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2 TRADERS WAY - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Department of Public Safety Est„I \lao>.tchuwil,Stair Building Code 1,780 C\IR)Seventh Edition v City of Salem ^� Bu ilding Permit Application for any Building other than a I- or 2-FamilyDwelling \ \ (This Section For Official Use Clnly) Budding Permit Number: Date.Applied: � Bwlding Inspector: SECTION 1: LOCATION (Please indicate Block s and Lots for locations for which a street address is not available) 'a ewa-&s \,.tn•A SAl'e . , tvxA o19�0 AS wrf.gh+' No.and Street Cin• i Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration .® Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Changeuf Ckcttpancy ❑ 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? j Yes ❑ No 93 Brief Descri lion of Pruposed Work: rtT- VP � tJ ig%' 'S-F fai f-CL. pu. & pu rlc�\� �(NtSuK 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 UseGroup(s): M Proposed UseGroup(s): M f 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.) o[ aHl of Total Area(sq.ft.)and Total Height(ft.) 311,�'•t\ ITC aL-Qta1 -1'6° SECTION S-.USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business 07717TTducational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-I ❑ 1-2 ❑ 1-3 O W❑ M: Mercantile R: Residential R-1❑ R-2 ❑ R-3❑ R-4❑ S: Storage SI ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 180 IIA ❑ 11Bfir IIIA ❑ Ilia IV VA VB ❑ 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: J A trench will not he Licen,ed Di>lw:s,d Site er PubLc f4L C hccA :),�uhnia•Il.noi Lunc❑ InJic.ne municipal nrt)uoed O ur trench �:r .prafc: I'nv.oc❑ ur u+dcn ulc Znnu:_ or nn.dr w.trm ❑ ).ermrt t,enclo. 1 ❑ _ �F Railroad right-of-wa Hazards to Air Navigation: xL\ 11,.t,-n, r ..nvn:......+ It....... (.....o•.: \. t \}'}`L:�!`IcM Lrlruiluru,vlhu+eirl"+rt.tppnadi.trva' Llhc:r rc+Ict.rmF•Iclyd.' n l n.cnt I, Itwld end 'VJ O le. ❑ Yc•.❑ \o ❑ SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY I:,i:to n.a ( ••.Ic �_ L..•l�n•upl.r M f+pv q l .rn.trutl wn' _ G Occupant [ ,,ad pc•r l Iniir I> •o. the bwlJu,�;onri.,in.+n}},nnAlvr?t.Icm`'. Spvc�al Slipul,tuunv ,. �Pwp lc ��� I SECTION 9: PROPERTY OWNER AUTHORIZATION lame and Ad.tress of Properly owner N:c1Jn,ai. A+ ta L'balk7 i sF 61b 01d410�L� Sirlc...aoti PA jgoti6 Name lPnnt) No.and Street C ily'/Town Zip Pn•pa•rty Uts'nrr(-ontact Information: Qncb, .1 ap. `Lz- ii9o- la go �L Qia 3 Ok A,Q `la�c�,. cb Title Telephone No. (business) Telephone No. (cell) e-mad address I(apphcable, t r pn+perty rncner heretw authorizes R:4t ICeN �I:Sa (3oxt,; bid Lo. c„d 14- MA 011a? Name Street Addre.. Cily/Toren State Zip to act on the pro�erty osyner'.behalf, m all matters relative to wmk authunzed by this buildin •pvrmitapplication. SECTION 10:CONSTRUCTION CONTROL(Please(ill out Appendix 2) (it buildin•is les>thin 35,011)cu.tt,of endovd s mce and/or not under Construction Control then check hem O and skip Seitiun 10.1) 10.1 Registered Professional Responsible for Construction Control ('Zt,;,c� '2,C1.Ard5�.+ -S`fh.�C,boo e�c\•arc ,.a.grlgr(t,;)V, 'rti16 Name(Registrant) TrI phone No. e-mail address Registratio Number 11 rw� S kAzV, ay. m an"g it, Street Address City/Town Sate Zip Discipline Expiration Date 10.2 General Contractor �o , Spa. 13.,tl�saa5 ly. (vvC- Cff y N,6 gg C Name of Perin Resy+in le for Construction Limnse No. and Type if Applicable 141 I��1.•a q� g� MA gooa 5t-r_eet,�\ddress City/Town Sta a Zip -y�d0, 83 > 61 - -936b ;ckkev'•St 6�+ldersca• cow, 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 ij ance of the building permit. Is a signed Affidavit submitted with this application? Yee fib No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=s [6, . Building S 1 �- Building Permit Fee=Total Construction Cost x_(Insert here . Electrical $ 3c> per. appropriate municipal factor)=$ . Plumbing $ ) o m• . Mechanical (HVAC) S -o otoo. Note:Minimum fee=$ (contact municipality) . Mechanical (Other) s Enclose check payable to Total Cost s Oziz>• (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT tr oti my name below, I hereby attest under the pains and penalties o(prrjury that all of the information cnnlained in this al+ - anon is tru a a c . to the best of my knowledge and under.tanding. Qo/� � >1�r4 loll 199' . q­3bb bl)�la 1`Ir.+..},nrtt Jn• i name tk'� Title O "Toleph.me N, Date i _61 S C.os, r �` 'r!•4,n;w S�.aw. M�RI p strrel A,fdrel. C nv;'To+vn St. Zip i Municipal Inspector to fill out this section upon application approval: \a a Il,+te CITY OF SM.ENI, UxSSACHUSETTS • BUILDING DEPAR'nm\''T 120 WASHNGTON STREET, 3"0 FLooa TEL- (978) 745-9595 FAX(978) 740-9846 StBRRT FY DRISCOLL MAYOR THoww ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LNUSSIONER 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 Debris, and the provisions of MGL 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. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name of facility) io n lay rad t�� r"g (address of facility) signature of permit applicant date a�t,ri>vlr.a�c CITY OF SMY-AI, IN'LkSSACHUSETTS • BL'1LDL\G DEPART%cLN ' d 120 WASHINGTON STREET,3'o FLOOR �f TEL (978)745-9595 FAX(978) 740-9846 KI.,,IBERLEY DWSCOLL ,MAYOR Tt�IontAs Sr.P1ERRla DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%511ISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information /� Please Print Legibly Nance(Business:OrganizatioNlndividual): ��s•�v+ Gv,\&o v p a. 1�,k, Address: 6Ti P_,v.,ev42 eA- City/State/Zip: �ram:ti �l wr MA 0110--k Phone #: Arc ou an employer?Check the appropriate box: Type of project(required): I. 1 am a employer with 3 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ® Remodeling ship and have no employees These sub-contractors have & ❑ Demolition working for me in any capacity. workers'comp.insurance. 9, ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.0Electrical its or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees. [No workers' I3.❑Other comp. insurance required.] 'Any opplicam that aihecks bone NI most also fill out the section below sbowing their workers'compensation policy infumhatioa t I Iomeawnws who submit this affidavit indicting they are doing all work and then hire outside contractors must submit a new affidavit indicating such ;Comramn that check this boa must anached an additional shad showing the name of Me subeonuacton and their worltas'camp.policy inicram fan. i am an employer that Is providing workers'compensation Insurance for my employee& Below is the polley andJob site information.Insurance Company dame: Al 6- Policy#or Self-ins.Lic.p: ��� - ' 7 bH'3 Expiration Date: I arol\ Job Site Address: r l t°+c��i3 �gh Ciry/State/Zip: MA t 0fItO 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 of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fix of up to S250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of Invesligaliun. the DIA for insurance coverage verification. i do hereby cA ad t pains and penalties of perjury that she information provided above is true and tarred SiLutum \ Date: 6W+A t— Phone tt: � 1 3 Official use only. Do not write in this area,to be completed by city or town official, City or Town: Perm ldLicense p Issuing Authority(circle one): I. hoard of Ileallh 2.Building Department 3.Cilyrrown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person• Phone#: �� CERTIFICATE OF LIABILITY INSURANCE OP ID PS DATE(MM/DD/YYYY) VISIO-2 OS 28 10 PRODUCEII THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern States Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 50 Prospect Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Waltham MA 02453 Phone: 781-642-9000 Fax:781-647-3670 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: First Mercury Ins. Co. 10657 INSURER 8: american international Group 43974 Vision Builders CO. , Inc. INSURER C: Hanover Insurance Co. 22292 615 Concord Street INSURER D: Framingham MA 01702 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. bK LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMFOD� DATE MM/DDT LIMITS GENERAL LIABILITY EACH OCCURRENCE $ $1,OOO,OOQ A X COMMERCIAL GENERAL LIABILITY FMMA002645-2 04/01/10 04/01/11 PREMISES Eao=rence) $ 50,0 00 CLAIMS MADE [7X OCCUR MED EXP(Anyone person) $ PERSONAL B ADV INJURY $ $1,000,000 GENERAL AGGREGATE s $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ $2,000,000 POLICY PRO- JECT OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 C ANY AUTO ADN-0163109-04 04/01/10 04/01/11 (Ea accident) ALL OWNED AUTOS BODILY INJURY S X SCHEDULED AUTOS (Per person) X HIRED AUTOS ' BODILY INJURY $ X NON-OWNED AUTOS (Per accidenl) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE s $2,000,000 A X OCCUR ❑ CLAIMSMADE CUMA000372-2 04/01/10 04/01/11 AGGREGATE $ $2,QQQ,000 DEDUCTIBLE $ X RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X T ORY LIATU Eft Y/N B ANY OFFICER/MEMBE�XCLUDED?ECUTIV4 I WCOOS-85-7643 05/27/10 05/27/11 E.L.EACH ACCIDENT s 500000 (Mandatory in NH) u E.L.DISEASE-EA EMPLOYEE $ 500000 U yeedesaib E.L.DISEASE-POLICY LIMIT $ 500000 S PE CIAL PROVISIONS below E.L. OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION EVIDENC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL Evidence of Insurance IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2009/01) ©19 -200 RD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of CORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement . on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2009101) G R L A Gorman Richardson Lewis Architects 77 Main Street Hopkinton, MA 01748 T-508.544.2600 F - 508.435.0072 www.griarchitects.com Thomas J. St.Pierre Inspectional Services Director Public Properties Department 120 Washington Street,3 d Floor Salem,MA 01970 CONTROLLED CONSTRUCTION AFFIDAVIT Project Name: AJ Wright Retail Store Location: 2 Traders Way, Salem,MA 01970 Scope of Project: Renovating Existing Retail Space for AJ Wright Retail Store In accordance with Section 116.0 of the Massachusetts State Building Code Seventh Edition, I, Craig P. Richardson, Mass. Registration No. 5416, being a Registered Professional Architect, hereby certify that I have directly supervised the preparation of all design plans, computations, and specifications concerning: • Architectural Components 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 applicable engineering practices and all applicable laws for the proposed project. Further a representative from our office will make periodic site visits and issue reports to the Building Department. Registration.STAMP Signature: m R05416Craig .Richardson fl°a ffik MA Reg.Number 5416 -Architect t1 nwe s Then personally appearled this \day of lAA e 2010, the above named Z 1^acc�Sav1 appeared before me and made oath that the above statement by him is true. Notary Public. -k-601-�\—, My Commission Expi e : 6 ( h Connecticut Office: 1080 Main Street South -Woodbury, CF 06798 T-203.573.1 752 GNGIRVlCES ItC do-9; T Thomas J. St.Pierre Inspectional Services Director Public Properties Department 120 Washington Street,Yd Floor Salem,MA 01970 CONTROLLED CONSTRUCTION AFFIDAVIT Project Name: AJ Wright Retail Store Location: 2 Traders Way, Salem,MA 01970 Scope of Project: Renovating Existing Retail Space for AJ Wright Retail Store In accordance with Section 116.0 of the Massachusetts State Building Code Seventh Edition, I, William T. Mayer 1II, Mass. Registration No. 46021, being a Registered Professional Engineer, hereby certify that I have directly supervised the preparation of all design plans, computations, and specifications concerning: • Mechanical Components 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 applicable engineering practices and all applicable laws for the proposed project. Further a representative from our office will make periodic site visits and issue reports to the Building Department. Registration Signature: WO ,:_.. I kip L2tvtflE Willia T. ayer LIP" M mt try MA Reg. t>A6021 -Engineer S Then personally appeared this /5 day of i,[t�2 2010, the above named f,0,I I t 7 A(av e r Za' appeared before me and made oath that the above statement by him is true. r— BARBARA J. PAUL NOTARY PUBLIC Notary Public: STATE OF RHODE ISLAND M Commissi Ex ires: / a My Commission Expires November 23,2011 Y P 141 Industrial Drive Slatersville, RI 02876 T- 401.765.7659 F - 401.765.7659 eNG1' t�t G T ERV7CES Thomas J. St.Pierre Inspectional Services Director Public Properties Department 120 Washington Street,3'"Floor Salem,MA 01970 CONTROLLED CONSTRUCTION AFFIDAVIT Project Name: AJ Wright Retail Store Location: 2 Traders Way, Salem,MA 01970 Scope of Project: Renovating Existing Retail Space for AJ Wright Retail Store In accordance with Section 116.0 of the Massachusetts State Building Code Seventh Edition, I, Raymond W. Dusseault IIl, Mass. Registration No. 40709, being a Registered Professional Engineer, hereby certify that I have directly supervised the preparation of all design plans, computations, and specifications concerning: • Electrical Components 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 applicable engineering practices and all applicable laws for the proposed project. Further a representative from our office will make periodic site visits and issue reports to the Building Department. Registration STAMP Signature: Raymond .Dusseault III A �u;�St;LT ill o = _, m ELECTf:i I ®"' = MA Reg.Number 40709-Engineer Thnersonally appeared this day of v6-2- 2010, the above named � e � peared before me and made oath that the above statement by him is true. BARBARA J. PAUL NOTARY PUBLIC Notary ublic:mmission STATE OF RHODE ISLAND My Co Expires M : y Commission Expires November 23,2011 141 Industrial Drive Slatersville, RI 02876 T - 401.765.7659 F - 401.765.7659 CNCIRt G ERNCFS + o Thomas J. St. Pierre Inspectional Services Director Public Properties Department 120 Washington Street,3rd Floor Salem,MA 01970 CONTROLLED CONSTRUCTION AFFIDAVIT Project Name: AJ Wright Retail Store Location: 2 Traders Way, Salem,MA 01970 Scope of Project: Renovating Existing Retail Space for AJ Wright Retail Store In accordance with Section 116.0 of the Massachusetts State Building Code Seventh Edition, I, Glen G. Markey, Mass. Registration No. 41542, being a Registered Professional Engineer, hereby certify that I have directly supervised the preparation of all design plans, computations,and specifications concerning: • Plumbing Components 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 applicable engineering practices and all applicable laws for the proposed project. Further a representative from our office will make periodic site visits and issue reports to the Building Department. Registration SSTIP Signature: <... a GLEN o MARKEY Glen G. Markey MECHANICAL MA Reg. Number 4154 En 'veer �. No.41542 ,off GISTVS ''0 �4 ry ��`SSIONRL VVVVJ-q Then personally appeared this day of ��_ 2010, the above named !Uc✓✓kkr appeared before me and made oath that the above statement by him is true. BARBARA J. PAUL NOTARY PUBLIC Notary Public: STATE OF RHODE ISLAND My Commission Expires November 23,2011 My Commis `on Expires: 141 Industrial Drive Slatersville, RI 02876 T - 401.765.7659 F - 401.765.7659 I