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3 TRADERS WAY - BUILDING INSPECTION (2) i CITY OF XL-kSSACHUSETTS • BUILDING DEP-mmENT xaw" 120 WA STREET,SHINGTON 3"D FLOOR D TEL. (978) 745-9595 FAX(978) 740-9846 KJ%fBERIEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\L%USSIONER CONSTRUCTION CONTROL DOCUMENT Project Title: RIOCK B s-re'K Date: I I ' 29 -O"1 Project Location: 3 TRAoe R5 W A SALG-" MA Scope of Project: In accordance with SECTION 116.0-116.4.2 of the 6th edition of the Massachusetts State Building Code : 6- -39 7q2- I, D6 N Se-N N -0•E- Mass.Registration Number M -3993a being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] Entire Project [ ] Architectural [ ] Structural pQ Mechanical [ J Fire Protection D4 Electrical [ ] Other(specify) 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 engineering practices and all applicable laws for the proposed project. Furthermore,I understand and AGREE 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 by the building permit and shall be responsible for the following as specified in section 116.2.2: I. Review of shop drawings,samples and other submittals of the contractor as required by the construction contract documents as submitted for the building permit, and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to dctemilne, in general, if the work is being performed in a manner consistent with the construction documents. I shall submit periodically, in a form acceptable to th ial, a progress r er with pertinent comments. Upon completion of the work, [shall official the satisfactory completion and readiness of the pro' PENN 1a FN pENN Signature and Seal of registered professional: ELECTRICAL N `' ^v"1{No,39742 N9ECFIAh GAL No.399 .01 11 CITY OF SM EINt. 1 WSACHUSETTS 1 uUMING DEPARTmENT • 126 WASNLNGTON STREET,3RO FLOOR 'ILL- (971) 745-9595 FAx(978) 740-9M KINIBERLEY DRISCOLL MAYOR THObfAS ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/BUILDDZG COWMISSIONER CONSTRUCTION CONTROL DOCUMENT Project Title: Date: 01 Project Location: Scope of Project: �rtt Jt S gl2t° t tlzlLr CJJ- In accordance with SECTION 116.0-116,4.2 of the 6th edition of the Massachusetts State Building Code: I, i ltC Mass.Registration Number being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: [ ] Entire Project bQ Architectural [ ] Structural [ ] Mechanical [ ] Fire Protection [ ] Electrical [ J Other(specify) 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 engineering practices and all applicable laws for the proposed project. Furthermore,I understand and AG REE 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 by the building permit and shall be responsible for the following as specified in section 116.2.2: 1. Review of shop drawings,samples and other submittals of the contractor as required by the construction contract documents as submitted for the building permit,and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. I shall submit periodically, in a form acceptable to the building official,a progress report together with pertinent comments. Upon completion of the work, t shall submit to the building official a final report as to the satisfactory completion and readiness of the project for occupancy. Signature an,0 Seal of registered professional: � o C4W )' • CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT 6 lY:WA"N1Ir1ftae2 M. a SA 'old:97L7eiPM a F.vx:WW40-'1tW Workers•Compouadora lasursaee A(Wavir BWkknlCOMmetn iMleeMdanwVt lmben Aital ant lararmadox Most Print-Laft Name tat�.ine wors,.;:,,;a,vtny, �,.n: �7 11 ®h- - tt, C Phow a: 3 700 Are yom ap em~Cheek the approprlsts boss Lla;m a employe with� 4. Q 1 am a Scri aal coobacmt mw Irya�t�J�(rytdrod)iYeas(roll an ator puratime).• have hired the ptacorrectom 6. 0 New con,"1etim soot praprfeoor orpatine. listed on the at4eLed soat t 7. 0 Rmpodslimg nd bew ereotepbyttm Them hew k ❑Demaition ng rormaIn any capacity. workers'o*n 6 innunnoaq, ❑ �additipeorkers'comp. insurance S. 0 We am a corporation ara1 itsI *Mcw&have exercised their 10.0 Eleetriew repairs or additions homeowner doing all work =__ • rightofwmnP iotpeMCL 11.0 Plumbing repairs or additions (No wertcrs'cutup. c. 152.01(4).and we haw no !2.0 Risoftepoirs me reyuint j ► r cmtpbyeea(No workers' comp inauraarx tequirtxd] 13.0 Otbe •n"y vilk an err ntarY.two al stars oho all ur the arrr r tsbw+wiry rtrir ease' garrukvms Who.Usar uis affidwk me"6"am di wet am um uw that �OMWO . arxtan ton ifta#air ttm apt r arraehal w addhlmd. a earramas atom.Want a naw ambvit kwi wiait rwA. 111111� sae W mate of ate niwatnnetaera/t►a0 waken'eaq.Pwky /aim an,ampteyer that fr prsv/d/ng workers•coai0nuadea hunraner jar iwy rarp/oyaes Bifow 4 rant pdNa7 dNr/%*slf� Insurance Company Mamt t°G� Psw=jar/ Policy a Or Self-ins. Lie.w. IA/(' 9( 7 .CS. Eap;ratton Dare: 4 ,ob Site Address: Sa e( Ciq Suw2ip: Attach a COPY or the workers'compensatiun pulley d aratloa page(showing the Polley number and expiration date), Failure m wcum coverage as required wider Soetion?SA of.MGL c. 152 cap lead to the imposition of criminal penalties ofa rin.up Os SI.500.00 and/or one-year imprison ment..0 well as civil perinniCa is the form of a STOP WORK ORDER aryl a fiat if up to j350.00 a Jay agaiaat tits violator. lie advised that a wpy urthis statccutm may be t'urwarded to the Office ur 1,1%s-Nf ru of the DIA for in,urarce covcraiu vcrirtcuiun. /JY hereby reffifir ueJai the puinr pe Y/Nrs of prr/Yq that the bra/araray/oa proru/ed dhow L-Ho Ad correct v.,re �oyivw / 110Irfaf a4f WIN/N MIS area,to de rdarp4mdAy[Ny or Poww off/e/aL City or Town: Permiol Ieesae M_ Ivsuing .\trthurity (circle cum): 1. Quard of flesh! 2. Building Department J. Ciq•/foNa Clerk 4. Electrical Inspector S. Plumbing Inspector (.Other Gnuue! Penmc�_ Phone p: Information and Instructions ' all employers m provide workers compensation foe dolt etpwyn& ' v bta"achuasetu General Laws chapter I S2 tegtmiruetm` Plq is the service of another under any reenact of bin. pursuant m this statute.as"Who tsa is def mad es .•.every persna eapeeso•r implied.oral ar,vrittm� _ ataoeiatiae.oospsratiaa m odmsr�estdry.ar aaY two or mate �itsuhe fotetmcsu engaged �tnc�"'lets repeasemm�vas of a deceased campbYftwever cr the recsivar of ttttstw of a mbvtdua4 pc�sb*am mad"ar other►q smaq,emPbY1Oi croP1oY� otdme hq�wise eats men dm throe SParaueta and whs msWft rhea's.tar the aacvPsm dwe lm� ofboass anorber who employs persona m do u akemenc e.cuoatuctierr or repeic work on such deroUias boos or bsiiditts pP tharem ahs11 sot beeteme cf aaah amplaymom be deettep to be an employer. oronthe grounds a _ htCsL chapter 152.42SC(6)edge soars that"very stab or ieasl)bx�s•tt/aeyis�eemneswealth Me is"Wee or resewd of a geese str petrsk u cPenN•sager=or a eesstrset ba{I/4mkp��coverw rogatrw wM W iMt psodeeod wWsee of eosp�esce trot aepr of its poildeel sbdivisiaas dull appUcem ad lly.mal.chapter 1 S2.125CO)Oam N*idwr the commaswtult` of eamplianee w ieb the ieutttrsoea enter into any contract tar the performance of public week until aoceptab rcquirg - ,of this cbopur baw bees ptermtmd m the cotwwbM aurhsrity' App�ta e to oar situation end.if Please MI near the workers' compensation sfildsvit completely. ebeckM elm boxy tbtK apply Y agK Maraceot(s)carne(s).adtkess(cs)and phone nutnber(s)class with their cectiticant(s)of necessary.AwplYCompanies or Limited Liability partrrsbips(LLP)with no employees other then rite instrattte. LW%kWLi&bWt ten oat m carry was. mermen. if as LLC or LLP does have; members or ptrtsars. that this zfa&vit may be submitted m the Department of Industrial employees.•policy le tegatr� 60 advised�� up a sun m sip sad dots rho atlldavM. 71»affidavit should Accidcrm for coaAmmdm that the application fa the patmit ar Bream is being requested. sat the Deportment of be returned to the city ar sown taw or if you an required m obtain a wotkt:n' Industrial A"idanu. Sbould you have any questions regarding ies should enter their lor co hsmo s policy. Pit"*call the Department�out mbar llistedtbelow. SsU irmsund companies self-itusurstta licence ttmabar on the Mom City W Town Oillelals at w pl,ase be sure that the al"avit is complete TM Dspormtaat has provided a specs and p ' limos Of the affidavit far you to fill our in don event the Office of Investigations has to contact you regarding spP t•lease be sure to an applicant till is the purmtit/C�number u ach ny g enbe ye year.need only submi as a reference t ono afridsvit indicating curtent that must submit multiple perta PP lob Site Address the applicant should write"all I"MiGas in (city ter policy information(if necessary)and under- tawnl"A VY of rha affidavit that has been officially stamped n marked by the airy or town may be provided m the applicant y proof that s valid afRdovit is oa file for fount permits at licenses. A new affidavit must be filled out each yam, WTtere a been owner a c. . is obtaining a license or permit not related to any buuineu or commercial venture t i.e.a dos Itea ha ux permit m bum leave eqJ said parson is NOT required m complete this atYldavit. ha l)I(l:e you advance for your cooperation and should you have any questions. of IUYestig3tiuna would like to thank ptu,e du rwt hesitate to give us a call. The Mpartment's address, telephone and fax number. The Cotemottwealth of Massachusetts DepultIMot of IflduaUW Accidents oft*of Inntudpden we waahinow Saed 8otio^MA 02111 TeL 0 617-727-4900 at 406 or 1-977-MASSAFE Fax 0 617-727-7749 revised 5-26-05 www.num.gov/dig CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ,.u�uWr arrt► \W.w Lai",MAvtU:w VAAS*"Or. Tits:vw4bam •fate IW404" Construedes Debris Disp"af A(Adsvit (required fix an deaudidos and rennvad"wort) is mcortlases with the sixth edidi s of the State HuiWas Code67SO ali soetios 111-S Debris6 wA the provisions of NGL a 40.S Sk 9uildin4 Permit 9 _ _ is issued with the coed dos floe dw debris reaaldns ham this work shall be disposed of is a properly licensed wave disposal fbcility as dented by MCIL e L 11. S 15OA. The debris will be transported by: (ISA— i" f- v�{s maws of hawt.� fhed.-bds will be disposed of in : tuame of ixd�ty) aSs 00e � a C'Y'- 46 y8O cv la-/3�D7 �r,t acORD. CERTIFICATE OF LIABILITY INSURANCE CSR DATE( /13/Y STURG-2 12 13 7 07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Thomas Fahy Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 433 •South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Suite 118 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Hartford CT 06110-2816 Phone: 860-232-1330 Fax:860-232-8267 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Peerless Insurance Company24198 INSURER B. Sturges Construction, LLC INSURER C: 540 North Main St. Suite N2 INSURER D. Manchester CT 06040 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. I LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/ODm DADS MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY CBP9678294 02/07/07 02/07/08 PREMISES(E.occurence) 1; 300000 CLAIMS MADE OCCUR MED EXP(Any one person) 810000 PERSONAL B ADV INJURY $ 1000000 X EBL GENERAL AGGREGATE s 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO s2000000 X POLICY PRO 71 LOC Em Ben. 1000000 ECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A X ANY AUTO BA9674321 01/09/07 01/09/08 (Ea accident) $500000 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE s3000000 A X OCCUR CLAIMSMADE CU9675096 02/07/07 02/07/08 AGGREGATE $ 3000000 8 0DEDUCTIBLE $ X RETENTION $10000 $ WORKERS COMPENSATION AND X TORY LIMITS ER A EMPLOYERS'LIABILITY WC9676595 02/07/07 02/07/08 E.L.EACH ACCIDENT $500000 ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Re: Blockbuster, 3 Traders Way, Salem, MA CERTIFICATE HOLDER CANCELLATION SALEM-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL City of Salem IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 120 Washington St Salem MA 01973 REPRESENTATIVES. AUTHOR E REPRESENTATIVE ACORD 25(2001108) _01ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) 12/12/2007 16: 27 FAX 6174673878 INTEGRATED SOLUTIONS R 004/004 Lam: PS 88679 . 4113H965 AP34MG Tr# 12458 g0 WELL$AVE I P1EWfON,MA 02469 i PUBLIC PROPERTY xl-lye�l— rC7.eo DEPAR 'iVIENT AI\p1CM N DRA V V L NAvat 130 WASHINGTON S'rxFET•SAL LK NUAA01LSh-1-R 01970 TM,978-74S-9595 •FAx:976.740.9S" APPLICATION FOR THE REPAIR. RENOVATION. CONSTRUCTION DEMOLITION,OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Locadon Name: Building: Property Address: c.1c . Property is located in a:Conservation Area YIN _ Historic District Y/N h 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: 13t S W LlSS7wTT---� PIz—. U►O04�7sTDc-k= f Gr4 3o t�S Telephone: 1 3.0 COMPLETE THIS SECTION FOR WORK IN EXL TIXG BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: ontact /Applicant }S't©©c:> Kent Fahey 800-556-8641� Fax 281 579-2227 rtlpermits@aol.com Mail Permit to: What is the current use of the Building? Material of Building? If dwelling, how many units? will the Building Conform to Law? Asbestos? Architect's Name Address and Phone Mechanic's Name Address and Phone Construction Supervisors License# , goo 7 q HIC Registration 0 00 Estimated Cost of Project$ Permit Fee Calculation Permit Fee $ 00 Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercl* An Additional $5.00 is added as an AdministraLka charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above ad specifications. Signed under penalty of perjury X Date 11 r' k 0 `o $ v aq o C7 y . 3 I