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0017 PARADISE RD - BPA-15-615 STAPLES The Commonwealth of Massachusetts Departatent 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: - SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 17 &9Q/S6 ROAD 54kAM 44, 0 ZM 1 5 ,S, j 07%1, SAAS No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2.PROPOSED WORK Edition of MA State Code used �j_ If New Construction check here❑or check all that apply in the two rows below r Existing Building IN Repair❑ 1 Alteration X I 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 J$ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No P( Brief Description of Proposed Work *44 1 U, SA0 ZW /$7 X.�GzsS srtrx$ r7t��acdti3 coflY .tv�ar3S� ,ttr,Ii,f/a� s sic$ s s FGoc14 _ _ct<wl. ini aR Ftetr2 urea P,cyis —' 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)A Area Per Door(sq.ft.) Z wt — 20,;jj/B, �t r Avla? Total Area(sq.ft.)and Total Height(ft.) 000 urr 3jg0jF 32 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A_4❑ A-5❑ B: Business ❑ E: Educational ❑ F. Factory F-1❑ F2❑ H: HI Hazard --H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-0❑ M. Mercantile ( R. Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1❑ S•2 Cl U: Utility❑ Special Use❑and please describe below: Special Use: SECHON 6.CONSTRUCTION TYPE(Check as applicable) TA ❑ IB ❑ IIA O HE ❑ IIIA ❑ ITIB O - IV.tt VA ❑ VB Cl SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply. Flood Zone Information Trench Permit: Debris Removal:Sewage Disposal: A trench will not be Licensed Disposal Sitex Public Bf Check if outside hood Zone❑ Indicate municipal Dr Private❑ or indentify Zone: or on site system❑ required lg or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: NM Historic Commission Review Process: Not Applicable 11 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No 1( 1 Yes❑ No 5( SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code:&t Use Group(s): /mil _ Type of Construction: 31r= Occupant Load per Floor. 4 .S, Does the building contain an Sprinkler System?:�Special Stipulations: 3 Ar3s Cc tl _ 605 oogy, 779 7�O 3813 f� SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner W,AW FaaY toRr ?1�3 AYX W A gD Aad 1Fyx PmRK/ W-Y o z Name(Print) No.and Street City/Town Zip Property Owner Contact Information: ��1 �,C AWY VMkH &17 -ZLG2-� &7 -18F- ?O IO AWQ9 U4*CORt'i5U- C-dA! 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 't application. SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2) building is less than 35,000 cu.fc of enclosed space and or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control RAA,f*K•4afr' "r• 78) 3�- " ew i 'X 07 Name 26N4 tranQ DRI✓� Telephone No. e-mail address Re ' tratinNumb NA•YY/W2 al Street Address City/Town State Zip Discipline Expire on Date 10.2 GT V Contractor co 44-h rJVI !U Co N an aa oq o3z Name of Pe n Responsible for Co License No. and Type if Applicable treet Address � 2�ty/Town � State Zip Telephone No. mess Telephone No. cell e-mail address SECTION 11:WORIMRS'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 issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No O SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ W fw Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ 5Vj ffil appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) S.Mechanical Other $ Enclose check payable to $6.Total Cost �i•J (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 avOication is tru� ``r9curate to of my o and understanding. A`, 14ff-- �W/fiC/ s_� - r'A1 t Please t and s' name Title Telephone No. Date Street Address City/Town //n State/�/J Zip Municipal Inspector to fill out this section upon application approval• ✓ �o , Name Date 1 ® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDf YYY) ACOKO 10/1/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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(les)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 endorsements. PRODUCER CONTAC NAME: The Driscoll Agency, Inc. PHOC.NE ac No:781-681-6686 93 Longwater Circle EWAIIESS: P.O. Box 9120 Norwell MA02061 INSURERS AFFORDING COVERAGE NAICII INSURER A Malley Fo[ge Insurance Co. 20508 INSURED 2279 INSURERR:N '1 Fire Ins Co of Hartford47 Coastal Construction Corporation INSURER C:Continental Casualty Co, 20443 22 Depot Street INSURER D:North River Insurance Company11 P.O. Box 1644 Duxbury MA 02331 INSUE: n l Fir In r n INSURRERERE: COVERAGES CERTIFICATE NUMBER:981292160 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 TYPE OF INSURANCEADDLSUBR POLICY EFF POLICY EXP LTR INSR VND POLICY NUMBER MWDD/YYYY MM/DDIYYYY LIMITS A GENERAL LIABILITY C5088297566 /24/2014 /24/2015 EACH OCCURRENCE $1.000,000 x AMA E T RE COMMERCIAL GENERAL LIABILITY PREMISES Ea ocwnence $300,000 CLAIMS-MADE OCCUR MEDEXPIAnyoneperson) $15,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $2,000,000 POLICY x PRO- X LOC $ JECT B AUTOMOBILE LIABILITY SAP5088297602 /24/2014 /24/2015 Ea accident 1 000 000 ANY AUTO BODILY INJURY(Per person) $ ALL OMMED x SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OMED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ E C UMBRELLA UAB X OCCUR C5088297597 /24/2014 /24/2015 EACH OCCURRENCE $10,000,000 D EXCESS LIA9 5227485084 /24/2014 /24/2015 CLAIMS-MADE AGGREGATE $10,000,000 DID RETENTION$ $ E WORKERS COMPENSATION /24/2014 /24/2015 STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE❑ N/A E.L.EACH ACCIDENT $500,000 MI OFFICEREMBER EXCLUDED9 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE 8500,000 If yes,describe under DESCRIPTION OF OPERATIONS be. E.L.DISEASE-POLICY LIMIT $500.000 A Leased/Rented Equipment r 088297566 /24/2014 /24/2015 Mas Limit Per Item $100,000 Deductible $1,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more apace Is required) are included as Additional Insureds for General Liability and Excess(Umbrella)Liability as required by a signed written contract or agreement with the Named Insured. are included as Additional Insureds for General Liability and Excess(Umbrella)Liability as required by a signed written contract or agreement with the Named Insured. CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sample ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1644 Duxbury MA 02331 AUTHORIIED/REPRESENTAWE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD - i I Initial Construction Control Document y ` I; ti;/; To be submitted with the building permit application by a Registered Design Professional 4 >,, ,t; ;:J ,h -.� ;�I �/.', for work per the 8 edition of the is � % Massachusetts State Building Code, 780 CMR, Section 107 Project Title: $Tg]'IAlfS j;oWalt Date: 0f/2�� Property Address: 17 44WSir dKq4p SA40-A'i///A ' Project: Check one or both as applicable: New construction x Existing Construction Project description: 6//' / A44 i lZff W i/ sTaz a�oe�a eo�Y rli�c/liv sa•-� I •LA'�d04A.-• MA Registration Number: Jt4 Expiration date: g 0i/ ,am a { registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: �J Architectural [ ) Structural ( ] Mechanical [ ] Fire Protection [ ] Electrical [ } Other for the above named project and that to the best of my knowledge, information, and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I (or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: I. Review, for conformance to this code and the design concept,shop drawings,samples and other submittals by the ' contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 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 if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official O ARC T Upon completion of the work, I shall submit to th 16f 1 Construction Control Document'. co Q Enter in the space to the right a"wet"or No. � W electronic signature and seal: o � PEMBROKEa =V 'toy MASS. t wh of Phone number: mail:mail: Rc�i'f�4G4e° Building Official Use Only t Building Official Name: Permit No.: Date. [ Version 06 11 2013 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 2 Foundation 3 Structural 4 Fire Suppression _5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 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&Inspections Program 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 MMi tion Documentation 20 Other(Specify) 21 Other S 22 Other S *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 Male the original permit fee. Registered Professional Contact Information Rai} lc•e4ff1'& ?AI V/ _44g 410�1' 4319 Name(Registrant) Telephone No. e—mail address Registration Number 02 Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci Town State Zi D�suphne Expiration Date �r Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 8u'edition of the Massachusetts State Building Code, 780 CMR, Section 107.6.2 Project Title: STAPLES Date:06.09.15 Property Address: 17 PARADISE ROAD SALEM,MA Project: Check one or both as applicable: ( )New construction ( )Existing Construction Project description: I,Raymond W.Dusseault lll,MA Registration Number: 40709 Expiration date: 0613012016 ,am a registered design professional, and 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 Protection Electrical X Other: for the above named project and that such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 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 if the work is being performed in a manner consistent with the approved construction documents and this code. When required by the building official, I shall submit fieldiprogress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work,I shall submit to the building official a `Final Construction Control Document'. Enter in the space to the right a"wet"or `\V§ •t•fiH OF electronic signature and seal: m DUSMONDW. _ • EL C CA °o • Phone number: 401.765.7659 Email. oivice.com �'`jattNtALE�`„��o- Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an 'x'project design plans,computations and specifications that you prepared or directly supervised.If'other' is chosen, provide a description. Trial Version 10 09 2012 f, co City of Safem, Massachusetts Fire Department (DavidgV Cod' 48 Lafayette Street C(ie Sareur, 94assac(usetts 01970-3695 re(BPliureau 978-744-6990 eutiore 7ef 978-744-1235re978-745-7777 dcnt(yCsn(erra.cons FnrC978-745-4646 FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR A BUILDING PERMIT IN ACCORDANCE WITH 7'HE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND THE SALEM FIRE CODE, APPLICATION IS HEREBY MADE FOR TILE APPROVAL OF PLANS AND THE ISSUANCE OF A CERTIFICATE OF APPROVAL FOR A BUILDING PERMIT BY THE SALEM FIRE DEPARTMENT. (Ref. Section .113.3 of the Mass. Bldg. Code) JOB LOCATION: ; _ OWNER/OCCUPANT: 6ht�Y7" S ELECTRICAL CONTRACTOR: FIRE SUPPRESSION CONTR SIGNATURE OF APPLICAN PHONE#: q��/ ,,& � `^A n - ADDRESS OF APPLICANT:��� CITY/TOWN'y\ to�CI(��� •.......................................................................................... APPROVAL DATE: (P , (S - /5 Certificate of approval is hereby granted on approved plans or submittal of project details, by the SALEM FIRE DEPARTMENT. All plans are approved solely for identification of type and location of fire protection devices and equipment. All plans are subject to approval of any other authority having jurisdiction. Upon completion, the applicant or installer(s) shall request an ,inspection and/or test of the fire protection devices and equipment. (ADDITIONAL REQUIREMENTS SEE OTHER SIDE) .............................• ........................................................... NEW CONSTRUCTION PROPERTY LOCATION HAS NO COMPLIANCE WITH THE PROVISIONS OF CHAPTER 148: SECTION 26 C/E, M.G.L.RELATIVE TO THE INSTALLATION OF APPROVED FIRE ALARM DEVICES. THE OWNER OF THE PROPERTY IS REQUIRED TO OBTAIN COMPLIANCE AS A CONDITION OF OBTAINING A BUILDING PERMIT. PROPERTY LOCATION IS IN COMPLIANCE WITH. THE PROVISION OF CHAPTER 14S SECTION 26 CIE M.G.L. EXPIRATION DATE: SIGNATURE OF FIRE OFFICIAL UNDER 7,500 SQ FT- $50.00 OVER 7,500 SQ FT- $100.010 CHECK# u�