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0017 PARADISE RD - STAPLES Na• City of Salem Ward APPLICATION PERMIT TO BUILD ADDITION, MWAITIMTIONS OR NEW CONSTRUCTIO gi�ORTANT•Appitr�nt eo aM Nana 1n soedom-4 r, A% W,and a L�/�/�� ATUCAT101s i l2anrS� ►_ 0111...:... AM ."' to1�R " . 10110SsmRT sunortL401i lOT BLOCJt S13 L TYPE AND C68T OF BOR* •As appYCa/!AI cQmPkM Pafb A-Q- A. TYPE OF ilvnOVBABfT AL PIKN/p INR FOR"08#0UTIOW USE M06i RECEWT USE... 1 ❑ New woom _.. .; uaRieauollof 2 Q Aaa,senan..errr ararawtlerdnw- 12 p "ww is Aaerrra ro.ror foaene WWSNmd to*a JUNO.lb _ .. is pQ On 13 aM!a!eeDb!& 3 eAeaanr4W7aearel ft 1t%1M�•6�f�rAnnOto 20 kd WW - ♦ ❑ Rear npYwnwa. 14 p TiaRltr * s a Y sio*�or ' .2113 �9asM"aor�rtoa w:_ o 40 p rrergo 23 p tt"*Kha*eiD" awaa.artlYpnPr1413).. . to ❑Ostoaeeeltarleeew" 6 ❑ Mo•nqlry 1, to _. _ 1s p weer 26 p �a!n t p Rarlgrenaey . - 13 . srre►f6a•aaea«wrerr 17 ❑ � •so,c.F L OMT1ERawe _ r ft e [7�f•�.r.,ndartaaraaranrtnopato. 28 p Oe.•Sa.ew as utm ae, 9 i]Pubw dofta Oft or Iwo rOta,nneP,. C.COST .. 10efanw Nrwrier Oewre w OWN reaam Win Go eaeenyL 04.toae areeeerro am apat"O mtoi—eWdgseo�pe�MaAeier¢aLml,eaoaiiefrrerrraalsm 1a Costal arownw s area"waese►sslunow�6o.areaw�.6aw wnwas�erard�v 6we.a+d�s - r yye�araYr,a/b�i�,F6j�s oe�e6q�ge4.~WOPN aera �4tirararoormyaae_ Yl fto rr`e a1a - a f9lefn>rftenewilp rn/�4e/A� a. Helft ar aarrwp a Ohrwwaa.aW 11. TM COW aF oz R SELECTED CHARACTEFUUM OF BULDM •far now 6udd npa and addltlona, corril"Pans E-L. drffoNebfb e Parts J 6 A4 aN O&AMMOIDIV L PRafCaAL TYM OF FRAW F. pFAc L TYR aF IW=AS1 d TYFS UWAOE OMMSAL L TYPtt OF M50"W IL 3o O etoerrrleafearAw 3613 On 401 Nftorokaommom, VA weeavadw 31 0 woodkan,r 31100, 41 Q Pdeto mom tortSW aaierrume 320 9 uclwa aw v p escso tr M p rib ae p We 33 ❑ Rrraosmmre 3110 car M TYP[ MMTElltifi/LY waetorermewom n 3e Q O91or•Sam* 36 Q Ogas-ISee4 a2 PsoarpawaaatorM ,a p-yn 47 ❑ Ne 43 0 fte`alaa drq - _- a orerboodt A. DEMOLITION OF STRUCTURES' 48 WOW a,gem as. TCII SMWM M CO%W WW APP,"Ubm Hiskn d C4flwnmm been received eoa�owa on�swr t lM WUC Ln Over ft(50)Yw? Yee_ Nb_ aumor + Sd&Number 5a Tod W4 R q sl Enea�e FCUDWm UTLffM BEEN DL9CONNECTED! a-_No . r L ... " s... sa M"040: _ >N-Dom, RATION F THE ABOVE MW gF�0i1�1t PE W CAN BE N CC k Hfi!CoeA � _ Yea_ Now: - _ Hiebib Diaklet� Cormervatian Neer ram_. iw:= (�rya Pew e 0 Ha �. d Fn!P+ewraon<_ and stamped P"or � , ., .. ,.".', Is property bcabd N IhR SAA dieYbl? Yed__ NR_: ' -tom Ya.:.. . .. .. , s�::�C.r.�;.'" % rta•re�rZ :: „. .,. C,cinpfy Willi Zdrr7ir — No-- m no,enclose Bard d Appw decbioni mck_ IM yea abm5 docuntstl pnM no,abnil Board d APPW-d9cWM) B new," krL M Prop!! Sap been en(ioeed� 1IlA,_ Ne_ app _.� � m o,bmit.doam+enmgom) - Ia Arq>iEmpaal AOceas Bard ovai re9ried4 AAA StaEra_CaMraeler l;certee! sawn uo mw FbnI00iMisa BOW ions(il wkmW Yee_ NCB oN Tq VY�FYM 9pl 1s?AAOQITHB OF 13BlIAN;E OF,BULDMP PERMif.v ` Ran eawtelon r r etxeeory, atbmR CON8TRUCTIoN IB To BE COMPLETED.BY;_ _. in b the Imp I-'; al - Y. DOMCATM• To be taorr►Plefed by aN appliem►ia momemA•m~..snt CIA.wroWIN DFCaew. Tr Mn 1 017 0 2 G7A GE5 uC, S-co Sr LjF-S Dstue F&Ami en M4. 6233 ew11e1 canuaer Nerwra of I hereby�that ms Pr000ed vrark b amtafud by eN oweler ol reeerd ab that 1 hm been adWmW by the Owr=b meb IM aPOi�mn ad a e0as b COrlbrm b al a k;aw levee of this utlSdCaOn. ot#mam Address SA dae DO NOT WRITE BELOW THIS LINE VL VALIDATION FOR t1EMNIMEDR USE OW Building Permit number ur ame /� Perms ems' issued �C� F..clue n0 ggUMyyN // 27, ►�.�.a•w Permit Fee Soca pow Lod CertlNcale of Ocovanefi s Appraed Drain Tile s Plan Review Fee s S SLR. IAI-e T1r1J: NOTES AID Data•(For depaf+asrrt uaeJ I f 1 I PERMIT TO BE MAILED TO: DATE MAILED: COnstruodon to be started by. comolew W. 7 -------------- i A ZONWG PLAN E%AMNNERS NOTES DISTRICT USE FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES 4 NM OR PLOT PLAN•For AXbcW Use 0 N I DATE: APRIL 28, 2006 PROJECT: STAPLES STORE LOCATION: VINNIN SQUARE PLAZA 17 PARADISE ROAD SALEM, MA 01970 FIRE PROTECTION SYSTEM NARRATIVE REPORT: A. BUILDING DESCRIPTION 1. BUILDING USE GROUP"M" (MERCANTILE) 2. TOTAL SQUARE FOOTAGE (STAPLES ONLY) IS 20,334 3. BUILDING HEIGHT IS±35'0"AFG 4. ONE (1)STORY BUILDING ABOVE GRADE 5. ONE (1)STORY BELOW GRADE-UNOCCUPIED BASEMENT 6. CONSTRUCTION TYPE IS 2C-UNPROTECTED WITH SPRINKLER SYSTEM 7. THERE IS NO HAZARDOUS MATERIAL USAGE OR STORAGE 8. THERE IS NO STORAGE OF COMMODITIES OVER 12' 0"AFF B. APPLICABLE LAWS, REGULATIONS &STANDARDS: 1. NFPA 13-INSTALLATION OF SPRINKLER SYSTEMS CODE 2. NFPA 70-NATIONAL ELECTRICAL CODE WITH MASSACHUSETTS AMENDMENTS 3. NFPA 90A-STANDARD FOR THE INSTALLATION OF AIR CONDITIONING &VENTILATING SYSTEMS CODE 4. NFPA 101 -LIFE SAFETY CODE 1 i 5. 521 CMR-MASSACHUSETTS ARCHITECTURAL ACCESS BOARD/ADA 6. 780 CMR-MASSACHUSETTS STATE BUILDING CODE 7. CITY OF SALEM LOCAL JURISDICTION CODES, AS MANDATED. 8. FEDERAL OCCUPATIONAL, SAFETY AND HEALTH ADMINISTRATION STANDARDS 9. NFPA 72-INSTALLATION OF FIRE ALARM SYSTEMS C. DESIGN RESPONSIBILITY FOR FIRE PROTECTION SYSTEMS: REGISTERED PROFESSIONAL ARCHITECT(S)AND/OR ENGINEER(S) FULLY DESIGNED AND/OR SUPERVISED THE DESIGN OF SAID SYSTEMS. CONTROLLED INSPECTIONS TO BE PERFORMED ON A WEEKLY BASIS PURSUANT TO 780 CMR. RESPECTIVE DESIGN PROFESSIONAL TO CERTIFY PROPER SYSTEM INSTALLATION FOR CODE COMPLIANCE AT COMPLETION OF PROJECT VIA NOTORIZED AFFIDAVIT(S). D. FIRE PROTECTION SYSTEMS: 1. EXISTING WATER SUPPLY, MAINS AND HYDRANTS ARE TO REMAIN AS IS. 2. THE EXISTING FIRE SPRINKLER SYSTEM, AS INSTALLED PER NFPA 13(IN CONJUNCTION WITH ALL OTHER APPLICABLE CODES)AND APPROVED BY LOCAL AUTHORITIES HAVING JURISDICTION, IS TO REMAIN AS IS. ONE (1) SPRINKLER HEAD NEEDS TO BE RELOCATED (DROPPED DOWN)AS REQUIRED TO ACCOMMODATE NEW OFFICE. THERE ARE NO ADDITIONAL ALTERATIONS REQUIRED DUE TO SCOPE OF WORK BEING PERFORMED FOR THIS PROJECT. 3. STANDPIPE SYSTEMS&COMPONENTS-NOT APPLICABLE 4. THE EXISTING FIRE ALARM SYSTEM,AS INSTALLED PER NFPA 72(IN CONJUNCTION WITH ALL OTHER APPLICABLE CODES)AND APPROVED BY LOCAL AUTHORITIES HAVING JURISDICTION, IS TO REMAIN AS IS. THERE ARE NO ALTERATIONS REQUIRED DUE TO SCOPE OF WORK BEING PERFORMED FOR THIS PROJECT. 5. AUTOMATIC FIRE EXTINGUISHING SYSTEMS-NOT APPLICABLE 6. MANUAL SUPPRESSION SYSTEMS-PORTABLE FIRE EXTINGUISHERS ARE EXISTING AND SHALL BE RELOCATED AS REQUIRED AND SHALL CONFORM WITH NFPA 10 WITH LOCAL AUTHORITY HAVING JURISDICTION. 2 7. SMOKE CONTROUMANAGEMENT SYSTEMS- NOT APPLICABLE 8. KITCHEN COOKING EQUIPMENT AND EXHAUST SYSTEMS-NOT APPLICABLE 9. EMERGENCY POWER EQUIPMENT-NOT APPLICABLE 10. HAZARDOUS MATERIAL MONITORING EQUIPMENT-NOT APPLICABLE 11. SEISMIC CONSIDERATIONS-NOT APPLICABLE E. FIRE PROTECTION SYSTEM BEING INSTALLED/REVISED: STAPLES IS CURRENTLY PROTECTED BY A BASE BUILDING (MALL) FIRE ALARM SYSTEM. THE FIRE ALARM CONTROL PANEL HAS BATTERY BACK-UP. ALL INDICATING DEVICES ARE ADA COMPLIANT WITH STROBES SYNCHRONIZED ACCORDINGLY. EXISTING INITIATING DEVICES ACTIVATE SYSTEM AS FOLLOWS: 1. MANUAL PULLSTATION: UPON ACTIVATION, THE EXISTING FIRE ALARM CONTROL PANEL SHALL GO INTO ALARM. EXISTING FIRE ALARM CONTROL PANEL SHALL INDICATE WHICH ZONE IS IN ALARM. ALL INDICATING DEVICES SHALL ACTIVATE. EXISTING LOCAL ENERGY MASTERBOX#552 SHALL ACTIVATE AND ALERT THE CITY OF SALEM FIRE DEPARTMENT OF ALARM. 2. SMOKE DETECTOR: UPON ACTIVATION, THE EXISTING FIRE ALARM CONTROL PANEL SHALL GO INTO ALARM. EXISTING FIRE ALARM CONTROL PANEL SHALL INDICATE WHICH ZONE IS IN ALARM. ALL INDICATING DEVICES SHALL ACTIVATE. EXISTING LOCAL ENERGY MASTERBOX#552 SHALL ACTIVATE AND ALERT THE CITY OF SALEM FIRE DEPARTMENT OF ALARM. 3. DUCT SMOKE DETECTOR: UPON ACTIVATION, THE EXISTING FIRE ALARM CONTROL PANEL SHALL GO INTO ALARM. EXISTING FIRE ALARM CONTROL PANEL SHALL INDICATE WHICH ZONE IS IN ALARM. ALL INDICATING DEVICES SHALL ACTIVATE. EXISTING LOCAL ENERGY MASTERBOX#552 SHALL ACTIVATE AND ALERT THE CITY OF SALEM DIRE DEPARTMENT OF ALARM. 4. SPRINKLER SYSTEM FLOW SWITCH: UPON ACTIVATION, THE EXISTING FIRE ALARM CONTROL PANEL SHALL GO INTO ALARM. EXISTING FIRE ALARM CONTROL PANEL SHALL INDICATE WHICH ZONE IS IN ALARM. ALL INDICATING DEVICES SHALL ACTIVATE. EXISTING LOCAL ENERGY MASTERBOX#552 SHALL ACTIVATE AND ALERT THE CITY OF SALEM FIRE DEPARTMENT OF ALARM. 3 5. SPRINKLER SYSTEM TAMPER SWITCH: UPON ACTIVATION, THE EXISTING FIRE ALARM CONTROL PANEL SHALL GO INTO SUPERVISORY ALARM. EXISTING FIRE ALARM CONTROL PANEL SHALL INDICATE WHICH ZONE IS IN TROUBLE. ALL INDICATING DEVICES SHALL NOT ACTIVATE. EXISTING LOCAL ENERGY MASTERBOX#552 SHALL NOT ACTIVATE. F. TESTING CRITERIA IF REQUIRED, COASTAL CONSTRUCTION CORPORATION, SAID PROJECTS GENERAL CONTRACTOR,WILL COORDINATE ALL FINAL ACCEPTANCE TESTING AS WITNESSED BY APPROPRIATE CODE OFFICALS. CONTACT PERSON FOR COASTAL CONSTRUCTION IS JAMIE KELLEY. JONN F\ PJo. i2D74 C; I K � i i i 9 L m No. 5730 E HANOVER � MASS L_�J C.r^p 16 Dg -IO 4 4�Ta OF M 4 MASSACHUSETTS ENGINEERING DESIGN AFFIDAVIT PROJECT TITLE: Staples Store PROJECT LOCATION: Vinnin Square Plaza— 17 Paradise road, Salem, MA 01970 NATURE OF PROJECT: Office Supply retailer IN ACCORDANCE WITH SECTION 116.2 OF THE MASSACHUSETTS STATE BUILDING CODE I, John E. Colcord, jr. REGISTRATION NO. 12074, BEING A REGISTERED PROFESSIONAL ENGINEER, HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ❑ ARCHITECTURAL ❑ STRUCTURAL ❑ MECHANICAL ❑ FIRE PROCTECTION ❑ ELECTRICAL [XOTHER ire Alarm) 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 AND ALL ACCEPTABLE ARCHITECTURAL / ENGINEERING PRACTICES AND ALL APPLICABLE LAWS AND ORDIANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY 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 FOR 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 building permit, and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Special architectural or engineering professional inspection if critical construction components requiring controlled material or construction specified in the accepted architectural / engineering practice standards listed in Appendix B. PURSUANT TO SECTION 116.1, I SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. (V Lei p l a Signature S AND SWORN BEFORE ME THIS o?� "- DAY OF t / 1 200b 90HN g E. COLCORD, JR. N i 90 �GISTEP .4, '&ic: SESSIONAL�� MASSACHUSETTS ARCHITECTURAL DESIGN AFFIDAVIT PROJECT TITLE: Staples Store PROJECT LOCATION: Vinnin Square Plaza— 17 Paradise road, Salem, MA 01970 NATURE OF PROJECT: Office Supply retailer IN ACCORDANCE WITH SECTION 116.2 OF THE MASSACHUSETTS STATE BUILDING CODE I, John E. Colcord, jr. REGISTRATION NO. 12074, BEING A REGISTERED PROFESSIONAL ENGINEER, HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS ZOSTRUCTURAL FICATIONS CONCERNING: ENTIRE PROJECT VARCHITECTUR ❑ MECHANICAL ❑ FIRE PROCTECTION ❑ ELECTRICAL El OTHER ❑ (Fire Alarm) 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 AND ALL ACCEPTABLE ARCHITECTURAL / ENGINEERING PRACTICES AND ALL APPLICABLE LAWS AND ORDIANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY 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 FOR 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 building permit, and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Special architectural or engineering professional inspection if critical construction components requiring controlled material or construction specified in the accepted architectural / engineering practice standards listed in Appendix B. PURSUANT TO SECTION 116.1, I SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. STEREO 4#C A, 19 o o /p�c _ Signature S� 1 SU m D DT W RN BEFORE I a DAY OF F 20 0. EHANOVER MASS J4 ! T or 1A U� The Contnroxwedth ojMassachuselis Depardnene ojlndusdid Aceldeea Ofa 6"wasiiing1lix Sired Boston,MA 02111 tawtamaassot AN Workers'Compensadon Insurance Affidavit BoM s/Coutradors/Elecbickn*Tlumben ADDNcant iofq=atioe Phase Print Ulzibb Name Cons`rn r Address: ZZ jkp(A s°T. City/8t eq* `7y �.E` Iy14, Phone l6. 761 - 93 4--576 7 Are you an esn"W?Chet tir ipproprlde bon' Type o(prel«t(rMWem: 1.93 ,:am a employer with 4. [2 I an a geaaai aoutraclor and I d; ❑New couttacdon employes 0A and/or par6l=l* have bbed*a subaouaaetota 2.❑ 1 am a sole pwprielm or partner- Hood an the susdol:beet i y ❑ Resoodcliqg ab*and bave no tmrployees These sub-contr ecom have tl. ❑Dcm lwm wadft fwmnis a w capaft. jai'pump7k==CL 9. Q Building addition (No wwW asp•Manna 5. ❑ We art omppimoi and its' • I their officers bx"es la❑ Ehx iesl npain or aadditionsrega$edl_� � sod 3.❑ I am a h a omeowm .doiog aQ wort tight ofextj r p�pear MGZ. 11.0 Pbtmbing repass or additions Myself[Nowoskewconv c. 152,41(W%ioWiphave�i 12.pliodrepai kmugsae requhou t: CUP ragofitid J 13.❑ Other •Auy.ppHc�t»m ahxbbmeil mus raLo�a94itk teeth..bel.ty eho.i.a tttiirlwt�p' yotiey mSoim.tbc - t tromeownwoo euhtmlthY.�devit ad�a tteex m dom{•A part eeel aem]�s'ooEddt m .sioe:emu.eenv.�devlt iodieetfia�..sit 1Cmu.eee.ti.teleet tlh tea¢mmt aucLed ee.ddAia..t-.�eet.in.mK>>r mnlMmreobomtrKyen e.dt6eiewodrat.'camp Per�o+*+� learatsateployerthefbprovldiedtwri<ace'eompsesedoabtsamie?jeratptiipfiyted adowbtiFapofk�e:rdJobaLas Informal" Insurance Company V Policy#or Self-in.Lie. # X Cep D 6-2 S 4 2 5"3 9 Expiration Date: 9. zq,042 Iob sue Addm- f pAa a.d:5 4=- �d C$y/Staoe2ip: ,, • �I�, Attack a copy of the worieW comlmundoa porky declaradon page(showing the policy nigher sad expiration date). Fatal=to secure covaape ar requked under Section 25A of MGL a. 152 can lead to the imposition of criminal penalties of a The up to$1,500.00 and/or onc-year imprbonmeA as well ar civil pasida in the form of a STOP WORK ORDER and a fhre of up to$250.00 a day against tie violmor. Be advised that a copy of this statement may be forwarded to the Office of Iavestigations of tie DIA for insurance Wv/wp verification. ]As 40 pwfary Mat*9 bejormedon provfdcd abow Is aw and cerreat i D O Lo Ohkkf am a* Do eat wr6llm rA&area,m by complsred by clly or ow o,OlcleL City or Town: Purmitll cem g Issuing Authority(circle one): 1.Board of Haltk L Building Department 3.Cky/rowu Clem 4.Electrical Inspector S.Plu7Inspeecator o.%JUW Contact Person Phone#• Information ,and Instructions 1S2 mprires all cm&V Ip PF°V*- °II y tuba ct o fbk% puraU osw(i taral Laws c byw is defied as"••.every>�m Ate aesvtoe gf nodwranda awry aonnact ofb3te, Poraaant m this stance, as s"'PfOla e�at implied,oil of wraclr a other legal aft of my two Or more n de ? a daaArod c1V1 of 11M ft An a � and iacbtdiog the lei f�' �. of Ate foregoing association or odw legal ca tY.cap"empbyag Ho%mq tba receiver or trustee of an individosi.parwasldp. and vi to raids 6aein.Or the ooarpmt of'� owns of a dwelling house having mitt mine tha three bone dwelling home o[tmother wbo employs penmu to do mamtemmok aonmuctim or mP*wOt#an such dwellmi on the gromtds m btr1ft aPPmtaaa thereto sW wtbeemw of inch empWm robe deemed to be m emPloya" MGL ebgm 132,125C(6)*0 state Atat"eveq state or loot dceasing a`esey aunt wdtbbdd the Mnaaee Or rcwwd of a license or pa ft to Operate a badness°f to eroestr>tel haiWlaO Is the eotnreoawge r reen for any wbe bas adproda ced ovlde au o f comPA"n**b the luau aaee emvonga ldred Addidonany,MGL.abwtef 15Z 12SC(7)states"NcRW the eommonwabh nor any of ib political mbdivisioul ahan of he wort anal acceptable evidence of eompfimce wi&the insnance eau into any contract for the t°the eontractint{aa Y" regniremouts of this d3aptor have beenpraated APPl Please fq,oat the'.ricers'comps nation affidavu c=Vk*,by d wclvog the bow that VplY b yin atmadcm ate.if mtewsa�Y.ill's0, s)we(s),addren(es)an¢phone matber(s)along with their aatifcaue(s)Of Limited Liabrltly COmpmm ol4 or Limited Lubtlr'ty Pa masbips OIY)widl no cOVIWJ es other thin the memberf err partners,ate not toga. cd to ca►rl'wwkeW Woance. If an Id.0 or Id.B does have employees,a pohcy o ralaned. Be advised that this Ad"maY be�°�to the Department of ffiehrstrial Army Sur confirmation of iuwran"covmge. Also by am to dgr and date the aMdav1L the affidavit sboald be retnrnad to DepartzbM Of the city or Iowa dw 1be apple for the pamit or license is being regoesacd,° a workers' Watrial Ac adanti. MMM you have anY PcffWm law m if you we rogatred ahonld eater their ce Taney;p ca the DepWUMM at the munba*ad below. Self msmed compama Self-insurance ukase> 1,11111,Mr on die VPMP416 lim city or Town OtfleWa Please be sore that the sMavit is complete and prmtcd 1,&Iy. The Department bas provided a space at the botmoa of the affidavit for you to fin out in the cvcm gm 0,kg °will be used as a rcfcraa number, addition,an applicant please be amto fin in the PamWlicadebas to contact you TeV fic 3PPH bkh licationt in any give year,need only submit one affidavit indicating current that mot submit multiple Permeese aPP policy iaformanon(if necessary)and coda"Job Site Addraa"the apphaat ShoaM wrtte"an location m (citY Of town}"A copy OfdW affidavit that has boas officialbt stamped,XnWW,by d w�or town may be provided to des applicant s proof that a valid a Wxvit is oa fik far flame pamns or licasa A new affidavit�stbe ffitod out each year.where a home Dana or ddM is Obtaining a liceme or permit not related,to any busioem or commacial venture (ic a dog license m peamtit to burn kaves cte.)said person is NOT npired b complete this affidavit, The Office of Invatigations would lulus to thank you in advance for your cooperation and should you bave any questions, please do not baitale b give us a calL The Dcpartromes address,telephone and faammbW The Commonwealth of Massachusetts Department of Industrial Accidents Oftlae of Inveestipt iou 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 east 406 Of 1-877-MASSAFE Fax#617-727-7749 Rcviscd 5-26-05 www•mass•gov/dia sCITY OR SALEMV MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASNINGTOM sTREET. 3*0 FLo00 SALEM, MASSACNUSETrS 01970 STANLEr J. USOVICE. J9. TELEPHONE: 979.743-9995 EXT. 380 MAro3 FAX: 970-740-9846 Wem Building Deoartunent Debris Disoom9il Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. The debris will be disposed of in: (Location of F ) ature o Ap cant y. Date DATE(MMIDDIYYYY) ACORQ CERTIFICATE OF LIABILITY INSURANCE 05/04/2006 PRODUCER (781)681-6656 FAX (781)681-6686 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION J Barry Driscoll Ins Agcy, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 600 Lo ater Drive HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR °gw ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 9120 Norwell, MA 02061 INSURERS AFFORDING COVERAGE NAIC# INSURED Coastal Construction Corporation INSURERA'. Ohio Casualty Insurance Co. 22 Depot Street INSURER B. P.O. Box 1644 INSURERC. Dnxbury, MA 02331 INSURER D: NSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE 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 HEREINJS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR kDD-L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY BR05254ZS39 09/24/2005 09/24/2006 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,00 PREMISES Es—rurence) CLAIMS MADE T OCCUR MED EXP(Any one person) $ 5,QO A PERSONAL BADVINJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG $ 2,000,00 POLICY X P O- X LED AUTOMOBILE LIABILITY RA052542539 09/24/2005 09/24/2006 COMBINED SINGLE LIMIT ANY AUTO (Ea amdent) $ 1,000,00 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ A X HIRED AUTOS BODILY INJURY X NON-OWNEDAUTOS (Per accident) $ PROPERTY DAMAGE $ (Peramiident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY. AGG $ EXCESSIUMBRELLALIABILITY US052542539 09/24/2005 09/24/2006 EACH OCCURRENCE S 10,000,00 X OCCUR CLAIMS MADE AGGREGATE $ 10,000,00 A $ DEDUCTIBLE $ X RETENTION $ $ WORKERS COMPENSATION AND XW052542539 09/24/2005 09/24/2006 X I WCSTATU- orH- EMPLOYERS'LIABILITY E.L EACH ACCIDENT $ 100,00 A ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 100,00 VPECtlLPRO PROVISIONS E.L. ISEASE-POLICY LIMIT $ 50O 0O SPECIAL PROVISIONS Below , OTHER BBO52542539 09/24/2005 09/24/2006 Leased/Rented Equip: $100,000 eland Marine, $500 A ed., Actual Cash Misc. Tools & Equip: $5,000 alue Installation Floater: $50,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS Staples, Salem, MA **See Attached Addendum*** vidence of Insurance for work performed within the Insureds scope of normal business operations. otice of Cancellation provision is 30 days except 10 days applies for non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Staples, Inc. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 500 Staples Drive OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Framingham, MA 01702 AUTHORIZED REPRESENTATIVE /I B. Driscoll/PDB ACORD 25(2001/08) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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 endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) Staples, Inc. Certificate issued to Staples, Inc. 05/04/2006 J Barry Driscoll Ins Agcy, Inc 05/04/2006 Staples, Inc. is included as Additional Insureds for General Liability and Excess (Umbrella) Liability as required by a signed written contract or agreement with the Named Insured.