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0050 ST PETER STREET - BPA-10-872 r ; The Commonwealth of Massachusetts G I`� Department of Public Safety \laxsachm vill.Male Budding Code(%80 C\IR)Seventh Edition City of Salem Building Permit Application for any Buildinfit other than a I• r -Fa*ily 13 ellin (This Section For Official Usr Only) Budding Iv,rmit Number: Date Applied: 5 L V 10 Building Inspect, AvAt c 6 c 4 cr SECTION 1: LOCATION tPlease indicate Block 0 and Lot s for locations for which a street ss is not available) so Sr feferst SareW tit f} o l470 GgA#- rr 5a"/ No. and street Cih• /Town Zip C'Kie Name of BVilding(it applicable) - SECTION 2: PROPOSED WORK If New Construction check hem 0 or check all that apply in the two rows below Existing Building el Repair O 1 Alteration ❑ 1 Addition O I Demolition O (Please fill out and submit Appendix 1) Change of Use &I- Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/ur construction documents being supplied as part of this permit application? Yes a No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No RL Brief Description r, of Proposed Work: pvr /d , r 3va0 s o b•e t>S-c acs a -e devcYcwdL. eo st-=uc )oti 4-c i is- lvae P 6mlora c}ct� ! Co 9� vcf e, r- EJooc( 9 Sfewri bench srid Se.,< cU rred s o[ as suer r eL r SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): t5�1°�an-t r Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area (sq. ft.)and Total Height(ft.) _ SECTION 3-USE GROUP(Check as applicable) A: AssemblyA-1 ❑ A-2r O A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business 9iil ' E: Educational ❑ F: Facto F-1 ❑ F2 O H: Hi Hazard H-1 O H-2❑ H-3 ❑ H-4❑ H-5 0 1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14 0 M: Mercantile 0 R: Residential R-10 R-2❑ R-3❑ R-4 0 S: Storage S•1 ❑ S-2 0 U: Utility❑ Special Use❑and lease describe below: SpecialU.se: 4`'esd-4.va 'Ztgt er(�^ A2 Z SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA O IB ❑ IIA ❑ IIB O IIIA IIIB O IV ❑ VA O Ve O 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 0- Check it uul>tde 19uod Lunv❑ Indicate monirilml(FL A trench will not tie L1ce•n. i Dispii., l Site 121� requtreddlU:r trench or .pecdp: Prnvte❑ ur indentifv Zone: or on .1te m,tem ❑ permit i.enclo�e.t ❑ Railroad right-of-way: Hazards to Air Navigation: xL\ I11,h.r.. It...,... I'n \nt \pphcal'1VA, I.structure wrthm aopurt.lp)•roachaeea' 1,their rev trw completed.' ui\ n ,vot to Bud,I enclo,t-d ❑ I I v,❑ or No 18L. )e 0[1 . \U ❑ - SEc'n5N 8:CONTENT OF CERTIFICATE OF OCCUPANCY 1,fitwo „t C „de: ___ L,v C mip,.l: r%pc of Con.tntcuon: Occupant Lead per I-lo.ir I),,... the budding c.,ntain.ln sprinklerse,tem': -)I spacial stipulation.: 70_ 3 j F0 7 tvlit pe4r lz 5 a. SECTION 9: PROPERTY OWNER AUTHORIZATION 5VtS,'�' 0-1Name(Nnnt) .No.and Street Cih'/ rown Pniperty Chi�cner Contact Information�: �� y7ognoi4 kqn, H (L -7! - l_ OU D�Vddi�1 oTitle Telephone Nu. (business) Telephone No. (cell) a-madaddrl(aaprlicabiv,,�the_pniperty owner hereeb/vauthorize+ /kawe fTn(Tc-4,5 kiru:ct !(y 1 -e f• I Sd Peeej+v G, Y �Name Street Address lily/Town/ Stale Lip loact on the +ro+ertyowner'.behalf, inall matters relativeto workauthorized by thisbuddin • permita p dicationSECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If buildin is less dun 35.(M cu. It.of endascvl s+ace.mWor nut under Construction Contiul then check hen Oand si S 10.1 Registeredg //Professional Responsible for Construction Control l/Jbdt i `74/ kVS L 506 .5" l2% `!f V14 &g//Cr/S4ss0c Name(Registrant) Telghune No. email adders �) 'r° Registration Number., /0 '50 u1-(4 Mrst°C 5? cyAS �:e(4 - Street Address City/Town State .Zip Discipline Expiration Date 10.2 General Contractor y pt LI S ! c a� G LDS 6-raw Co (1 �q� � d t�- Pr f r n� less Jp fur P�iun fof-W.e No. and Type if p icabl�q 5/ C%(--F" /'l�7l �� bt its/`Towne/ State Zip Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'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)=S 1. Building IS Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical S tf 00 appropriate coon cipal factor)=E J. Plumbing E ni? Note: Minimum fee-S�5contact municipality) 4. Mechanical (HVAC) E { (Jp 5. Mechanical (Other) S Endow check payable to 6. Total Cost S Q (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 cunhuned in this Application is true and accurate to the b sl of�',v t n�wlr_dge and tmderslanding. Sltk.c f� 1dr�5 ki z�kz� �r -t f __ Co M 19ca.e print and sign name �r ride rcicphnne No. Dale �Irecl :Nddres Cih/Town sate Zip Municipal Inspector to fill out this section upon application approval: 1 CITY of S.U.Ea[9 NLNSSACH SETTS 110 WAiHINGTON STRRRT. )'o FLOOR T L (973) 745.9599 F.%x(97I) 7449&" Kl.%.®EaZV DRMOLL T}M"ST.lem"Al %"YOz Dtt WMIL Of R aLIC PRO►ERTV/K dDLVc CO-%L%0SSIO\ER Workers' Compenaatlon Insurance A Mdavif: Ouilders/ContracterwEleetrlclanslPlumbers a t Ikan In n to y V7tneltlu„nesrOraaeetraa,nitnYreduslY• C t-7 Y �e c l7 Address: sr- A CilyistatdZiP: '^ Plrorle 92 A reyou tapNyer!Ckesk the a//n/elaM trot Type of preless(regelrttq; .. raltpkle wits r•. ❑ IantaSeesaw contractor MW 1 ti. ❑Neer cenamaction yees OWl aadew put-tiowl•d have hired tM adocornractnr listed m the anaehad sheet= I.'gRemaklinEsole proprias nr PMrru"ed Rave no empbyees Thee sub-oomrasass have L ❑nemontiaa - g ror ms in any capacity. workers'comps inaoraace. 9. ❑uuiWitee additionrker'comp.insurance S. ❑ We are a eerperti,n and is otllkers haw otaedaed their 10.❑Electrical repair or addition ).❑ tc'9 &hou ri of MO1. 11. Plutnbin a addWonn I am a horrtaotreter,doing all work IlW ��Per ❑ i npun myself.(Ne worltero'comp. a IS2. I(4�and rn haw tte 12.❑Rao/repair insurance requindl r crnp LNe wmkwa' 1).❑OtAsr comp.insuranceteviiven l -Any+PrrrrIIIII rat cataaa ba et cruse 860 ne uat eti twits brM iwiy edr r" 'cegeteite pwtM feamaseeL 'mim she w ts"sale ams esY idstslq they ere doind as reek erne era hM wadi cssswre dtr,uldaka raw aleeYek irdierine M& t'..+r nos dr cbwb 1W here edtee aaerbee r,sYleietel Jura rMrdrr 1M eaten 1sr wieerrrare awl lhAt+erbwa'esF r+kr is bmwYi I rue as eaepiysr ado&serewdips Mierhera0 cewpsewstia ItaattrrasrAw dq aayriyws eebr to/he p,ft aNAds s/b in�rrarlwa, Imutunce Company Name: I'alicy 4 or Self-ina, Lie.N: Expiration Dab: Jub Sire AtWreso City/StattYlipc .mach ace"o(tke worken'2eusepeastuke pe ft doelantke pep(akowing tb polky sasellser and espil atlen dttb)6 Failure to atcrtn coverap as required under 5allos 25A of SIOL a. 132 can lead to the imposition oferiminal penalties of a fine up tog 1.300.00 and/or one-year imprisonmene,as wed as civil penalties in the form of a STOP WORK ORDER and a floe .)f up to$_50.00 d Jay igaisem the violator. Its advi.*W that a cwpy of this sratament may be rurwdrded to the Office of Invc.tt aatius ulYlte n1A for insurance covcrap vtsilk+aws /Ja hereby reswo under t 'ors yensills e/pr/eq these the infrwar/w previdttd ulavr is true dad r,rrea't ��j porn 7 � 2G / 0lo yr t a• � dY f' O/f1i"ieI use dnliet Oil,nee ecru,in this dreg n L4.urnyhtd by rile d barn.t//!t•irp( city at ruwn: I'rrmicMieenttN__ Iauint.\WAortty lcircle anal: I. Ifuard of lleiltb I. Nutrslna neteirtmunt ). ('illfrown Clerk A. ftectrical Gnpector S. Pfumbrnet Inrpeetor 6. Other Lr,nt art Person: _ .. Phone a: w I CITY OF SALEM I PUBLIC PROPRERTY DEPARTMENT ARTMENT I'.II: M I r I "Mlv I'll 1I.1J 11\1..,4V 5fatr T a fit•"J, 1111A I I•Q ill -4 �t . • M I'rl;vlt•NS•7t•7! � I°tX:77t1J S' CAurcd D Affidavit (m-ql ,jr all dmoltionxl renovation In accordance with the sivtlf edition of the State Building Code, 730 CMR section 111.5 tsiona of MGL c 3U, S Debris, and the prov MGL c is issued with the condition that the debris resulting from Building Permit q��; licensed waste disposal facility as defined by this work shall he disposed of in a p Perl Y 111. 5150A. The debris will be transported by: LP- — lame of hauler) The debris will be disposed of in (nurrle ul aci Ity plddress of I'acllily) _ ,I�nature, •rnlitapplicam dale •° ACORD CERTIFICATE OF LIABILITY INSURANCE DATE 6126120 0YYY' TM. PRODUCER Phone: 413-781-7475 Fax (413)781-0050 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE CENTER SPECIAL RISKS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 246 PARK STREET I P O BOX 1185 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR WEST SPRINGFIELD MA 01090 ALTER THE COVERAGE AFFORDED By THE POI ICIFq RIPIL INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Essex Insurance Company GP CONSTRUCTION INSURERS: 72 WALNUT STREET,APT 4 INSURER C: PEABODY MA 01960 INSURER D: INSURER E: COVERAGES 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 WTH 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. wee ADD'L rypEOFINSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRAIrl N LIMITS LTR INSR DATE MM/DO GATE MM/OOM GENERAL LIABILITY 3DD9320 05/25/10 06/25/11 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY pp M E TOee NTT nce) $ 50,000 CLAIMS MADE� OCCUR VIED EXP(Any one person) $ 1,000 A X $250 Deductible PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTSCOMPIOP AGO. $ 1,000,000 X POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accidenp $ PROPERTY DAMAGE S Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETEWION $ $ WCT OTTER WORKERS COMPENSATION AND TORYSTA uMLLITs EMPLOYERS'LIABILITY ANY PROPRIETORPARTNEWEXECUTIVE E.L.EACH ACCIDENT $ OFFICERMEMBER EXCLUDED? E1.DISEASE-EA EMPLOYEE $ It yes,desedne Knee. SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT Is OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CARPENTRY CERTIFICATE HOLDER CANCELLATION CITY HALL SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS 120 WASHINGTON STREET WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO SALEM,MA 01970 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Attention: avid�Florla;/�y0k.—. ACORD 25(2001108) Certificate# 1506 ©ACORD CORPORATION 1988 t WILLIAM BALKUS ASSOCIATES ARCfHMM 2 1.. t814504THMA1N.5'I't2EBrTOPSF10.DMA01983 WMBAIXUSASSOC4MAC.COM T E L 9 7 8 8 8 7 3 3 5 1 FAX 9 7 8 8 8 7 9 2 9 0 t i a May 26, 2010 Mr. Tom McGrath Assistant Building Inspector 120 Washington Street $ Salem, MA 01970 3 s Dear Tom: I will be providing Controlled Construction as per section 116 of the Massachusetts State Building Code for the New Restaurant that will be going into the Renovated Salem Jail. I will review all shop drawings, submittals and samples including any drawings submitted by the subcontractors and I will visit the job site at regular intervals to determine that the work is being performed in a manner consistent with the construction documents. i a if ve any questions. lly alkusr No. 4452 4 ,OF�p A