true and correct
Date /') / /I /d
J
Phone#:
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#:
'�(2BP, CERTIFICATE OF LIABILITY INSURANCE 09/24/2010
PRODUCER (860)848-2201 FAX (860)848-2207 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Curtin Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
620 Route #32, Box 387 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Uncasville, CT 06382-0387
INSURERS AFFORDING COVERAGE NAIC#
INSURED VAN HORST GENERAL CONTRACTORS INSURERA: Peerless Insurance Co. 24198
17 Nelson Street INSURER B: ACE
East Hartford, CT 06108 INSURER C:
NSURER D:
NSURER 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 OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR OD" TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
DATE ii,innnim
GENERAL LIABILITY CBP904323720 09/01/2010 09/01/2011 EACH OCCURRENCE $ 1,000,00
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 2SO,OO
CLAIMS MADE O OCCUR MED EXP(Any one person) $ 5000
A X X,C & U Coverage PERSONAL&ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00
POLICY PRO LOC
JECT
AUTOMOBILE LIABILITY BA304325720 09/01/2010 09/01/2011 COMBINED SINGLE LIMIT $
X ANY AUTO (Ea accident) 1,000,00
ALL OW NED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
A
HIRED AUTOS
BODILY INJURY $
X NON-OWNEDAUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGO $
EXCESS/UMBRELLALIABILITY CU504325720 09/01/2010 09/01/2011 EACH OCCURRENCE $ 6,000,00
X OCCUR CLAIMS MADE AGGREGATE $ 6,000,00
A $
DEDUCTIBLE $
X RETENTION $ 10,00 $
WORKERS COMPENSATION AND C4579149A 09/01/2010 09/01/2011 We STATU- X OTH-
EMPLOYERS LIABILITY E.L.EACH ACCIDENT $ 1,000,000
WITS FR
B ANY PROPRIETOR/PARTNER/EXECUTIVE
Oyes,de/MEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYE $ 1,000,000
If SPECIAL
describe antler
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT E 1,000,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
dditional Insured: City of Salem
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
City of Salem BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
120 Washington St 3rd Floor OF MY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Salem, MA 01970 AUTHORIZED REPRESENTATIVE �y
Justin Cook/GT
ACORD 25(2001/08) CACORD CORPORATION 1988