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96 SWAMPSCOTT RD - BUILDING INSPECTION (34) r ( V The Commonwealth of Massachusetts UODepartment of Public Safety I •', SIasa, it,,r11s SI.ite IIoi It ing CuJr(780 C,\IR) Building Permit Application for any Building other than a One-or'I'wo-Family Dwelling (Ibis Scdion For Official Use Only) BuilJillg 1'ernit Number: _ Date Applied: Building Official: __ S ECFION L• LOCATION(Plea�_s/et indicate Iilock M a�ndr�L/ut B fur locations for which a street address is not avvailable) . . k�._._cZ--ltc,)_lfY�,�$CP IWC__. S•4/CM ._._!�`l_...-_--_ _�v`�:S"_U-^"rc� __�06 K�?J' No and tilrrrt Cily ;lowo /if,Cute Nance of Building(if applicable) --_.— SL'CI'ION 2: PROPOSED WORK Edition of,,\I:\State Code used It Nyw Construe lion check here❑or check all that apply in the two rotes below _-- v I-ci.vling Building❑ Repair❑ :\Iteration .Addition ❑ Demolition ❑ (Please lilt out and submit Appeodis l) Ch,mge ul L'se ❑ Change of Occupanry ❑ Other ❑ Specify: _ Arc building plans and/ur construction documents being supplied as part of this permit application? Yes �/-Nu ❑ Is an Independent Structural Engineering Peer R� t required? Yes A No ❑ Brief Description of Proposed 11'urk:.__�G)1.r S fLe.t.L� AAAA-ic__ �.z,4,vtA/Q SECTION 3:COMPLETE"rots SECTION IF E)(ISTING BUILDING°UNDERGOING RENOVA"PION,ADDITION,OR CFI AN E IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is cncloied;(5lte 7,40 C\Ili 34) ❑ Existing Use Group(s): . ____-_ -= °.. Pro posed Use GrouP(sf:__— .___— SECTION 4:BUILDING IIEIGIIT,A7JD;AREA Existing Proposed No. of Flours/Stories(include basuntent IeVeIS)eF Area"Per Fluor(ski. It.) r, Total Area(sq. ft.)and Total Height(ft,) SECTION 5: USE CROUP(Check as applicable) .\: :Assembly:\-1 ❑ A-'_❑ Nightclub ❑ A-t ❑ A4_0 -"A'-5❑ 1 B: Business ❑ T•.: [iducatiunal ❑ P: Facto F-1 ❑ 1:2❑ 1 If: Hi h Hazard 11.1 ❑ H-2❑ 11-3 ❑ 11-4❑ 11-5❑ 1: Institutional 1-1 ❑ 1-2❑ 1-1❑ 1-4❑ \I: Mercantile❑ It: Residential R-113 R-2❑ R-t❑ R-4 ❑ S: Storage S-I ❑ S-2❑ U: Utility❑ 1 SJecial Use O and please describe below: Seri ial Use SECTION 6:CONSTRUCTION IYI'F. (Check as applicable) IA IB ❑ IL\ ❑ IIB ❑ IllA ❑ IIIB ❑ IV ❑ V:A ❑ VB ❑ _ SECTION 7:SITE INFOR\CATION(refer to 7N0 CMR I I L0 far details on each item) Water Su I IIouJ Lune Information: Sewage Disposal.. Trench 1'ermiC Uel+ris Renuw Jl: —�- PP y Public Check if mamdt, Hood /_one❑ InJic,nc municipal \ Irrnclt will not be Licensed Di,pns,tl Sitc Cl Pric,de❑ or indenlih' /1 it _.- or,in ,ne cy scent ❑ rryuimJ ❑or�tronch or spec ifs: - - I(ailmad right-of-way: Ila/ards tu.Air.Nair igatiun: I .N'ot .\pphc.nbly❑ Is;truetore t,nlhm .urport appm.nr h ow,i I Is their rec it w,omph-w+i' ,�r C„mynt to 11mid rn.lo,r.l ❑ \ys❑ ,n.No❑ I le,❑ \', ❑ SF(`IION 9: CON I I N 1'OF('I[R IIPI(',Al 1:OF O('('UPAN(Y JitWn of ln,le. ( ,r l:nnipl,l. IA pr.,I Cam+lru.mnn' lOt up,urt lo,id prr,Lloor I toy, the biiilJm);, ,ni,un.m �prinklyr Kt,Irm` . .__ire 1.11�liindaron, \ SR IION9: 11RO111:BI'Y O1tVNI:RAU'lllORILAIION______ Not mid :\dd ross of Property Onvner Name (Print) No, and titnrl CItY/Town -IP . I+roperty Owner Contact Information: i11e _------ -- frlcphone No. (business) �icicphone Nu. (tell) —e-mail address r - If applicable, the properly owner hereby authorizes Name _ Gtns•t Address _city/ town Slate Zip to act on tilt, +ru wrl ownei s behalf, in all matters relative to work authorized b • this building +omit a +,licatiun. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If build in g is Icsv th,m 35,000 cu.(t.uF endured s,aee and ur nut under Qnstructiun Control then check here 0 and skip Scdiun 11)1 IB.1 Registered Professional Responsible for Construction Control Name(Registrant) .. Telephone No. _ . .. e-mail address Registration Number Street Address y/Tu vn Stale Zip Discipline Expiration Date 33 A 10.2 General Contractor / / c Company Name `` OCA c. Name of Person Responsible for Construction i License No. and Type if Applicable Strcet Address City/Town ' State Zip —T C6VU � KlQ CGrr Tole ,hone No. business Telephone No. cell o-snail address S It_TION IL: %%% q,,, !_t'nlrrN:,:\uk+N_l>,r•ut:.�Ny b ..\IIq�,'•\'n M.G.L.c. 152.j 25C6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to proviate this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this a lication? Yes 0 No ❑ SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Item ,nod Materials) Total Construction Cast(from Item 6) I. Building 5 Building Permit Fee -Total Construction Cost x _(Insert here 2. El"Irical 5 a appropriate municipal factor) -S 1. Plumbing .. ._ 5.. _ _ .. . ._ _. 1. \Icchanical (liVAQ 5 Note: \linimum fee 5__(contact numirip,nlity) S. \Icchanical 101horl S 1?ncluse ihcck F+ovable to t+. fotel Cost S ©� (contact numici p,dih'),md write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 14e vntvring me name below, I herebv attest under tilt- pains and penalties of perjury that all m the infunualion till' nrJ in this •nppliraliun is true and accurate to the best of my knuu Ivdge and understanding. 1 1 ",,se print un 1 sign moue I itle frlcphnor No I)olc �tr,rl \.Id Tess City; I'„ ,11 ?talc _./ip .1,11jnicipal Inspector to fill out this section upon application approval: _None ILnr COSTA ARCHITECTS 333 MOODY STREET WALTHAM, MA 02453 TEL/FAX 781 /647-5831 CONSTRUCTION CONTROL AFFIDAVIT Project Number: 2012.10.4 Project Title: Proposed Tenant Improvements Project Location: 96 Swampscott Road, Unit 1 Salem, Massachusetts 01970 Project Name: Jacqueline's Gourmet Cookies Scope of Work: New interior office; steel mezzanine,GWB, metal studs, doors,frame, hardware; Glazing; suspended ceilings, paint, carpet, life safety, electrical, sprinkler, 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 )0( 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. -- � �wca�S��RTA oH2lF�f i 0 No. 19OZ Signature of Architect - 3 e°a^^• oW' I '� Aiesa, 9`glTH OF MPSS j Crry OF S,1LE,%11 NWSACHUsE"CTS 1 1 BUILDING DEPAIMLE.\T 1_0 WASH6VGTON STREET, 3a`FLOOR TEL (978) 735-9595 F.i-((979) 710.9844 .<1>I13 ERL F-Y D RISCO L L MAYOR T4ionits ST.Jamma DIRECTCR OF FOLIC PROPERTY/OCILONC CONMISSIONER Workers' Compensation insurance AITidavit: 1)uiiders/Contract4)rs/Electricians/Plumbers 1opileant Informatlnn Please Prhst Legibly t� � t .V;ut1c111usiixtrUQrrgtlmrttian ��Jt/UQeS Address: I b 5>bi '�� SGO� tc City/Sratc/Zip: Phone N: \M1r�e you in employer?Check t appropriate bolt Type of project(required): 1.L� I am a employer with � a. ❑ I am a general contractor and 1 6. �Now construction employees VU and/or part-time).• have hired the subcontractors 2.0 lain a role proprietor or purtnur- listed on the attached.sheet. t 7• ❑ Remodeling .hip and have no employees These subcontractors have V. C Demolition working liar mein any capacity. workers'comp.insurance. 9. Building addition I No workers'.camp. insurance 3. Cl We are a corporation and its required.) officers have exercised their 10.[] Electrical repairs or additions 7.❑ i ain a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself. (No workers'comp. c. 132, §1(4),and we have no 12.0 Roof ropairs insurunca required.( f empiuyees. (No workers' cump. insurance mquired.1 I l.Q Other •.Nay appll.wn dial d unmet bee rl mwr+lye fill our the yaedue butaw showing Chair waken'compansaff pulity anutnarion. '16vnauwnun who whit it this adl&vir indiudne they an doing all work and then hire uu4itL camncron MIet ntlnen a flaw anidavit indlatins.uch. <'•muxtan that chdsk this box muat ntahud an addrnunul.hwr showing the nwne of the nlb-onlmwm and that,woekci rump.policy inrotnudoe. /urn an rtnP/uyeP that Is pruv/d/n,q rvorkers'cumparrodun lnsarance�ar my e/nPlayers. 391,011011 rho poflay and job site iafortnullon. InItlnnlCe Contpany.Nmne: _ 1'olicy 4 or Self-his. Lie. it: Eapirution Date: - Jub Site Address: Cityistatel2:ip: Altach a copy,of the workers'compensalloo pulley declaration page(showing the polley number and expiration dato). h'ailur s to secure cuvenga as required under Scction 3JA of biGL c. 132 can lead to the imposition of criminal penalties of a tiro up to i 1,500.00 and/ur one-year iinprisnnmcnt,is well is civil penalties in the term of a STOP WORK ORDER and a tine of up(o S_'iQgO a day iquinst the violater. lie advised that i copy of this.ulcment may be furwardcd to file Oftwo of iavesf igut ions ui the OIA ter insurance coverage veri rival iun. !du hereby •er 'y r d e p fir aitd penalder a/perjury 1/101 the iu/unrwdun pruvidaJ abuv ie,rue and earreca Oflf.iu!use wdy, pa nor vrirar is this area, m he runtPlirod by sits uP town nJJlrfuL City ar I'tndn:. i'crmitii.lccnse i hutinq Aulhorily (circle one): I. I:uord nl Ileolth !. ILtihlln-, Uep.u'Iweut I.G. Other City/fan u Clerk I. Eketrical ln,pecntr i. Plnnlhing Lltpeerar CITY QF S,V-&N(, AkSS,kCFi(.'SETTS dt;MDLNG OE1P.1A-n LNr I =0 %p.UHLVGTON 5r"-tT, J'O FLOOA I'RL k978) 745-9595 Kl1G3ERr Y OUXOLL FAX(973) 740L984 NCAYOR M40M fST.Ptzux D(ascrott OP PL BLtc PROPEATY/at:anLNG C01a,ISSIOV E4 Construction Debris Disposal Affidavit (required for sll demolition and renovation work) In accordance with the sixth edition of the State Building Cade, 780 CUR section 111.J Debris, and the provisions of MCL o 40, S 54; Building Permit At is issued with the condition that the debris resulting from I If work shell be disposed of in a properly licensed waste disposal facility as defined by&ICL c I 1 I, S I JOA. The debris will be transported by: LA-`jA-SSCe Pa�4 11,1gC (n.une orhauler) The debris will be disposed of in : (name or r udily) (rLldrefs or fuyhly) Ns ofpe rt rpplwanf :Jte 06/22/2012 09:10 FAX 6034340977 MACWAC Z 002/002 CERTIFICATE ®F LIABILITY INSURANCE o67z'z�ioiz -_ _ - .._._.j tsJHIS CERTIF CATE 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. TH,S �,ERTII ICATE 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 Ji the terms anc 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.- ..-Rich._MCCarran MaCWac Insurance PHONE -P.O. Box 77 E No.E.u:_603 560-1151 ,fn1c092=434 5051 . IL ADDRESS. rmccarran_insurance_(dcomcast.net _ ! ]last Derry, NH 03841 — NAILa INSURERS)AFFORDING COVERAGE k _ _INSURERA _ Nautilis Insurance IINSURED .INSURERS Preferred Insurance. I JMD Construction Company ,:fames Doherty INSURER c:_ Scottsdale Insurance 93 Wells Village Road jNSUR_=RU:__Flrst_ Comp Chester, NH 03036 INSURER E: _. INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO'i WITHSTANDING 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 TERBIS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. GE FRAI. LIAEILTY RAI.LIABILITY - — � - - __ EACH OCCURRccune_nce $ 1 - _000, 000 J ` TYPE OF INSURANCE POLICY EFF -POLICY EXP T I— I _ INSR WVD POLICY NUMBER IMMIODIYYYVI IMMIDRYYYY) LIMITS INSR ' OCCUR ADDL SUBR EACI{OCCURRENCE $RANGE DAMAGE TO RFNTCD X CO,IMERI IlL GFNE _ —_ { Ed 1 GLAIIA MADE X ( 1n11 EXP(Any one oe�n .R 5 000 ! --_ _ ..____._ , !A ___- �NN052901 8/1 /11 !8/1 /121 PER AL a ADV INJUR c l 000, 000_' - GENERAL AGGREGATE s 2 . 000, 000 0- j GSNL AGGRECn LIMIT APPJES PER: PRODUCTS COMP_!OP AGO i s 2, 000, 000 I OI ICYy PRO- ' TY I COMBINED SINGLE LIMIT JrrT I . I_(E?accidw) __. $_1 , 00 0, 000 oc AwOMOBILF.LIABILI ! ANY AUTC n BODILY INJURY(Per person) S B X REonuLos AUTOS IX_In"uros`vNED XpCF1002396 7/1 /11 7/1 /127BODILY INJURY(Per nccdent) o FPROPFRTY DAMAGE S renewal 7/1 /1I :7/1 /13 �eraud I) —IA UMBRELLA _ I- IOCCUR -- ' EACH OCCURRENCE 1 00X LAIM$AADEI AGGREGATE 0 , 0 ,, 00-0 R IRN' IXTIG0 0 6 743T WORKERS G SAT OTh�1 AND FMPLOYrlS LIABILITY XWRYL(\1 Y/N 1$ _ B NY PRo RIETORIA FNERIEXECUTIVe EL EACH ACCIDENT FIERMRdBIR EMRUDEO? ,NIA, 500 000 Dy(Mandatory "{) :WC1560423 8/4/11 8/4/12 E.L.'DISEASE EA EMPLOYEES 500, 000 ^�UF$CR.PI I sr I OPERATIONS c,ION C- Indic, j I E.L.DISEASE-POLICY LIMIT s 500 .000 I I j DESCRIPTION OF OPE iATIONS/LOCATIONS/VEHICLES Attach( ACORD 101,Additional Remarks Schedule,If more space is roquirod) - ' I I CERTIFICATE HOLDER CANCELLATION ^ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Pile City Of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN li Massachusetts 01970 ACCORDANCE WlTd,.THE POLICY PROVISIONS. AUTHORIZEOREPR SIN ATE _ -- -Ir 8=2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010'05) The ACORD name and logo are registered marks of ACORD