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96 SWAMPSCOTT RD - BUILDING INSPECTION (28) t , (� t �1 The Commonwealth of Massachusetts 4 Department of Public Safety V➢u ,` Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (Thi-Section For;Official Use_Only) Building Permit Number: Date Applied Build ng Offiaal SECTION 1:LOCATION.:(Please indicate Block #and Lot#for locations for which a street.address is not available) S. C L S W A-M Scu-t't No.and Street City/Town Zip Code Name of Building(if applicable) 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 I�r_ Addition Cl I Demolition ❑ (Please fill out and submit Appendix"1) Change of Use ❑ 1 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 0� Brief Description of Proposed Work: Cn"Aucl- riLe f Zz-R- — CeoI�IZ�rx. W�oFn•�t (Y�H t�1�-cNnvre J1n-c,R 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 730 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): - i SECTION 4-BUILDING HEIGHT AND AREA.- Existing Proposed No.of Floors/Stories(include basement levels)8r Area Per Floor(sq.ft.) Total Area(sq. ft.)and Total Height(ft.) l t, /od SECTION St USE GROUP(Check as a plicable)• A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ L• Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ ❑ TR. esi M: Mercantile : Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6i CONSTRUCTION-TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.D foc details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal; Public 93' Check if outside Flood Zone a Indicate municipal A trench will not be Licensed Dis osal Site❑ Private❑ or incientify Zone: or on site system❑ required 0 or trench or specify:C-hiv'-10s permit is enclosed❑ b-come- Railroad right-of-way: Hazards to Air Navigation: TMA Historic Canunision Re tvicsv rtr.ess: Not Applicable®� Is Structure within airport approach areIs their review completed? or Consent to Build enclosed ❑ Yes❑ or No 2__� Yes ❑ No 0' SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: �c `V 697�1NO SECTION 9c.PROPERTY OWNER AUTHORIZATION t ` Name and Address of Property Owner .� ncryve.�ivcs CJoCies q(, ScvFr.•.psco'i't Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes SPMcs. �c�cC}ti f�uisvt7la+ic _ G(nes4c+L 03036 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 permit application. SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix#) If buildin Bless than 35,006 cu.ff:df enclos'ed's'ace and/or'iiot under Construction, ontrol then'check here and skio Section 1D.1 101 Registered Professional.Responsible for Construction Controh - A lhe,+ /ems t - 4Y7_ SY31 t9 Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractors TYt t7 CO ai'� ¢ car c nt Cb. Company Name Name of Person Responsible for Construction License No. and Type if Applicable G1� L�lells ud(A1e 9A G�cs NN p3036 Street Address City/Town State Zip 26_69?_ C AoL , con-t Telephone No. business Telephone No. cell e-mail address SECTION II: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 is ante of the building permit. Is a signed Affidavit submitted with this application? Yes Or No ❑ SECTION:12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (tabor and Materials) Total Construction Cost(from Item 6)=$ JS 73, 930-00 1. Building $ ,j/O O CIO.UU Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ 1 0p .Ou appropriate municipal factor)_$ 3. Plumbing $ yam. ji7,otl d. Mechanical (HVAC) $ y Z.00 ,oo Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ 573, 130,00 (contact municipality)and write check number here SECTION 13:SI,GNATURE 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 application is true and ac rate to the best of my knowledge and understanding. 44+ist* 'lJfCcso �_6�7_ s'lyfl Please print and sign n. Title Telephone No. Date R-5 _ ,ei is V'i J IA e. ek G 14eA kH 03036 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name. Date COSTA ARCHITECTS 333 MOODY STREET WALTHAM, MA 02453 TEL/FAX 781 /647-5831 CONSTRUCTION CONTROL AFFIDAVIT Project Number: 2012.114.2 Project Title: Interior Freezer Expansion Improvements Project Location: 96 Swampscott Road, Unit 1 Salem, Massachusetts 01970 Project Name: Jacqueline's Gourmet Cookies Scope of Work: New interior tenant freezer expansion; removal, Pre insulated panels (PIP),GWB, metal studs, doors,frame, hardware;Glazing; suspended ceilings PIP panels, paint, life safety,electrical, plumbing,and HVAC (note:some of the disciplines are the responsibility of others) In accordance with section 107.6 of the Massachusetts State Building Code, I Albert Costa Mass Reg. # 1907 being a registered professional architect hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project_ Architectural )O( Structural_Mechanical_ Electrical Fire Protection Other: 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, all acceptable architectural practices and applicable laws for proposed project_ 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 building permit and shall be responsible for the following as specified section 107.6.2.: 1. Review,for the conformance to the design concept,shop drawings,samples and other submittals, which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code required controlled materials. 3. Be present at interval appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determined,in general,if the work is being performed in a manner consistent with the construction documents. Pursuant to Section 107.6.1, t shall submit periodically, a progress report together with pertinent comments to the building inspector. Upon completion of work, I shall submit a final report as to satisfactory completion and readiness of the project for occupancy. Signature of Architect n N3. 1907, r t{ y�Fq[TH OF t``� i CITY OF SiU EF_M, ANSSACHLSEM j BU=ING DEPART\W_NT 120 WASHI.IIGTON STREET, Sao FLOOR TEL (978) 745-959 5 F.A.e(978) 740-98�t6 ICl\[BERLEY DRISCOII MAYOR THo.\w ST.PlEm DIRECTOR OF PUBLIC PROPERTY/BUtLDING CO\MIISSIONER - Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant information Please Print Leeihiv Vann:(0usi[1e-ss,UrgtniratioNlndividual): �Y Mb fontS+aN.c{+on/ !.-J Address: 01 �;, (,)ells v i 1(640- 79- City/State/Zip: Alff- Phone#: c(78 657--51Y8 Are you an employer?Check the appropriate boY; f (�-r ' ypa of project(required): 1.0 1 am a employer with 4. am a general contractor and 1 6. ❑New construction employees(tLil and/or part-time).• have hirer)the sub-contractors �,,� 2.0 partner-am a sole proprietor or paer- listed on the attached sheet.1 7, ga remodeling .ship and have no employees These subcontractors have a. 0 Demolition working for me in any capacity. workers'comp. Insurance. 9. []Building addition (No workers'comp,insurance S. 0 We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.0 i am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions myself.[No workers'comp. e. 152.§IM.and we have no I2.[] Roof repairs insurance required.)r employees.LNo workers' Gump.insurance required.) 13.❑Other •Any applicam that chwks box 01 most arts;fill out Ihv u+tion belowshowing thair warkers'campensadun pulley intunnallon. 'I hvnauwners who suhmit this aRldavie indicarina they ars doing all work and Ihca hiN wlside conuac'm mrag tubmlt s tuts,alildavil indicating such. �Cunlractors Thal check this boa must attuhed an addidunul ahmt showing the namo of[he sub-con melons and[halt workers'wmp,pulley infamalica. lain an earplayer that It provldluR workers'camprasodan lnturance for my employees: Below la eke polley and fob site irrjormudom `� Insurance Company Name: ` b�`AGk �.-ti.ISt-t-n.grtnC� Policy 4 or Self-im. Lic. N:— N VQ6Z q0( — W C P 156 d `f 23 Expiration Date: Job rile Addruss: 'J` 5W-a0y t dT r a rr ry i f- 9*Z City/State/Zip: SA k&\- Attach a copy of the workers'compensation policy declaration pags(showing the policy number and expiration date). - Failum to secure coverage as required under Suction25A of ML c. 152 can lead to the imposition of criminal penalties of a line up to S 1,500.00 and/or one-year imprisonmcrik as well as civil penalties in the form of 4 STOP WORK ORDER and a line of up to$350.00 a day against the violator. Ile advised that a copy of this statcmcnt may be forwarded to the OI'lica of Investigmiults of the DIA for insurence eoverag¢writicatiun, do krreby cr Ijy folder the pu nt and penalrlet ojperfary drat the krfarmallon pravlded above is true and correct. J=,ilure: = led: 1 Z 'ZolrZ Phone 178 (o( 7 5 1 Y 0 01)iriul use mrly. Do not write in this uretq to br camplered by city at lown afflrlul City nr Town: __..___ Pcrmtdl.Iccnre N Issuing Aulhurily(circle one): I. Board of Ileailh 2.Ruilding Department 3.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.0111or _.._ !. Contact Person: .... . . _—.._._._ Phoned: CITY OF S�U.F-M, NL-uSACHUSETTS BUILDNG DEPART'LMNT t� 130 WASHNGTON STREET, 3" FLOOR, T FL (978) 745-9595 F.mX(978) 740-9846 KI.N(BERL.EY DRISCOLL AvLkYOR T osw ST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUILDING CONWISSIONER 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 111.5 Dcbris, and the provisions of N1GL 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 N1GL c l 11, S 150A. The debris will be transported by: C�.n,��s Cs�orute (name of hauler) The debris will be disposed of in (name of facility) (address of facility) s' nature of pern&&pplicant date tawwfd, - CERTIFICATE OF LIABILITY INSURANCE 1 z"li'F120iYZ 4C�RQ 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 CO_NANiNTACT Rich McCarran MacWac Insurance PHONE E.1603-560-1151 na 3-434-5051 E-MAP.O. Box 77 ADDRESS: rmccarran insurance@comcast.net East Derry, NH 03041 INSURERB)AFFORDING COVERAGE NAICN INSURERA:NautiliS Insurance IWRED INSURERS:Preferred Insurance JMD COnstruction Company INSURER C:Scottsdale Insurance James Doherty INSURERD:First-comp 93 Wells Village Rd INSURER E: Chester, NH 03036 INSURER IF COVERAGES CERTIFICATE NUMBER: 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 ADDLSUBR POLICY EFF POLICY EXP LIMITS Ltk- - TYPE OF INSURANCE POLICY NUMBER MMIDD/YYVY MMIODIVYYY GENERAL LIABILITY EACH OCCURRENCE $1 1, 000 000 _5AMAGE-TO COMMERCIAL GENERAL LIABILITY PREMISES EaoccurrDence 8 50 OOO CLAIMS-MADE 1 OCCUR VIED EXP(Any one cement $ 5 1 OOO A NN052901 8/1 /12 8/1 /) 3• PERSONAL B ACV INJURY $1 , 000, 000 GENERAL AGGREGATE S2, 000, 000 ' GEN'L AGGREGATE LIMIT APPLIES PER: a PRODUCTS-COMP/OP AGO s2, 000, 000, POLICY PRO LOG $ AUTOMOBILE LIABILITY EOMaBeNdEeDt SINGLE LIMIT $1 , 000, 000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED QPCA002396 7/1 /12 7/1 /1 BODILY INJURY(Per accident) $ AUTO AUTOS S NON-OWNED PROPERTY $ HIRED AUTOS AUTOS Peraccitlenl r $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $1 O, 000, 000 X' EXCESS LIAB AGGREGATE $1 0, 0 0 0, 0 0 0 ,C CLAIMS-MADE LS0062431 9/1 /12 9/1 /,1, DED RETENTIONS Is •'� WORKERS COMPENSATION WCSTATU- OTH- ANDEMPLOYERS'LIABILITY YIN 500, 000 ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ D OFFICER/MEMBEREXCLUDEO? 0 NIA C1560423 8/4/12 8/4/1. 500, 000 } (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under +° 50 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ PL%CRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 1� , CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City Of Salem THE EXPIRATION DATE —THEREOF, NOTICE WILL BE DELIVERED IN Massachusetts 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEI]R PR If If ©1988.2010 ACORD tORPOPATION. All rights reserved ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD COSTA ARCHITECTS 333 MOODY STREET WALTHAM, MA 02453 TEL/FAX 781 /647-5831 CONSTRUCTION CONTROL AFFIDAVIT Project Number: 2012.114.2 Project Title: Interior Freezer Expansion Improvements Project Location: 96 Swampscott Road, Unit 1 Salem, Massachusetts 01970 Project Name: Jacqueline's Gourmet Cookies Scope of Work: New interior tenant freezer expansion; removal, Pre insulated panels (PIP),GWB, metal studs, doors, frame, hardware; Glazing; suspended ceilings PIP panels, paint, life safety,electrical, plumbing, and HVAC (note:some of the disciplines are the responsibility of others) In accordance with section 107.6 of the Massachusetts State Building Code, I Albert Costa Mass Reg. # 1907 being a registered professional architect hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project_ Architectural XX Structural_Mechanical Electrical Fire Protection Other: 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, all acceptable architectural practices and applicable laws for proposed project. 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 building permit and shall be responsible for the following as specified section 107.6.2.: 1. Review,for the conformance to the design concept,shop drawings,samples and other submittals, which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code required controlled materials. 3. Be present at interval appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determined,in general,if the work is being performed in a manner consistent with the construction documents. Pursuant to Section 107.6.1, 1 shall submit periodically, a progress report together with pertinent comments to the building inspector. Upon completion of work, I shall submit a final report as to satisfactory completion and readiness of the project for occupancy. EgtD P,RC`rr No. 15�7. Signature of Architect v:zeo: i