90 NORTH ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
(�7 Department of Public Safety
Massachusetts State Building Code(780 CMR)
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: :Building Official:
1 '- SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
90 tio'C1 4 5 W.L— GAL F_iYt t /11A M1 q70
(� No.and Street - City/Town" Zip Code Name of Building(if a cablgpl
SECTION
1 r� �rn
Edition of MA State Code used If New Construction check here❑or check all that apply in the two ows Mrolq
Existing Building❑ Repair❑ Alteration 15( Addition❑ Demolition ❑ (Please fill out and submit AfFpendiqgi
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 9 N n
Is an Independent Structural Engineering Peer Review required? Yes ❑ Nd9 rn
Brief Description of Proposed Work:�,)�n Ar6a F ryzi 2 2F,..+o rn,,..: F�sn i R6,w- %46[ci
'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.) ) 1(p(p o 1 )(p&0
Total Area(sq.ft.)and Total Height(ft.) - ( U/ d' (9 i 7" -1 e)g
OF _z s-SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business G E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑ ,
I: Institutional I-1 El 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ - R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility ❑ Special Use❑and please describe below:
Special Use:
a4 I - s t. J6.1 "n SECTION 6:CONSTRUCTION TYPE(Check as applicable) --
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB fit
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 Flood Zone' A trench will not be Licensed Disposal Site 9
Indicate municipal l8• required Aor trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic 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 (, r r ="`a e ;1 „
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
- SECTION.9 PROPERTY OWNER AUTHORIZATION, -
Name and Address of Property Owner
01) 5S j Faxtir sm6F8 LLC HF1S5 PCA04 L QC0o9eAD&_- N5
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: -
TIM 1.1D(,aJ e1 -Q) �Ctx%c+fC�L15Pee
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name 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 application.
"SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2) _
boildm YsdesS than 35,000 cu;ft of encloses ace and or not under Constmction_Conuol then check here O and ski -Section 10.1
10.1;Re"stared Paofessronal'Res-onsrble for"Constructs'on Control , - .
V4,Ls-mP4Q12- poF4CCHLAv 6iY-_WL- 2000 9y6�
Name(Registrant) Telephone No. e-mail address Registration Number
J067 DISC L).,t I�LVD DfA&(I 11 1:,L4L
Street Address City/Town - State Zip Discipline Expiration Date
.,;
102 General Contractor ,
L 3
Company Name
Aj l CL 2a Z Atio
Name of Person Responsible for Construction License No. and Type if Applicable
-2 � I Pa,00 Fr 'iE �K V dg0I0*_-�
Street Address City/Town State Zip
y�3 d oaI fi 11 bal zcmo -e��i b--onc.[�. cctv�-
Tele hone No. business) Telephone No. cell e-niatFaddress
- 1.fi.- . :'.-SECTION 11:WORF' RS'CON[['ENSATION 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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
-SECTION-12:CONSTRUCTION COSTS AND;PERMTI'FEE -
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6) 000
1.Building $ O" ooO §II/ 000
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$#j GOO.
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ '0'B (contact municipality) -
5.Mechanical Other $ Enclose check payable to r!'_ 1T i OF SAID
6.Total Cost $ (�,0 000 (contact municipality)and write check number here
SECTION 13::SIGNATURE,OEBDILI,)ING 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 to the best of my knowledge and understanding.
NicA-focal 1Zar.-8tron 6fL3A�t_ l.11_Df �b Go. PF3 - - o! ll S
Please print and sign name Title Telephone No. Date
7 L41_ACbgrx) WAtIsC,_44 PCLOVIOG C,E Rz 6a9o3
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon-application appioval lt4r J'
CITY OF SM.ENI, 2 XSSACHUSETTS
• BUILDLNG DEP 1RTNIENT
130 WASHINGTON STREET, 3"FLOOR
TEL (978)735-9595
FAX(978) 740-9846
KIN fBERLEY DRISCOLL
THo
MAYOR t`tAs ST.P�RRS
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLMISSiONER
Workers' Compensation Insurance Affidavit' Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legibly
Name(Busingss.Organization/individual): CAI L GAJf_ &A t Mal L CQrnPl!ii '?
Address: 07idc.sot,.) tcLu n
City/State/Zip: Ruvioe cs I Xr- a-L 03 Phone#: ya/ ' 3Qa — 061 $
Are you an employer?Cheek the appropriate box: Type or project(required):
I.S 1 am a employer with 51 c15 O 4. 0 I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)•• have hired the subcontractors
2.0 I am a sole proprietor or partner listed on the attached sheet.t 7. B Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. workers',comp.insurance. 9, 0 Building addition
[No workers'comp. insurance S. 0 We are a corporation and its
officers have exercised their l0.❑Electrical repairs or additions
3.❑ required.]1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have12.0 Roof repairs
no
insurance required.)t employees. [No workers' 13.0 Other
comp. insurance required.]
•Any applicant that checks box 01 most also fill out the section below stowing their woken'compenntion policy infurmadon.
t I lorncuwneta who submit this affidavit indicating they am doing all work and that hire outside contncton must submit a new affidavit indicating such.
!Commcton that check this box most attached an additional sheet showing the name of ilia sub-contractom and their worker'comp.policy infomutlon.
l am an employer that Is providing workers'compensatlon Insurance for my employees. Below is the policy sad fob site
information.
Insurance Company.Name: /_1 a fRirY rhA,cxLt 9— =AJ c"t,4,.JC G
Policy#or Self-ins. Lie.#: Expiration Date: all S
Job Site Address: 90 /UAt1TN S-xr£Err 56l.Er-n rr�A City/State/Zip: :54riEnn /hst 01`170
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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
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.
1 do hereby certify tinder the pains and penalties ofperjury that the information provided above is true and correct.
S t m a t t tre9 =� � Date: CS b 117//t`
Phone#: —60 I Y
Official use only. Do not write in this area,to be completed by city or town afcial
City or Town: Permitfl.ieense#
Issuing Authority(circle one):
1. Board of Ifealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing-Inspector
6.Otlu r
Contact Person: _, Phone#:
. i
COMMERCIAL GENERALLIA1j1LITY DECLARATIONS Y.,1bert I`
OCCURRENCE �utu
- tN5l1RANQ6
issued By Liberty Mutual Fire Insurance Co_
Policy Number TB2-617 259068-024 Issuing Office WESTON, MA-SOUT
Renewal Of 762-61125906&023 Issue Date 2014-07-07
Account Number 1-259068 Sub Account 0001
I .
Named Insured and Mailing Address
Gilisanerfic. ......... i
7 Jackson Walkway
Providence Rt 02903-3630
Form ofl3usiness: Corporation
Policy Period: The policy period is from 0613012014 to 0&3012015 12:01 A.M,standard time atthe Insured's mailing
address.
In return for the payment of the premlum,and subject to allthe terms ofthis policy, we agree wdh youto provide the
insurance as stated in this policy.
LtMf1S OF INSURANCE
Each Occurrence limit $ 2,000,000
Damage to Premises Rented to You Limit $ 1.000,000 Any one premises
Medical Expense Limit $ 10,000 Any one person
Personal &Advertising Injury Limit $ 2.000,000
General Aggregate Limit $ 4.000,000
Products-Completed Operations Aggregate Limit $ 4,000,000
SCHEDULE
The declarations are completed on the accompanying "Declarations Extension Schedules)".
Commercial General Liability Coverage Part Premium $
Endorsement Premium $
Total Estimated Premium $
Other Charge(s) $
Polkywrtins3 Minimum Premium
FormsApp€icable; See Attached inventory
AON RISK W02003131
AON RISK SERVICES NORTHEAST 114C
100 WESTMINSTER ST 10TH FL
PROVIDENCE R102903
--Producer--PAOL-INO-- G 8823 - --.-.. _.,.... _.... ....... —.. ........... . -......_.. --
WESTON, MA-SOUT
LC 00 04 08 12 - 0 2012 Liberty Mutual Insurance,All rights reserved. Page 1 of 1
Includes copyrighted. material of Insurance Services Office, Inc.with
ds permission.
213201.400011500004
i
i
Liberty
M4C 44R.�fM �
Pt@a[NStlRA,\l1+COAtPANY
Hwtea„Atassad,o5etls' EXCESS LIABILITY POLCCY DECLA.... S
25 90 68 0001
Policy Ne. TD/CU Sales Office Code Sales RepreseaNtive Cade N/I( 151 Yr.
Uab.Pal.
TIC-611-259068-054 74/0 Boston,MA 0001 2006
Item 1. INSURER'S NAME AND AC)DRESS: .
— -- -
Gilbane, Inc., I
7 Jackson Walkway
Providence RI 02903
Item l POUCY PERIOD: -
From: 06=12014 . To: 0613012015
17;01 A.M.Standard Time at the address of the Named insured as slated above.
j
..Item 3. UNDERLYING INSURANCE
Limits:
5 See Attached Schedule Each Occurrence
s, See Attached Schedule Aggregate(whet applicabie)
Immediate underlying lnsarfr. Cee Attached Schedule
immediate Underlying Policy Number. Seg Attached chedule —
immediate underlying policy Period: Ofi/3 ! 014 to D6130Y1015
item,. LIMITSOF1.1"1LI'M
$ 10 000 000 F ch Occurrence
S 10 000 000 General Aggregate
S 10000000 ProdoW/Completrd Operatiioto
Item S, PREMIUMISPAVARLE:
_ [Ycmivat -
g TRIA
y Total Mirdmum Earned Premium: S
tlemfi, ENDORSEIgENTSt See attached Schedule of Forms and Endorsements
This Policy is countersigned By—
by our Authwiaed RrprescutattNT AUTHORIZED REPMENTATIVE
N-91400
TERM I Rcmwel of Date POI Audit AUDIT RATING BASIS Line Class ARC ACCT Wr"
ID Issued HG 9asis SYMRDL9 Evp.RMd Retro Code Code Di++on Ept'ul+ry
TE3 Ownai Hired
T z srl.zseaas osa 07122l2014 0 Nit 374 99935
KRD 498 R.2 TL 06 05 Page I of 1
• 195201400032WI12
l WORKERS COMPENSATION AND EMPLOYERS LIABILITY � Mutual.
INSURANCE POLICY
INSURANCE
INFORMATION PAGE 175 eerkaley sheet eastan,MA82110
Issued by Liberty Insurance Corporation (a stock company) 21814
Policy Number WA7.61D-259068-034 Issuing Office Lewiston, ME
Renewal Of WA7-61D-259068-033 Issue Date 07/092014
Account Number 1-259068 Sub Account 0001
1. Insured and Mailing Address FEIN 05-0147010
Gilbane,Inc. NJ TIN 050147010000
7 Jackson Walkway Risk ID 9103562B3
PROVIDENCE RI02903-3623 MI Risk ID 2582791A
_ .
Status Corporation
Other workplaces not shown above: See Item 4. Premium-Extension of Information Page
2. Policy Period: The policy period is from 0 613 0 201 4 to D6/302015 12:01 A.M. standard time at the Insureds
mailing address.
_3.. Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: AL AK AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY
LA ME MD MA MI MN MO NE NV NH NJ NM NY NC OK OR PA
RI SC TN TX UT VT VA WV
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Rem 3.A. The
limits of our liability under Part Two are:
Bodily Injury by Accident $ 1,000,000 each accident
Bodily Injury by Disease $ 1.000,000 policy limn
Bodily injury by Disease $ 1,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states. if any, listed here:
All States except those listed In Item 3.A and the States of:
ND OH PR WA WY
D. This policy includes these endorsements and schedules: See Item 3.Coverage D-Extension of
`Information Page
4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required below is subjectto verification and change by audit.
Classifications Code Premium Basis Total Rate per$100 Estimated Annual
Number Estimated Annual Remuneration of Remuneration Premium
See Extension of Information Page
Minimum Premium Total Estimated Annual Premium $
Premium will be billed Annual Deposit Premium . $
Deposit Tax/Surcharge/Assessment $
Producer 0002 003131 Countersigned by Authorized Rep. (AZ)
AON RISK SERVICES NORTHEAST INC
100 WESTMINSTERST 10TH FL
PROVIDENCE RI02903
Producer PAOLINO 8823
Weston. MA-Soul
s
WC 0000 01 A 01987 NationalCouncil on Compensationinsurance,Inc. WC 00 00 01 B (C41NJ)
Ed. 07101 2 0 1 1 All Rights Reserved Page 1 of 1
CITY OF S.,UX-A4 TAXSSACHUSETT$
BUILDING DEPiRi*% NIT
120 WASHINGTON STREET, Yo FLOOR
TEL (978) 745-9595
FMX(978) 740-9846
KI-,fBERLEY DRISCOLL
T
j41AYOR HOhL15 Sr.P[ERRH
DIRECTOR OF PUBLIC PROPERTY/BI:ILDLNG CO3-MaSSIONER
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:
Go S�zyi t,ES
(name of hauler)
The debris will be disposed of in :
(name of facility)
6 Ez/ 1J 5'M�t`�, 6a57rac.J n-A- Oa u 9
(address of facility)
signatwe of permit applican�
date
debrisaffJoe
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block # and Lot # for locations for which a street address is not
available)
No-and Street — — City/Town — -Zip " ' Name of Building (if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
. e
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural x
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC 7�
7 Electrical
8 1 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Ins ections Pro am
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
C�OLE.y�J A ReL.A&eL &q-o - 70n^-
Registration Number
Name(Registrant) Telephone No. e-mail address
7067 DISCn%/QtY 6Lv0 D1401'(4 ; Ola O N3617
Street Address City/Town State Zip Discipline Expiration Date
("i�t2lSCOPttE2 IL. /
00iK -ILA 6tV-�- 7a'° on
Number
Name(Registrant) Telephone No. e-mail address Registration -
7co7 O/Scnvfaq gl✓o DU601') el-I c. O/7
Street Address City/Town State Zip Discipline Expiration Date
6r-p"T 5. trpw OraATIFd Uy- 63y 7000 -.1530G
Name(Registrant) Telephone No. e-mail address Registration Number
7007 m75lnvwiye SGVP DOAMrl Od _L�J� M�Mtsrr.
Street Address City/Town State . Zi Discipline Expiration Date -
R-ecoc2,1 g. Hbcft*rJ '/St 6a0
CITY OF' SALEM,
ROUTING SLIP
,Neu Construction
Certificate of Occupanc '
LOCATION _ DATE
ASSESSORS DATE
93 Washington St.
CITY CLERK DATE
93 Washington.St. yl
PUBLIC SERVICES DATE `
120 Washington St. (j
WATER DATE
120 Washington St.
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNING DATE
120 Washington St.
CONSERVATION DATE
120 Washington St.
ELECTRICAL DATE
48 Lafayette St,
1
FIRE PREVENTION DATE.
29 Fort Avenue
HEALTH_ .. DATE
120 Washington St.
BUILDING INSPECTOR DATE
120 Washington St.
t