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12 SWAMPSCOTT RD - BUILDING INSPECTION cr �, rile Connnonwealth of Nl issacltusetts S Board of Building Regulations and Standards CITY OF � 1Gib AYL,E�I pp Massachusetts State Building Code,780 CMR Rev�sed,V#t-120?i 2 Building Permit Application To Construct,Repair, Renovate Or Demolish ft One-or Tivo7ainily Dwelling This Section For.OfrMh)Use Only BuildingPeraiitNumber. Dnte.Appl]edv -Du]Iding Official(print Name). - ,SIature Data kn . SECTION I;SITE INBORi IATION.' 1.1 Property Address: 1.2 Assessors:Vlap Sr Parcel Numbers 12 Swampscott Road-Salem MA 7 07-0068-0 L Ia Is this an accepted street?yes_ ac_ Afap Number Puree]Number 1.3 Zoning Information: 1.4 Property Dimensions: Industrial Zoning District.": Proposed Use Lot Area(sy ll) Frontage(II) . 1.5 BuildingSetbacks(ft) . Front Yard - Side Yards Rear Yard Required Provided Ruquimu. Pmlded. Acquired Provided 1.6 Water Supply:(M.G.L'c.4o,§54) 1.7 Flood Zone Informntioni 68&Wage Disposal system: Public 0 Private O. Zone: _ Outside Flood Zone?esm Municipal 13 On site disposal systemIN Checkif : . . SECT[ON2: I!ROPERTY.0)V..KERSHI]?�`r: 7.7777 2.1 Ownerl of Record: Salem,MA 01970 ,Cif of.Salem. . y—Mp(print) City,State,ZIP ._ . 93 Washington Street—City Hall 978-745-9595 dknowlton@selem:taco No.mid Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED°WORK'(check nll.that npply) New onstraction O Eii]sting Building❑ 1 OwnerOccupied ❑ Repairs(s) ❑ Aiterndon(s) O Addition E7 Demolition ® Accessory Bldg.❑ I Number of Units_ Other ❑ Specify: Brief Description of proposed\}fork": Demolition of entire property SECTION 4:EST[tVIATED CONSTRUCTION COSTS- Item Estimated Costs: Official Use Only Labor and Materials) 1. Building $ 150,832.29 I, Building Permit Fee;$ Indicate how fee is determined: 17 Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cosh(Item 6)x multiplier x 1.Plumbing $ 2�Qlher Fees: .S 4.Mechanical (HVAC) $ List 5,i\lechanic;d (Fire $ 'fetal All Fees;$ Su ression) Check No. Check Amount: Cash Amount:_ 6.'rotal Project Cost: $ 150,832.29 ❑paid lit Full ❑Outstanding Balance Due: \/o uSSCi (le��� �l0I - LO33s Flu S111 5 SECTION5: CONSTRUCTIONSERVICES 5.1 Construction Supervisor License(CSL) CS-089983 3/30/2018 Joseph Pasquerella, License Number Del. None of CSL Huider List CSL'fype(see below) 12 Jordan Road ' No.told Street 'type'. :_ •: Description, U Unrestricted Ouildin su 1 to 35,000 oil. 11.) Lynnfield,MA 01940 R Restricted U2 Family Dwellingj Cily/rmm,State,ZIP M Masorary RC I Roofing Covering WS Window end Sidin SF Solid Fuel Burning Appliances (401)943-7100 ipasquerella tDirvinagrowni coo 1 Insulallon Telephone Email address D Demolition 5.2 Registered Ilome Improvement Contractor(HIC) HIC Registration Number Expiration Dille No.IIC Company Name or HIC Registrant Name - No.and Street Email address City/Town. State,ZIP Tele hone SECTION 6:IVORKERS!COMPENSATIOPI INSpRANCE AFFIDAVI'P(Mt(hC:.c.152. 25C(6))j Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this nRidavit will result in the dental of the Is4usnce of the building permit. Signed Affidavit Attached? Yes..........M No...........11 SECT[ON 7n:OWNEHAUTHORIZATION-TO BE.COMPLETED IVHENG OWNER'SACBNTOBCONTI2AC'�OR��PPLIE9`FOi1'DUII:DINC.PERhtIT'• I,ns Owner of the subject property,hereby authorize J.R,yinagro Corporation _ '1*Reton �lily'b''eell If, rs In All matters relative to Fwork authorized by this building permit application. Print Owner's Name(Electronic Signature) — 0 Data SECTION 7b:OWNER'OR''AUTFIORIZED ACENT DECLAPUTION- By entering my name below,I hereby attest under the pains and penalties of perjury that all of the Information contalued in this application Is true and accurate to the best of my knowledge and understanding. V I Del VC(,U-4 �5 h Print Owncr's or Authorized Agent's Numu(Electronle Signature) Onle NOTESe, - 1. An Owner wilo obtains a building permit to do his/her own work,or an owner who lilies an unregistered contractor registered In the Home Improvement Contractor(HIC)Progrom)I will na have access to the arbitration progrmn orguaranty fund under M.O.L,c. W2A.Ullher mpartn�ilbrrinntioni 6n 1he HIC-I ogrnm can bath fi der'-'-----"'-- ' www.mas;ueWoui Informntion on the Construction Supervisor License con be.fbund of www.nmss.�mv/dhes - t 2. When substantial work is plmtncd,provide the Information below: Taint floor nrea(sq.ft.) b .(Including garage,finished bosement/attics,decks or porch) Gross living area(sq.11.) Habitable room count Number of I)replaces Number of bedrooms Number o f bathrooms Number of hnl0bnllis Type of healing System Number of dccks/porches 'type orcooifng system Eucloscd' Open .i. "'I'oml Project Square Footage"may ue subslitued lbr"rutaf Project Cast" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ ) 1/21/20162016 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Jamie Hebert, AAI, CRIS Ga110 l T11omas Insurance Agency, Inc. Es. (401)732-9100 pN EXITIC Noll (401)732-0091 117 Metro Center Blvd EMAIL s:'Tt'ebert@gallothomas.com Suite 1004 INSURERS AFFORDING COVERAGE NAIC It Warwick RI 02886 INSURER 4,exingrton Insurance Company 19437 INSURED Tel 800-762-0244 / Fax 401-647-5041 INSURER B Arbella Insurance Group 41360 J.R. Vinagro Corporation / Patriot Hauling Co. Inc. INSURERC Beacon Mutual Insurance Company 24017 J.R. Vinagro Leasing LLC INSURER D Nautilus Insurance Company 17370 2208 Plainfield Pike INSURER E:Federal Insurance CompanV 20281 Johnston RI 02919 1 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 JRV Master Cert All 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 INSURANCE wcoADD $U rh POLICY NUMBER MMI�D� MMIDDY EXP IYYYY LIMITS LTR A X COMMERCIAL GENERAL LIABILITY 021778204 6/12/2015 6/12/2016 EACH OCCURRENCE $ 1,000,000 DAMAGETORENTED 250,000 CLAIMS-MADE � OCCUR PREMISES Ea cocunence $ X Per Project Aggregate MED EXP(Any one person) $ applies if required by PERSONAL B ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: written contract. GENERAL AGGREGATE $ 2,000,000 X POLICY� PRO LOC PRODUCTS-COMPIOP AGO $ 2,000,000 OTHER' $ AUTOMOBILE LIABILITY 1020020996 6/12/2015 6/12/2016 COMBINED SINGLE LIMIT $ 1,000,000 B Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED Physical Damage ACV - Per BODILY INJURY(Peraccident) $ AUTOS AUTOS X NON OMED Pe�aeatlentDAMAGE X HIRED AUTOS '4 AUTOS Vehicle Schedule $ A X UMBRELLA LIAB X OCCUR 018017696 6/12/2015 6/12/2016 EACH OCCURRENCE $ 10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED I X J RETENTION$ 10,000 $ C WORKERS COMPENSATION 69677 - RI 6/12/2015 6/12/2016 X AND EMPLOYERS'LIABILITY STAT YIN UTE ER ANY PROPRIETORIPARTNERIEXECUTIVE NIA VIA, CT, NB or NJ Work Crory E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEM(Mandatory H)EXCLUDED? Certificates to follow E.L.DISEASE-EA EMPLOYE $ 1,000,000 (Mandatory in NH) If esdescOunder D ESCRIPTIONN OF OPERATIONS below direct from carrier. EL.DISEASE-POLICY LIMIT $ 1,000,000 D Contractors Pollution&Prof CCP1515775-15 6/12/2015 6/12/2016 Each Claim l Aggregate 10,000,000 E Contractors Equip / Cargo 06675613 6/12/2015 6/12/2016 LeasedlReoted Equip/Cargo 500K / 1MM DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space is required) Project: Contract R-42, Abatement & Demolition of the Former Municipal Incinerator Facility, Salem, MA. The City of Salem and Tighe & Bond, Inc. are named as Additional Insureds on a Primary basis as respects General Liability for "ongoing & completed operations" and Automobile policies if required by written contract regards covered operations of the Named Insured. Coverage subject, to policy forms, terms and conditions. Should any of the above described policies be cancelled before the expiration date thereof, the issuing CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washington Street ACCORDANCE WITH THE POLICY PROVISIONS. 4th Floor Salem, MA 01970 AUTHORIZED REPRESENTATIVE Thomas Disanto/JHEBER ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 r7cnaml 9 I c: Massachusetts Department of Public Safety ®f Board of Building Regulations and Standards License: CS-089983 Construction Supervisor _ JOSEPH M PASOUERELLA 12 JORDAN ROAD LVNNFIELD MA 01940 "^ Expiration: Commissioner 03/30/2018 Request Number: 20162000751 Date 05/16/2016 Time 08:15 Latitude: Longitude: State: MASSACHUSETTS Municipality: SALEM Address I Intersection: 12 SWAMPSCOTT RD Nearest Cross Street 1: HIGHLAND AVE Nearest Cross Street 2: 1 ST ST Additional Information: FORMER MUNICIPAL INCINERATOR FACILITY Nature Of Work: DEMOLITION Area Of Work: PRIVATE PROPERTY Area Is Premarked: Y Start Date: 05/19/2016 Start Time: 08:15 Caller: VANESSA DEL VALLE Title: PROJ COORD Return Call: 75 Phone#: 401-943-7100X174 Fax#: 401-647-5041 Alt.Phone#: 6174616335 Email Address: VANESSAD@JRVINAGROCORP.COM Contractor: VINAGRO, J R CORP Address: 2208 PLAINFIELD PIKE City: JOHNSTON State: RI Zip: 02919 Excavator Doing Work: J.R.VINAGRO CORPORATION Member Utility List Code Abbreviation Name MM NGRDEL NATIONAL GRID ELECTRIC-MASS ELEC ON ONTARG ON TARGET LOCATING RJ VERIZN VERIZON SC NGRDGS NATIONAL GRID GAS-BOSTON SE VERIZN VERIZON T I COMCAS COMCAST • There may be non-member utilities in the area that you need to notify. • Electric and other companies may not mark lines they don't own or maintain. You may want to contact them for more information. • The excavator is responsible to maintain markings placed by member utilities... nationalgrid 40 Sylvan Rd Waltham MA 02451 May 2, 2016 12 Swampscott Road, Salem, MA RE: Service Removal for Building Demolition Work Request number - 20970612 Dear David, This letter is to confirm that, per your request, National Grid has removed the electrical service and meter number 65789103 and 75346463 from 12 Swampscott Road, Salem, MA. If you have any questions or need further assistance, please feel free to contact me at (508)357-4628. Sincerely, am* St. Unge Customer Order Fulfillment (508)357-4628 AMY.ST.ONGE@NATIONALGRID.COM nationalgrid f nationalgrid March 24, 2016 Re: 12 Swampscott Road, Salem, MA This letter is to notify you that after our investigation it has been determined that there is No Gas service© 12 Swampscott Road, Salem, MA. If you have any questions please feel free to contact me at 781-907-2922. Sincerely C?o P Janet M. Pellowe GAS CUSTOMER FULFILLMENT National Grid 40 Sylvan Rd Waltham, Ma 02451 781-907-2922 verizon✓ Date:April 12,2016 From: Verizon Engineering MA-RI OSP Center 385 Myles Standish Blvd. Taunton, MA 02780 To: Vanessa Re: 12 Swampscott Rd in Salem, MA Vanessa, This is to inform you that the Verizon 12 Swampscott Rd in Salem, MA have been disconnected. Thank you, Paul Schneider Paal So4eidel- 411212016 Verizon Engineering 385 Myles Standish Blvd. Taunton, MA 02780 774-409-3152 paul.a.schneider@verizon.com CJ Pest Solutions 7 Keenan Street West Bridgewater, Ma 02379 617 285-1000/ Lic Ma 31369 19 March 2015 JR Vinagro Corp RE: 12 Swampscott Rd,Salem,Ma 01970 This letter confirms that the mentioned address has been serviced for Rodent Demolition on the date 18 March 2016. The service involved Inspecting the inside and exterior of the main building including the smaller structure at the entrance,where accessible,for evidence of any Rodent activity. Installing two Rodent Bait Stations along the exterior foundation and placing Rodenticide Bait/Snap Traps in seleck accessible locations. A Rodent Demolition Report has been written and submitted to JR Vinagro Corp. If you have any questions regarding the report,please give me a call at 617 285-1000. Regards, Craig Sp nc Owner CJ Pest So uti Service Report Q Pest Solutions Service Specialist-Craig Spence 7 Keenan Street License Number-MA 31369 West Bridgewater,Ma 02379 Time of Service YY\ 617 285-1000 /C)PestSolutions@Gmail.com Date of Service 1 Q In A 1 Service Address Billing Address CJ Y v\ b Y\0-LY10 (-b f Z S W m vv-'�S co S&1-evVtyYVCk O19?t) �a�� 9 �yy�a�� i iyn pe a r� Special Instructions Service Type Initial Regular Extra Service ne-S Form 33 Report Inspection. Target Pests Insects Codaoaches Ants Ticks "den Flies Mosquito's ers Wasps Bed Bugs Fleas BedLam 1.93% 1021-176 Oz S, CC Tem rid SC .075% 432-1363 Gal FirstStrike .0025% 7173-258 3 �. Ea V RBB E all/Ceil{tlg B A DC Termidor SC .06% 7969-210 Gal S, Talstar P .06% 279-3206 Gal M, CC, S Onslaught .025% .050% 1021-1815 Gal S, CC Contract .005% 12455- 99 Ea V RBB E JPBB B A DC Rodent - Inspect /Replace ----- Ea S e Equipment Map Inse Mouse) t- Glueboar Snap Tan kEa . S C,_ P S E / B K RMS, CCE B K RM tiGP4 Oz S, CC E B K Rb! 'Method Code- S=Spot,CC=CadcnCrevasse,G=Ganulam,P=Perimemr,A=AerosoLM=Rtiswr.D=Duster %ocation Code-A=Attic,B=Basement BA=Bar,BR=Break Room,D=Dining Area,E=Exterior K=Kitchen,L=Laundry,0=Office, P=Public Areas,V=Wall/Ceiling Voids,DR=Dry St age,Rh1=Restroom„DC=Drop Ceiling,FL=Fly Light FS=Food Storage,Res=Resident Room. LO=Lobby,RRM=Back Room,RBB=Rodent Bait Bo: —Note-After service.all food contacysurfles te ,toys etc...must be washed with soap water to revolve any possible the al residues. sum a a Uti1�. 1 ,a � �� � � n �t t.l.t-.t-vi+-Gr f `. V 1 �/1��.1 1 ')A„ :tcftof PJ�n�- vv�.C) M S a C Oft b a.A- eLJ U� ICCCI!/yJi C I Ol t.1� S . Additional Materials Used _ Follow up Call in Days/ Month Guarantee for Target Pe�ttt y SVSP Signature �� Customer Signature / 1 /< of Control# 800 222-1222 SHEET . No.: C 1 ,4! G✓� it/f of Z4, CALCULATE ,7 L DATE: �/ BY: ��CJf' �� Everett J.Prescott,inc. SCALE: IVO pA G1 51JAVI Wj�T7 ZO H ' y �r` C1 WHIZ j+4-iti C,-TF+ (-APdiO Mc(,ALvk--7-7H/1-dT!'/KJIf Cl k,n11L IkVil CAdlb/J %11EGA C�1F F 7H/lam% /cl/c c PUMEL CHAA06iJU i�HL Qt�SAFZt- Zvlbl.Go5 71 C L 9I ZL�%b C.w AM lrover.•.n.v � w_x I Abatement And \� I Dcntulitlon Of The frormer ,' ,` _..�,�.•.•f f ___ I Municipal �' % ?7i_� I j Incinerator Facility A ( ' r '�' ' ........... •.L Dxnm6nr.2015 nmo.:r C7.•p,• i .•. .. i mevµ II _••�-- •..�_ ..s ue 5HUri Cc v:.mr 1(30 � i T4 ��,. �.� hY� y i s;9 w tti i r �'' n " A t; •a 5 [ y ' a,� tb• � 1s Ak �„'" :�-[� i .., isr*� i���� Ys e•q .� p�����iy sr � +,q �,}..Y� �j 9 ! ! � ! 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(J�'S•+��t�'CT r" .� September Lane Labs 83 September Lane Beacon Falls, CT 06403 203-668-8533 03/25/2016 J.R. Vinagro Corp. 2208 Plainfield Pike Johnston, RI 02919 Project No: 12-SR-SM Re: Salem Transfer Station Scale House 12 Swampscott Road Salem, MA The asbestos abatement project is considered completed because the post-abatement re-occupancy criteria for the asbestos abatement have been satisfied. On March 25, 2016, a Licensed Project Monitor conducted a final visual Inspection and collected PCM Final Clearance air samples. No visible debris was found in the containment. All air samples collected p in the abatement work area were below the level specified in Federal and MASS Regulations, less than 0.01 f1cc. Attached are EMSL's PCM Air Clearance analysis results. ABATED ACM: Vinyl Asbestos Tile and Associated Mastic Textured Ceiling Paint MAe fne ;jMA LiCenA 6' September Lane Labs fm*m�lnl�Pimwn�u�t¢f�muua® p�pwartaaSmJrtfJY.Ari 83 September Lane Beacon Falls, CT 06403 203-668-8533 04/13/2016 J.R. Vinagro Corp. 2208 Plainfield Pike Johnston, RI 02919 Project No: 12-SR-SM Re: Salem Transfer Station 12 Swampscott Road Salem, MA The asbestos abatement project of Exterior Window Caulk/Glazing is considered completed because the post-abatement criteria for the asbestos abatement have been satisfied. A Massachusetts Project Monitor conducted a final visual inspection. No visible debris was found. Marc er er 1 September Lane Labs 83 September Lane Beacon Falls, CT 06403 203-668-8533 .04/0512016 J.R. Vinagro Corp. 2208 Plainfield Pike Johnston, Rl 02919 Project No: 12-SR-SM Re: Salem Transfer Station 12 Swampscott Road Salem, MA The asbestos abatement project of Exterior Roofing Materials is considered completed because the post-abatement criteria for the asbestos abatement have been satisfied. A Massachusetts Project Monitor conducted a final visual inspection. No visible debris was found. ro O A 041931 September Lane Labs 83 September Lane Beacon Falls, CT 06403 203-668-8533 03/28/2016 J.R. Vinagro Corp. 2208 Plainfield Pike Johnston, RI02919 Project No: 12-SR-SM Re: Salem Transfer Station 12 Swampscott Road Salem, MA The asbestos abatement project is considered completed because the post-abatement criteria for the asbestos abatement have been satisfied. A Massachusetts Project Monitor conducted a final visual inspection. No visible debris was found. ABATED ACM: Incinerator Structure: Brake Pads/Shoes Transite Boards and Panels Light Gaskets Duct Gaskets Scale House: Glazing Compound Exterior Caulk Asphalt Roofing Ma I ner f4 September Lane Labs seemeraar� 83 September Lane Beacon Falls, CT 06403 203-668-8533 03/28/2016 J.R. Vinagro Corp. 2208 Plainfield Pike Johnston, RI 02919 Project No: 12-SR-SM Re: Salem Transfer Station Incinerator Structure 12 Swampscott Road Salem, MA The asbestos abatement project is considered completed because the post-abatement re-occupancy criteria for the asbestos abatement have been satisfied. On March 28, 2016, a Licensed Project Monitor conducted a final visual Inspection and collected PCM Final Clearance air samples. No visible debris was found in the containment. All air samples collected In the abatement work area were below the level specified in Federal and MASS Regulations, less than 0.01 f/cc. Attached are EMSL's PCM Air Clearance analysis results. ABATED ACM: Boiler Room TSI 4se41 e r MA Lic September Lane Labs �xicamuoawreteauukm ro:xra:N,imrcmmnumran^_nvsr.9a:unxcas�-,e:cuesovomwuxwao+nwr+maonm� 83 September Lane Beacon Falls, CT 06403 203-668-8533 03/25/2016 J.R. Vinagro Corp. 2208 Plainfield Pike Johnston, RI02919 Project No: 12-SR-SM Re: Salem Transfer Station Incinerator Structure 12 Swampscott Road Salem, MA The asbestos abatement project is considered completed because the post-abatement re-occupancy criteria for the asbestos abatement have been satisfied. On March 25, 2016, a Licensed Project Monitor conducted a final visual inspection and collected PCM Final Clearance air samples. No visible debris was found in the containment. All air samples collected in the abatement work area were below the level . specified in Federal and MASS Regulations, less than 0.01 f/cc. Attached are EMSL's PCM Air Clearance analysis results. ABATED ACM: Vinyl Asbestos Tile and Associated Mastic TSI Pipe Insulation, Fittings, and Debris Ceramic Tile Glue r I o ner MA U s M04193 . CITY OF SAT_ENI, fASSACI-IUSETTS .,. .BUILDLYG DEPARTMENT 110 WASHINGTON STREET,31p ftoOR . \ TEL(978)745-9595 FAX(978)740-9846. KIm SEALEY DRISCOLL 11401W ST-I' RR& MAYOR DIRECTOR OF PUBLIC PROPERTIOHI.ILDHJG C0NLi11$SI0NER Demolition Permit Sign-Off (Supplement to permit application) I J.R.Vinagro corporation hereby supply the following releases as part of the application for a permit to demolish the structure located at 12 Swampswit Road-Salem,Ma and shown on the Assessors Maps of as being on Map# 7 Block# 6a Lot# 0 The 8",Edition of the Massachusetts State Building Code,780 CMR,states in part: "A perurit to demolfsh or remove a building or structure shall not be issued lentil a release is obtained from•om the utilities,stating that their respective service connections cord appurtenant equipment, such as meters and regulators,have been removed or sealed and plugged in a safe manner." Utility to be Notified :_• Notice Received by Date Received Gas Telc hone. Electric Public Utilitie�Munici al _ _ � i _ S 3 Health Department Fire Department Other - _ Other- Demolition debris hauler; J.R.Vinagro Corporation Location of licensed demolition debris landfill: 116 Shun Pike-Johnston.RI 02919 Signature of Applicantv- lIU�^ja Date: _._ Signature of Owner Date: This sheet must be returned to the Inspections Department along with a completed application for a permit, a site plan,and any other applicable information and fees: Pumoperm.dnc i OTY OF SAI E)4 MASSACHUSE`I7S BulLDING DEPARTMENT 120 WAsnwGrONSTBEEr,38 Roox TLL(978)745.9595. FAx(978)740.9846 SIMBERLEYDRISaOLL MAYOR THCWS STAEARE DIREcroxOPPLMIJ6J)ROAM/BUIi MpD7vZMOMR Construction Debris Disposa/Aff davit (required for all demolition and,.renovati®n work) In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, S 54; Building permit d is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: J.R.Vinagro Corporation z (name of hauler) The debris will be disposed of in: J.R.Vinagro Corporation (name of facility) 116 Shun Pike-Johnston,RI 02919 (address of facility) Signature of applicant (51 Ito Z110 Date The Conmtonwealth of Massachusetts Department oflndushial Accidents Wworkers'Compensation I Congress Street,Suite 100 Boston,MA 02114-2017 ww"tinass.govIdia Insurance Affidavit:Builders/Contractors/Electriciaus/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le gib Name (Business/Organization/Individual); J.R.Vinagro Corporation Address:2208 Plainfield Pike City/State/Zip:Johnston,RI 02919 Phone#: (401)943-7100 Fem"cthatall employer?Check the appropriate box: Type of project(required): employer with 200 employees(full and/or part-time).' �, ❑New eorlstIDetioh sole proprietor or partnership and have no employees working far me in 8. Remodeling pacity.[No workers'comp.insurance required.] homeowner doing all work myself[No workers'comp.insurance required.]1 9. ❑x Demolition 10 Building addition homeowner and will be hiring contractors to conduct all Nork on my property. I will that all contractors either have workers'compensation insurance mare sole I1.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.EJ I am a general contractor and I have hired the sub-contractors listed on the attached sheaf 13.❑Roof repairs These sub-contractors have employees and have workem'comp.insurance. 6.Q We are a corporation and its officers have exercised their right of exemption per MGL C. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp,insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compeusafion policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tConaactors that check this box must attached an additional sheet showing the name of the sub-con aucturs and state whether or not those entities have employees. If the sub=contractors have employees,they must provide their workers'comp.policy number. Zantanen:ployer,t/mtisprovidir:gwor/revs'conipensationinsuraiiceforn:yeurployees. Below is thepoliev andjob site information. Insurance Company Name:American Zurich Insurance Cc Policy#or Self-ins.Lic.#:6ZZUB6Bo5800315 Expiration Date:06/12/2016 Job Site Address:12 Swampscott Road City/State/Zip:Salem,MA 01970 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby certify under therp,allas'andpenalties ofperitay that the iuforination provided above is true and correct. Sir:nalure: V 1� I yC�IM Date: � b PhoneM (401)943-7100 FF. only. Do not 1prite in this area,to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: r I; y Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as".-every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced.acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license member on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e, a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.inass.gov/dia .�� City of Salem, Massachusetts Fire (Department (David`W. Cody 48 Lafayette Street Salem, -fassachusetts 01 9 70-3 695 (Fire(Prevention Chief 978-744-6990 Tel 978-744-1235 Bureau dcody®salem.com `FaX 978-745-4646 978-745-7777 5/11/16 JR Vinagro Corporation Attn: Mr. Dennis Quereux 2208 Plainfield Pike Johnston, RI 02919 Dear Mr. Quereux, It was a pleasure meeting you at the site at 12 Swampscott Road, the former transfer Station, here in Salem, MA. It is important that you clear your demolition with all city departments and secure all necessary permits before work is to begin. The building is composed of mainly masonry and steel and does not pose a fire hazard but after demolition, all debris shall be removed from the site in a timely manner. We will not require a fire watch for this demolition at this time. If you should have any questions for our office, please do not hesitate to call. I Regards, Lt. Peter Schaeublin Fire Marshal City of Salem