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44 PINGREE ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts yu Department of Public Safety r Massachusetts State Building Code(780CMR) Building Permit Application for any Building other than a One-or Two. i ell' (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SEGTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street re ��( 0 No.and Strut City/Town Zip Code Name of Br ding t a e) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ (please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No 18-' Brief Description of Proposed Work: Ga SECTION 3:COMPLETE I111b 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 basemen[levels)&Area Per Floor(sq.ft.) s 00 Total Area(sq.ft.)and Total Height(ft.) 66 - SECTION 5:USE GROUP(Check as applicable) I;; embly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑ F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ tutional [-1 ❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ ge S-1❑ S-2❑ U: Utility Special Use O and please describe below: Use: SECTION 6:CONSTRUCTIONTYPE(Check asapplicable) IB ❑ 1[A ❑ 116 ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) upply: Flood Zone Information: Sewage Disosal: Trench Permit: Debris Removal: ic❑ Check if outside Flood Zone❑ hndicate municipal❑ r\trench will nut be Licensed Disposal Site❑te❑ or indentify Zone: or on site system❑ required❑or trench or specify:ermit is enclosed❑ ilroad right-of-way` Hazards to Air Navi ation: . n g'of Applicable❑ Is Structure within airport approacharea? Is their review completed? sent to Build enclosed ❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): type of Construction: Occupant Lund per Floor: Does the building contain an Sprinkler System?: Special Stipulations: ' - �6ya Amo ��-ZP SEC"LION 9: PROPERTY OWNER Au-moRIZATION Name and Address of Property Owner Name(Print) No.end Street City/Town '7 Zip Property Owe er ntact Information: L{d/ �S� "----- Title' ' e-mail address Telephone No.(business) Telephone No. (cell) If applinble,the�ro^p_erty ow//ne^r hereby authorizes U4 y� �� -r�.YY1 _ tf�dress City/Town State Zip to act on the n? er mvner's behalf, in all matters !alive to work authorized b this build ut ermit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If buildin is less than 35,000 cu.R.of enclosed s am and or not onder Construction Control then check here O and ski Section 10a lU.l lie istered Professional Res onsible for Construction Control Re -) Name(Registy nt) Tcle hone No. a-mail address3�S�� Rc�istr lion Number_ Street Address city/Town State Zip Discipline Expiration Date 10.2 General ContKactor Company N I of Per oilR�espon�for Construction LiC`pse-No. and Type if Applicable tee` evsg -- Street Address City/Town State Zip �76 �t ,,o Telc hone No. business Telephone No. cell a-mail address SECTION 11:bVORKER5'Cc,)bll'ENSn VION INSUKAN(T AFFIDAVIT M.G.L.c.152. 25C 6 A Workers'Compensation Insurance Affidavit from the NIA 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 si ned Affidavit submitted with this application? Yes 0 No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) "Cola!Construction Cost(from Item 6)_$ L Building $ /P- 7 0Q z G b Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$132,04 3. Plumbinga74(/ $ Note: Niininuun fee=$ (contact municipality) d. Mechanical (Other) $ 5. Mechanical Other $ Enclose check payable to h QX�ih•_ 6.Total Cost $ (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 ation is true and accur a to the es o lily wledge, I understanding. 'lease int and sign name Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date Merrimack Construction Group Inc. 54 Chu'ch Street Lowell,MA 01852 )a<k Shanahan Cell 857-247-4658 Fa.888-465-7642 lack@me'rimackconstructiongroup.net www.merrimackconstructiongrou p.net From Tonry Fri-^Ct 25 12:13:45 2013 Page 2 of 3 CERTIFICATE OF LIABILITY INSURANCE °ATE`MM'°°"YYYT' ��� 10/25/2013 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(ies) 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 riq his to the certificate holder in lien of such endorsement(s). PRODUCER Colleen MaLlterls NAM:: Tonry Northwest Insurance Agency, Inc. 'HONE E, (781)861-1800 1F No,,.uailael-iew 238 Bedford Street ADDRESS,Cmathewsetoauyaw.Corn INSURERS AFFORDING COVERAGE NAICA Lexington b1A 02420 INSURERA:Endurance American Specialty 41718 INSURED INSURER S' Merrimaok Const"otion GrcUp, Inc. INSURER C' 54 Church Street INSURER o: INSURER E. Lowell MA 01852 INSURER F' COVERAGES CERTIFICATE NUMBER:CL132 7 05 862 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. NOTWITH5TANDING 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. I�1p TYPF nF INF11RANr'.F POLICY NUMBER MMIn°VYYVI MMIOOIYTYY IIMITS GENERAL LIABILITY FACH nrruRRFNr.F ; 1,000,000 $ GOMMtKUALChNhHA-UAVli-IIY ❑nMn(iH 1Oao¢urrcnce PREMISES 9: 100,000 A to nlM:+MnuH nUcu,H 8C10001460000 /4/2013 2/4/2011 rvIHI SAP(nny nnn perrrnJ Y 5,000 PHH:ewm KN)VIN,ilKY }' 1,000,000 GENERAL AOOREOATE T 2,000,000 <{FN'1 AN(iKi-(M I F I IMI I IIPH l4:i VFH 1,14(II111(All-(A)Mpoi,ANo f 2,000,000 X I V(111DY I PRO IOU $ 0.W UM06IL6 L1AMILI I Y GOM9INED uINGLE LIMIT 1 Fa acn0e1 ANY Ion n DOOILY INJURY(Pel Peuun) i AI Ouuwl-° ticHPuu1 ro BODILY IIVJVftY Per flaltlenq i. A °ti nw ati NON OWNED PROPERTY DAMnGE NIh"I nu l n, AUTO$ rnrar.r.in5n1 g y VMBRBLLA LIAR OCCUR HACH OCCURHPNI'P :$ EXCESS LIRE CLAIMS MADE AGGREGATE S 'FII HFIFNIIf1NY f, WORKERS COMPENSATION Wti STATU OTII AND EMPLOYERS'LIABILITY YIN IOHY IIMI IS FH ANY FROPRIFTOFPARTNFRIFXFM TIVF 01-i- NIMEMbER EECLUUEUi N IA C.L.EAOI ACCIOCIJT y (Mandeory in Nil) LUJ E.L.CISEASE-EA EMPLOYE i I yyc,dreribc under DC6 RIPTIOIJ Or OPEr(ATIOIi below E.L CISEASE-POLICY LIMIT b DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101.Additional Remarks SCheat le,H more space Is requlleal Project: Valerie Moratia, 44 Pingree Street, Salem, MA 01970 CERTIFICATE HOLDER CANCELLATION (978)740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington Street Salem, MA 01970 AUTHORIZED REPRESENTATIVE L Tonry Jr../CMATTH - ACORD 25 (2010105) 01988-2010 ACORD CORPORATION. All rights reserved_ INSn95 nn.nn�a m Th.Amnon.,en,e—A lnnn e.e•nn;cdamH,.,, 1k.,.F Arnon From Tonry Fri-Oct 25 12013045 2013 Page 3 of 3 MASSACHUSETTS ASSIGNED RISK POOL REQUEST FOR CERTIFICATE OF INSURANCE Use this form to request a Certificate of Insurance fiorn the Assigned Risk Pool Carrier(Liberty Mutual Fire Insurance Company). Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the Certificate of Insurance should be issued. If this form is fully and accurately completed, the Certificate of Insurance will be issued and distributed by facsimile to each fax number provided below,within two(2) business days of the carrier's receipt. This Form may be mailed or faxed to the Assigned Risk Pool Carrier. To obtain each carrier's contact information refer to the Certificates of Insurance section located in the Producer Community section of the Bureau's websito (ww.v.wcnbma oral. 1. Name, address, telephone number and facsimile number or email address of the INSURED: Name: Merrimack Construction Group. Inc. dba: Mailing Address: 15 Maplewood Avenue Tvngsborogh MA 01879 Physical Address: Phone: (078)512-9211 Fax or email: kenrv@merrimackconstructiongrouo net 2. Name, address, telephone number and facsimile number or email address of the CERTIFICATE HOLDER: Name: Salem Town Hall Mailing Address: 93 Washington Street Salem MA 01970 Physical Address: Phone: Fax or ernail: 978.740-9846 3. Name, address, contact person,telephone number and facsimile number or email address of the PRODUCER: Name: Tonry Northwest Insurance Aoencv, Inc. Mailing Address: 238 Bedford Street Lexington, MA 02420 Contact Person: Colleen Mathews Phone. (781)861-1800 Fax or email: (781)861-1804orcert5@toiiry.com 4. Policy Number, Policy Effective Date and Policy Expiration Date If a Certificate of Insurance is needed for more than one policy term,provide the Policy Number, Effective Date and Expiration Date for each policy term. If the policy has not yet been issued, you must attach a copy of the Notice of Assignment. Policy Number: WG13IS380863013 Effective Date: 2/9/2013 Expiration Date: 2/9/2014 5. List any special requests for optional coverages/endorsements(see Page 2 for listing of coverages available in the pool and the conditions of availability)or additional information(inchiding changes in exposure not yet reported to the carrier)that will assist the carrier in the issuance of tine Certificate of Insurance. NOTE:An additional insureds)shall not be listed on any Certificate of Insurance unless such additional insured(s)is a named insured on the policy. CITY OF S.U.1'M, NLNSSACHUSETTS BUILDING DEP ARTNIEINT 120 WASHINGTON STREET, 3"FLOOR � a TEL (978) 745-9595 Eta(978) 740-9846 (IN{gFRi fY DRISCOLl MAYOR THORIAs ST.PIERRH DIRECTOR OF PUBLIC PROPERTY/BCiLDING CO!,VAISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers A t tlicant Information (71 Please Print Legibly VntnE (Dusimsa'Organizatiom'Individual): C Address: Iup City/State/Zip: �aLP 1�1 , W-4 S r 61k52—Phone Are you on employer?Check the appropriate box: Type of project(required): i.❑ I am a cm to ith 4. ❑ I am a general contractor and 1 b. ❑New construction et yeas(full and/or part-time).* have hired the sub-contractors 2. 1 aln a sole proprietor or partner- listed on the attached sheet.t 7• El Remodeling ship and have no employees These sub-contractors have 8. Q Demolition . working for me in any capacity. workers'comp.insurance. 9. El Building addition [No worked comp, insurance S. ❑ We are a corporation and its officers have exercised their ID.Q Electrical repairs or additions required.) of 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers'comp. C. 152, §1(4),and we have no 12.0 Roof repairs insurance required.)1 employees. [No workers' 13.❑ Other comp. insurance required.) *Any applicant tits[chucks box#I must also rill out the section below showing their workea'eompensaion policy infi).ation. 'I hsmeuwnerrs who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. 'tlnl@Calla that check this box most anachcd an addilional sheet showing tlso name of the subwomraetora and their worker'camp.policy infomution. I am an employer that is providing workers'compensation in.surancefor my employees. Below is the policy and fob site information. ,�("1 {'yn ', r� Insurance Company Name' /p0�,�.,/ � /kl " w^,i-� C.f / Policy 8 ur Self-ins.Lie, 0: C L2 -� Y"n 0 00© Expiration Date: � f — Job Site Address: Y`t �.�n l �'�—e. cc-- City/Stair/Zip: 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 ofcriminal penalties of a fine up to S 1,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$230.00 a day against ilia violator. Be advised that a copy of this statement Inay be, forwarded to the Office of investigations of the DIA For insurance coverage verification. I da hereb r ' it d top is au penalties afperfulrthat the information provided above is true and correct. ll✓n'II Ife' :1 Uri �_ �� � �� pro C o? 7-Y5 '` 17 Official use only. Do not write in this area,to be cmnpleted by city or town official City or Town: Issuing Authority(circle one): 1. Board of llealth 2.Building Deparanent 3.C'ilylroiso Clerk 3.Electrical lnspector 5. Plumbing Inspector 6.Other Contact Person: ,_. ... . ._...--_....-- Phone#: MERRIIM�IACK CONSTRd�LT10�N Licensed and Insured Chris Shanahan 54 Church Street Lowell, MA 01852 978-512-9211 Attn: Valerie Moratis &Alex Suke Address: 44 Pingree St Salem, MA Email: Pingreestreet@yahoo.com Date: 7/16/13 Proposal Scope of Work: 1. Install new hot asphalt tar 3 ply baldy with aluminum coating plastic cement and membrane around all protrusions and junctures 2. Grind out and install all new lead reglet counter-flashings at all junctures 3. Fabricate and install all new metal parapet caps securing as needed Total Cost: $12,400.00 *Note: Inspect and report on condition of brick and/or mortar on parapet walls Provisions: h due at signing of contract /z due upon completion of job Any changes or add-ons in contract will be drawn up,priced if need be and signed by both parties before work is performed Acceptance of Contract The above process,specifications and conditions are satisfactory and hereby accepted. You are authorized to do the work specified. Payment will be outlined above � L ?,ma'ck Cm ction Group,Inc. H meowner mVl6rizetl Signature Date Date Thank you for choosing Merrimack Construction Group,Inc. Iwo w4 l Ale wl,1m0fvk Office of Consumer Affairs&BusiCT OR OME IMPROVEMENT CONTRA Ty pe: e9istrator. V2286 p(vate Covpo ralm Xpiration L014- v,c 3" PIING MERRIMAC(CONST0 FiAyN cHRISTOpHEg SHAN p 4 c� —1 .54 CHURCHST Ua&mecretarY ELL.MA01852- L6vv N n r P 6 k - - I ai'4iNXA.._ ." .. _ y-f .. is pp. -..au'C�r.. _ •�wagv" .w e a.. �}`#f Y�}fhY' AigM 1}}}}})x4 s - - Alassachusetts-Department of Public Safety Board of Building Regulattons and Standards C.in�tnu[inn Supcnnur . License, CS-058828 j JAMES E STE MAWE, ,•. 191071STSTNE'- -.� LUTZFL 335�9 t J..G.--IJ/A�c.. ErAaranon = Cortm•issnne' - 07/06/2014'. CITY OF S'Cu E1,I, tiL1SS.�CHUSETTS d . ' BUILDING DEPART\[E.NT 120 WASHNGTON STREET, 3'FLOOR T FL (978) 745-9595 F,ix(978) 740-9846 KimBERL•EY DRISCOLL AAYOX T Homis ST.PIERAB DIRECTOR OF PUBLIC PItOPERTY/B(: DNG COS0,1ISSIONER 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 t 11.5 Debris, and the provisions of NIG,L 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. '['he debris will be transported by: MiA- (name of ha er) 'rhe debris will be disposed of in (name of facility) ��`—(address of facility i signature of permit applicant date —