128 NORTH ST - BUILDING INSPECTION (2) �f y 6k-44 /oe 3 0 "3
The Commonwealth of Ma husetts
I V� Department of Public afety
assachusetts StateBuilding Permit Applicati n for any Building oth thauilding den a O R)
or Two mily Dwellin
(This Section For ffici I Use On y)Building Permit Number:
Date Applied: I I Bu ing
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for is a street address ' of av
orJ sr—
No and Street Gty/Town
Zip Code Name of Buildin zF
SECTION 2:PROPOSED WORK g( applicable)
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair lir Alteration ❑ Addition❑
Change of Use ❑ Change of Occupancy [IDemolition ❑ (Please fill out and submit Appendix 1)
Other ❑ Specify:
Are bandingin
plans and/or construction documents beg supplied permit application? Yes
as part of this ❑ No L9�
ge [�fz1
Is an Independent Structural Engineering Peer Review required? i
Brief Description of Proposed Work:_ _ Yes ❑ No
r
SECTION 3:COMPLETE THIS SECTION H 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
No.of Floors/Stories(include basement levels)&Area Per Floors Existing Proposed
Total Area ( 9•k.)
(sq.k.)and Total Height(k.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ ,yam❑
F. Facto F-1❑ p2❑ A-5❑ B: Business
H: Hi h Hazard H-1❑ H 2❑ H E: Educational ❑
1: Institutional I-1 ❑ I-2❑ I-3❑ I-4 ElM: Mercantile❑ 3 ❑ H-4❑ H-5❑
S: Storage S-1❑ S-2❑ R: Residentia] R-1❑ R-2❑ R-3❑ R-4❑U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑
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:
Public❑ Sewage Disposal: Trench Permit: Debris Removal:
Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site IV(
Private❑ or indentify Zone: required �trench or specify:
or on site system❑ rei p fy:f�r�SC u
Railroad right-of-wa permit is enclosed❑ — h� c.�
y' Hazards to Air Navigation:
Not Applicable 1P7 IS Structure within air airport a roach area? MA ti11oric Convnissk,n aeview process:
Yes[I or No�
or Consent to Build enclosed❑ P PP Is their review completed?
I
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Yes❑ No ❑
Edition of Code: Use Grou s)
Does the building contain an Sprinkler System?: Type of Construction:
Occupant Load per Floor:
Y Special Stipulations:
77
'Name'shd Address of Pro er O SECTION 9: PROPERTY OWNER AUTHORIZATION
P tI' caner
Ireer@c l�IdU I2fl ti�lZ it 9a
Name(Print) �
No.and Street �le^j
Property y Owner rConta City/Town
Information: Zip
[rAry �'nd 1nn 7 'I
Tttle Telephone No.(business —y,--- yprYk-6*P
If applicable,the roe ) Telephone No. (cell) tt cf.(;tjt~property riy owner hereby authorizes e-mail address
tPRry nc� st I'M�Name Street Address d Z�to act on the roe owner's behalf,in all matters relative to work authoriz Ci b/this build'n ermit a /]i anon.
CON
f buildin is less than 35,000T n State Zip
CcuLOft of mN 1 c ossed S acie and IONnC01dNTRO t(Pce n Conl out trol[henpcheckrhere®'and ski
10.1 Registered Professional Res onsible for Construction Contro]
Section 10.1
Name(Registrant) Telephone No.
e-mail address --------'--
Registration Number
Street Address City/
10.2 General Contractor Town
State Zip --
Discipline Expiration Date
Company ame
Name of Person Responsible for Construction —/O5D
License 7 No. and Type if Applicable
Street Address IXtJ I ytc Ia F-�� Dz l
Telephone No. usiness
Tele hone No. cell
SECTION II:WORKERS COMPENSATION IN URANCE AFFIDAVIT M.G.L.e-mail152.address
A Workers'Compensation Insurance Affidavit from the M 25C6
A 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 a lication?
SECTION 12:CONSTRUCTION COSTS AND PERMIT ME Mr No ❑
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$1.Building $
2.Electrical $ Q Building Permit Fee=Total Construction Cost x
3.Plumbing $ appropriate municipal factor)_$ (Insert here
4.Mechanical "7AC1 $ 0 Note:Minimum fee=$
(contact municipality)
5.Mechanical Other $
6.Total Cost $ Enclose check payable to
(contact municipality)and write check n-- -umber 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 to the best of my knowledge and understanding.
L"*hrnd Ctu.v'.9 %��v_1 sto{ehT ////��
Please print and sign time '� I�[L
,. 2R 3-y - --- �N Title „A^_TelephoneNo. Date
S eet Address i•u2
City/Town State Zip
Municipal Inspector to fill out this section upon application approval: ^ /�
Name Date
ACORQ
15 CERTIFICATE OF LIABILITY INSURANCE DATE 11/
(MMIDDIYYYV)
TH �CERT,:9 DATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 14/2011
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 certificate holder is an ADDITIONAL INSURED,the Policy(es)must be endorsed. If 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 endomement(s).
PRODUCER CONTACT
NAME:
Mackintire Insurance Agency, Inc. PHONE 508.366.6161 FAX
11 West Main Street E�-C.No Ell AJc No:508.366.5202
AIL
Westborough, MA 01581-1931 PRODUCER
00014183
INSURERS AFFORDING COVERAGE NAIC9
INSURED INSURER A: Selective Ins. Co. Of America 12572
9 To tman St.Inc. INSURER B:
9
Quincy, MA 02169 INSURER C:
INSURER D:
INSURERE: '
INSURER F
COVERAGES CERTIFICATE NUMBER: 11-12 Updated Master 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 ADDL SUBR
LTR TYPE OF INSURAN CE INSR WVD POLICY NUMBER MMODIVYYYY MMIDDV YYYJ LIMITS
GENERAL LIABILITY S 188974 06/05/2011 06/05/2012MAnny),
1,000,000
ENCE $
X COMMERCIAL GENERALLIABILITY DAMAGE ToNTEDrence $ 100,000
CLAIMS-MADE OCCUR PREMoneperson) $ 5,000
A DVINJURY $ 1,000,000
REGATE S 2,000,000
GENT AGGREGATE GATE PRO-
-IMIT APPLIES PER: OMPIOPAGO $ 2,000,000
POLICY JECT
JECT LOC $
AUTOMOBILE LIABILITY A909492 06/22/2011 06122/2012 COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $ 1,000,000
ALL OWNED AUTOS BODILY INJURY(Par pennon) $
A X SCHEDULED AUTOS BODILY INJURY(Peraccident) S
X HIREDAUTOS PROPERTY DAMAGE $
(Per accident)X NON-OWNED AUTOS S
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE
$
DEDUCTIBLE
S
RETENTION S
WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY YIN TB 10/01/2011 10/01/2012 X ORY UMRS CVR
ANY A OFFICER/MEMBEREXCLUDED?�ECUTIVE NIA E.L.EACH ACCIDENT $ 100,000
(Mandatory in NH) E.L.DISEASE-
If yas desctlbeOF EA EMPLOYE $ 100,DDD
DESCRIPTION OF0 ERATONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Salem
120 Washington Street AUTHORIZED REPRESENTATIVE
3rd Floor
Salem, MA 01970 Michael O'Connor
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
CITY OFSAL.EM, >. kss,kcHL'SETTS
9L'ILDNG OEP.jA-nLLNT
120 W.kSHNGTON STREET, JW ROCR
ht. (978) ?4S-9S9S
KIAMERLBY DRMOLL FU(978) 740.9846
MAYOR TNO.V u ST.PMUS
DIRECTOtt OP PC8L1C PROPERTY/8L:MDL%4G CONNISSIONER
Construction Debris Disposal Attldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.S
Debris, and the provisions of MOL a 40, S 34;
Building Permit 10 is issued with the condition that the dcbris resulting from
INS work shall be disposed of in a properly
111, S I SOA. licensed waste disposal facility as defincd by NIOL c
The debris will be transported by:
(n one of hauler)
The debris will be disposed of in :
(name O�i(Ijy)
(Jddrm! Or rJCI(1(y)
d f ermrt�pphc�nf
PARY INC.
9 TOTMAN ST
QUINCY, MASS. 02169
Phone # 617-479-6035
Fax # 617-472-9881
QUOTATION
11/11/2011
We will supply all labor ,equipment and materials for the following
Work at: 7-ELEVEN INC.
126 NORTH ST
SALEM, MA
1. REMOVE ALL DAMAGED FIXTURES AND DEBRIS
2. TEMPORARILY BOARD UP DAMAGED OPENING IN STORE
3. INSTALL TEMPORARY ENCLOSURE ON RIGHT OUTSIDE OF STORE
4. PREP AND REBUILD 18" HIGH KNEE WALL
5. REPAIR FLOOR ON RIGHT SIDE OF STORE
6. REPLACE ALL DAMAGED FIXTURES SUPPLIED BY 7-11
7. SUPPLY AND INSTALL I STONE TRASH BARRELL
8. REPAIR AND ALIGN CHECKOUT COUNTERS
9. REPAIR CEILING AS NECESSARY
10. COODINATE WITH GLASS COMPANY INSTALLATION OF NEW DOORS
AND WINDOWS
11. PRESSURE WASH SIDE WALK
TOTAL COST INCLUDING ALL INSURANCE AND TAXES:
$19,500.00
NOTES:
1. Prep work will be done so as not to interfere with customers or operation of the store
2. All work will be done during normal working hours 7am-3:30pm Mon-Fri.
Buyer Chris opher Gacicia
For Pary Inc.
Gary Knott
Field Supervisor
7-Eleven Inc
CITY OF SALEM
PUBLIC PROPRERTY
=' DEPART
MENT
i uc.n�l r ,nlx s a l
Ntttw
I!: lVn Hn.�U w.v i18 CY1' • inlhu, it u t I.�191.
• f t.r ')lM.!fC.'i.tM
Workers, Cumpenaatlon Inxurunc9 liffldeviC Liu!lderUCuntrocrury cite trlelenIt Plum beIts
\ t Rican In unnrffo
1 In a •hl
Ndlnt:Ilhnuk'FYI)/ay+t/1110N inJlrulYyl l( se-',
Ciry,Sfarc.%ip ,tnc - /fat c,
Ihuneih 7g
It,r,Y�ou ml enq)lOyer?Check the appr 1prlafs box:
1 lJ 1 ,Im u umpluyor wilhAMETIS 4 Ej 1 ,fin a jcnurul cautroetorand 1 l)M Yrprafuet(ruqulr.d);
'•❑ entpiu)vwY(lull and/or purt•linit).• huvo hired the.+uh•cunlraclurs rt' ❑N41W cunsituctian
I,fin a soft prnpriehw or poultice lived on rht.irtachcd sheet y ❑Remodeling
ship and have no u,npluycv's These sub contrscrars have warkind lite mu in any cipacily, worktn'comp insurance.
g' ❑ntntellirion
IKn wnt#crs'cutup. itlsura,lct 3. ❑ Will art o cntporalinn and its 9 ❑oudi ind addiliun
required.) oRlcers haw ejercisc'd their 10.0 Electrical repairs or additions
�.❑ 1 an+a homrtu+vner Juing all work right of arcmplian per M1I( L 11.❑Pfumbiny repairs or additinna
myscl/.(Ko+ctmkcn'comp• C. 132.41(4,14461%v hnvu no insurance required.) f cmpluyues. (No workers' 12•0 Ruufrepuire
cnrftrk insurance required.) 12• ther ,r
•t'tf.,�pLcus nwl.•hcb YoY of muY.Jw lilt tnu iM vcuun Iwhltr Jwwuq�Avir wwYw'rungnqull,,,l ln.li.y,nlintnYiav►
'll.,mu,lty,.rth rr1Y atarTil tYif cn'Itl vA inulurina ihur,p Juina all.rurk a.+e iMrl AIrY uYriM euerltrprr Mal.l,lrnil Y Mrw und�vil inJlvwina�kY.
•C..ntnwnn that tAecs iAr Dw1 nutty 41130wl.it ulutrlwyl,low,Ynwiux ihtr nOnit of the m►aonr _
%
INSINY
/met fill celptoyer that If pruvlrffge workers'CYrepf/Ifn/Ite IY.fY/gMC1/Yl/uy I/ep/plrrrABIf41Y I�x/h P1IIfly Ynw�n
,!"fur lrulkal,
Insurance Cuntpany Nnlnt G�Ct 71 re....�15urt:w
Policy Y fir Sulf•ins. Lic.rr: —
fcspirunon Dab: Q I I
JAL) Site Alddrurr:�2(� tior� C't- .1tv Zip; nr� •i2`•—
.\ltach Y euyy of Iht workers'cumpentatlua poile) declarallon pays(shawl NI Ihatpolicy nuJbu�arid etp�atfu duty. _
f.uluru to weura cureruge as required uudcr Scetiun:3/\uf.11GL c. 132 eau lead to lilt imposition Olcrirninal ptnalfiq of s
i •' iyt ru 1'1 JUO.tM sntYur uut•year itopri.rmuncnr, as troll as civil pcuuiha in the lunn ot'a STOP WORK ORDER and a tint
ai up rn i?fO rM.I JAY ryuinsl ih•vLtl,uar. Ile sdv,.a'J shut J uupy of 1hls,tutetncnl may be lur»arJuJ w the Ullicu vl'
Ia+.Hi y.atl,,,1r ul';hu WA I9r nt+nau'ce :uvcru;u tailiunun.
/du/r,•rrAy r ertrh,u /aY the/„rinr,Ili prne//ire u�pfr/nry/haf the ie Urmy"ow
/ yrvriJer/ubor#is true and correca
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t1//!riot,rtr�,dy: po,tnl�rrirr in thin arru, ru At ru,ny/vrrJ by
rjly fir rose Wift iug
rlirn: _
PermifrLlecnle e
It.viny .lulhnrily (tirclonnu):
1 IL,.IrJ "/Ilv.11lh !. IInJJm, Utlrulinwit I. 1.ill.'foan Clerk J. llccfric.l) hl+pev/ur ;, ('fumDiny In+yetlar
L. Illhvr
,I t' •„� tc1 I'tnmu
i
information and Instructions
on IJr their
are ,son in the )ervlce of mother on,ler•uly:unlct hire.
hl ,
General Laws:haprer lit Irywres all euyllo)en to provide
workers :JtIIPen3aU
ncll,p oyes.
I'ur>u.ull to taus slatule. In enrplovee is defined as a ry P'
)press or unplicd, Jrai or wniten." of Illytwo or lnore
artnenhip..isaacialloo,:oryorauon tar other legal3 de easedcritnCY lu of or the
to ,•,nplupar n JctincJ 3f"an tnntviduaL p' lu In arm loyees. However tht
,�t the G,regou,ll engaged to a Iwnl enurynse, Ind ulclu,ling the lerlal represenurives of a decease emp ,
,ccmver of trustee Lit.of uldlv,Jual, paamenh,p,assocwparllod or ether d who¢nary, s th Y g ' P
ft
e non)to el mainlenunce,construction or repua work an ;uch dwelling house
owner Ufa dwelling house having not more than thrd Iparananu and who resides thereto,tar the occupant of
it
dwv:Iling hou;a of anorhar who employ {x
Grounds or building appurtenant thereto)hull oat because of such employnlcnt be deemed to bean employer.'
Jr ill the
\IGL chapter 152. t15C(6) also states that"every flab or total Ile@s�iag agency s thelid withhold the lh for
or
compliance whir Iht Insurance coverage requlrad:
renawul of a Ilaena tar prrntit to uparab a Aualn@u ar to eoufruet built le the commeawaultk or any
;rypllauno nbo has not'pradueed acceptable avldeac@ u/sump
\JJitionully,SIGL chuptar 151, )11C(1)galas"Neither the cominonweallA not any of its political subdivisions.+hat
%Jji4mtdr into any:GL ch for the perfornwrlce nteJ m Iht canines g+ptabletyriJanct ufcumpliattc w ith the insuraneo
requirdmcnu of this chupl+r hav@ been p'
Applicats t our situation and.if
checking rho boxes that apply o Y
Kona number(0)along Wilk their crliffclltets)of
ple;,.ut rill out the workers' cumpeosadon ). davit completely,by with no em loylbs usher than the
necessary,supply subeontracwr(s)name(.addrcLimit and P
iesul anct. Limited Liability Companies to(LLCworkars'tcompansrlioed Liability e iluuranet,(If asILLC or UP does have
members or punnaa, are nut required w carry b@ submitted to the Depurtfnellt of Industrial
empinyads,a policy is requited. Be advised that this a111dsvit may
Accident for conalsmatiun of insuraneo coverogt Also be sure to sins trod Jutt Ike uflldav not the l4 Pls affidavit should
131
he relumad to ills city or lows that the applicationyquestions regarding regarding the law the pannil at of if being
wart required,to obtain a workers'
of
Industrial r\ccidenu. Should you have any
compensation policy,pleas@ call the Deputtrnant 4"Its number listed below. S@If•insuted eompaaiee should enter their
selPinsuranet license number on the appropriate
lino
('try of rows Otflal@Is I printed
Please
the sic ute that
you affidavit
l it isinuha lew ank the 0 Tic legibly.
investigations has to contact you regarding theho Department bus Pruvl�ild a speed at lappl bottom
Pltaso I sure to till in the penniNicenat elunber which will bo used as a referencc.nell'bcr: In addition,an;ipplicant
th;,t must submit multiple pun iulicesa iijunb applications wh in any given year, need only submit one,Ifiidavit indicating current
of dls utlidavit that has beat offlciully stamped or marked by d,a city or town nay be provided w the
policy informulion 1 if necessary)and under"Jab Sit@ Address'the applicant should Warta";Ill locations o (he or
tuwn).",\ copy
applicant Is proof that a valid uffldavit is on file for Ilature paamiu or licenses. A new affidavit ntust 6t tilled out each
y a u. \�'herc 4 a hums owner or citizen is obtaining a license of pennil not related to any business or comnareial venture
tie.. ,rug home
a permit to burn leaves Life-) +aid persml is NOT required to complete this affidavit.
Invesliyatiues would 11" to thank you in �Jvancu for your:euperatianand sltuuld yuu,hase,ny yuouenf.
I,ICa�e do nor heallal@ to iilve us a call.
+s
telc hone and fan number
fhcU.plrnn.n ) adJra
� •
t l � 4 ' � �t Thal Commonwealth of Ma+aachusetq
Department of Industrial Accident
Oflfe• of Ievadaadans
600 Wuhingtbn Street
Boston, MA 02111
Tel. 4 617.727.4900 eat 406 of 1.877-MASSAFE
Fax 4 617-727.7749
t,.t s www.rnau,jov/dial