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8 TRADERS WAY - BUILDING INSPECTION (2) i ECE►VE#Jp A i 'l4SPECi10YAE SftytC£3 The Commonwealth of Massachusetts ccW Department of Public Safety J Massachusetts Stale Building Code(780 CMR) Building Penuit Application for any Building other than a One-or Two-Family Dwelling lJ (nds Section For Official Use Only) (� Building Permit Number; Dale Applied: . Building Official; �.Y SECTION 1:LOCATION(Please indicate Block N mid Lot it for locations for which a street address Ts-At available) I No and Street City/Town Zip Code Name of Building(if applicable) 1 tuG i SECTION 2:PROPOSED WORK -- -' Edition of MA State Code used If Nev,Construction check here❑or check all that apply in the two rows below i ' Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ 1 Demolition (Please fill out and submit Appendix 1) j Change of Use ❑ Change of Occupancy Cl Other ❑ Specify: Are building Plans and/or construction documents being supplied as part of this permit application? Yes ❑ No i Is an Independent Structural Fnginee!ri�ng Peer Review required? Yes ❑ No 4a-- Brief Description of Pro nosed Work: iS EnlCArhl� CJf= Q.h2PE'f-I rJG, V 1 tJYL Y"r LE ,4 r.1h igi{E�r)Z�iC EmnJED f�� r t� E cacu P fJO VTUg P_13A ra s r Itt_c, P,€ P�K�o�m�-t� I f i l 1 SECTION 3:COMPLETE TIIiS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR 1 CHANGE IN USE OR OCCUPANCY Check here Jan Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flom's/Stories(include basement levels)tc Area Per Floor(sq.fL) Total Area(sq.ft.)and Total Height(ft.) SEC-1 ION5:USE GROUP(Check as a Bcable) A: Assembly A-1 IDA-2❑ Nightclub ❑ A-3 ❑ A4 ElA-S❑ B: Business E: Educational ❑ F Facts F-1 ❑ F2❑ �OM: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ 1-2❑ 1-3 ercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ tuily❑ Special Use❑and please describe below: '. Special Use SECTION 6;CONSTRUCTION TYPE. Check as applicable) >. IA ❑ Ill ❑ IIA ❑ IM ❑ HIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for detaik on each item) - - Water Swppl Flood Zone Information: Selvage Disposal: Trench Permit: Debris Removal: A trench will not be Licensed Disposal Site❑ Public Check if outside Flood Zone❑ Indicate municipal Nlffffh requiredWor trench or specify:_ Private❑ or urdentify 7_one — or on site system❑ permit is enclosed❑ AJ 1 Railroad right-of-way: Hazards to Air Navigation: MA Historic Cvaunission Review Process: t - Not Applicable'd- Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No WL- Yes❑ No 1!�— SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction:___ Occupant Load per Floor: Does line building contain air Sprinkler Syste:u?: ___Special Stipulations: w\ tom C,. c- - P� a SECTION 9:.PROPERTY OWNER AUTHORIZATION Name and Address of Properly Owner Highlander Plaza Realty Trust 261 Old York Road Suite 814 Jenkintown,PA 19046 Name(Print) No.and Street City/Town Zip Property Owner Conlact Information: 215 _690 . 3220 Title Telephone No.(business) Telephone No. (cell) e-mail address 1(applicabie,the property owner hereby authorizes N/A Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized b•this building permit apElication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.ft.of enclosed s rue and/or not under Construction Control then cheek here and skip Section 10.1) - 10.1 Registered Professional Responsible for Construction Control �j4AEt_ PpirRISSa -7yy y54S mPArR+sso�,ERvr �bR3o�em J P�16S� Name(Registrant) Telephone No. e-mail address Registration Numbe 11F_ ©N + +N S'k �SA n R � .01 R Street Address City/Torn State Zip Discipline piston Date t 10.2 General Contractor i i Company Name Name of Person Responsible for Construction License No. and Type if Applicable j Street Address City/Town State Zip Telephone No, business Telephone No. cell a-mail address :t SECTION 11:1'ORKESS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C(6) 1 A Workers'Compensation Insurance Affidavit from the XIA Deparinnent of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in tire denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ BuildingPermit Fee=Total Construction Cost x § (Insert here 2.Electrical appropriate municipal factor)=S 3.Plumbing S 4.Mechanical (HVAC) $ Note:Minunum fee=S (contact municipality) 5.Mechanical Other 5 Enclose check payable to 6.Total Cost (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I bercby attest under the pains and penalties of perjury that all of the information contained in this application is true avid accurate tolive best of my knowledge andunderstanding. y1 LA-4 fA f-v SSz) S�._ f �nto. / 1 `f L/�_ i Pleas print and sign name. vTitle Telephone No. Date ( F�t+ Jet, �i� — a j Street Address City/Town State Zip Aluntclpal hnspector to fill out this section upon application approval: Name Date 1 i i 1 i i j Appendix 1 i For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. i i Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. iProperty Location (Please indicate Block# and Lot# for locations for which a street address is not l� available) g TYZA06P_.S IJAY_ L5f)t-4__nA pi97o No.and Sheet City/Town Zip Name of Building(if applicable) j i j For the above described property the following action was taken: i Water Shut Off? Yes❑ No( Provider notified and Release obtained? Yes❑ No ❑ Gas Shut Off? Yes❑ NoM Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ p Other (if applicable) j Yes [I No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) I 1 i i i I i I j F i i i3 1 1 i i i i Appendix 2 i 1 Construction Documents are required for structures that must comply with 780 CMR 107.The checklist below is a compilation of the documents that may be required for this.The applicant j shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. i i Checklist for Construction Documents* Mark"x"where applicable S Item Submitted Incomplete Not Required No. 1 Architectural 2 Foundation _ 3 Structural 4 Fire Su ression 5 Fire Alarm ma•re ripe re pesters 6 HVAC 7 Electrical 8 Plumbin include local connections 9 Gas Natural,Propane,Medical or other f 10 Surveyed Site Plan Utilities,wetland,etc_. l 11 Specifications i I 12 Structural Peer Review 13 Structural Tests&inspections Pro am f 14 Fire Protection Narrative Re ort 15 Existing Building Surve` Investi ation i i 1.6 Farm,Conservation Report 17 Architectural Access Review 521 CMR) 18 workers Conp ensation Insurance 19 }lazardous Material Mitigation Documentation i 20 Other S peel ` i i 21 Other Specify) ' 22 Other S ecif• i -Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work I so identified must not be commenced nmtil this application has been amended and the proposed construction document amendment C ority having jurisdiction.Nbrk started prior to approval may be subjected to triple the original permit has been approved by the autlp j fee. Registered Professional Contact Information I i Registration Number jName(Registrant) Telephone No. e-mail address ` Town State Discipline Expiration Date City/Town Street Address >/ — ---_ Registration Number Name(Registrant) Telephone No. email address i -- Discipline Expiration Date Street Address City/Town State Zip I — = Registration Number Name(Registrant) 'Telephone No. e-mail address ( Discipline Expiration Date Street Address _ City Town State Zip I i i C,ay OF SALENIS AkSS��CH�;SE"I'I5 rj BuiLDNG DuP.�K"wN-c • '# ,• t'10\W.iSHNGTON STRLET, 3w FLOOR mi 1`t t- (918) 745-9595 F.ke(979) 740-9846 s,'tmi3ERLF_Y DRSSCOU -MOMAS ST.PMRK9 MAYOR tJl'21•C?OP.OF PUBLIC PROPERTY/Hla-DNG COI fNISSIOIVER 3 1 Demolition Permit Sign-Off Nupptenacnt to pernlit application) 1 Highlander Plaza Realty Trust ; hereby supply the tollowing releases as part of the application ,ov a pt,mut to<knnoii6h the Structure Iocated at _-. 8 Traders Wad— —^ Parcel aOM129 _ and shown on the Assessor's Maps 1s N,ing o i Map it Block if _—_----Lot it hhc sixth cdaum of the .4lassachu,etts State 8xii1ding Code,780 Cb1R,states lit part: "A poolit to dcmulisll or rculotre to buildinX or structure shrill not be issued antil a release is of lame(((rout the lttilihes, stilijilg that their re Spec litre service connections and appttrtenarrt rgmpme'rtt, .,uch r15 )nr!rrs rind regulniors, have (•em renwred or seeded and plugged in a snfe Ia(lrI/L!T." UtititTit> hz Notifii! Notice Received b Date Received j-— — Ga} 1 Itrle lhon�'. r — Elect i _ Public Utihii.> t`ttm;, to 7(j — -- ---T -- --� i 1 Tealth Firc Dcpartlncnt --- _-_-- �� Other - _ Other - : T entolition debrisi Mauler _ G/S_. "1-oW t O-C-p ConoeOUun 60,l crzsed oemoU#ion debris iandf711: (I Ap iwant Date: `iit natocc of ONVIlef - -(-` v { Da to tt�� This Sheet must be nrtur aea W tLu ha6pectr ns Department along with a Co... application fur a p<:frnit, a site plan, and any other applicable information and fees. n.•m q Nrm dn. I 1 rb L8YumLNCr 1.1GYAIxTm&\E 120 WASHLNGTON STREET, fkooA f a "T E1- (978) 745-9595 T RX(978) 74{►-9W KIIYBERLEY DPJSCOLL 7140sWS*. MAYOR PRY CTLS�t3F Pt BLY�P&ClP�ATY/Hi ��LtiG GO`LtiYS5Yt7 EA Demolition Penn it Sign-Off (Stippleinent to permit application) I Highlander Plaza Realty Trust . herchy supply the rollowing releases as part of the appiica6on for a permit io del-n ill h the structure located at a Traders way —_ Parcel nos olzs __.__. ._ _ and she wn on the .>ssessor s Maps asitxg raft flap Block it i ht a,At3h e dht c>n of the T, E ssic husetts State Building Code, 780 CMRs,states in part: ' A 'r rz air to derfiWiSh Or rr TracW i buildinL Or straic tare shall not be issued an tit a release is obtained„tron, ilat3 Ut77ut's, S18fiP g that ft.'2tr reSpectiM service ccnnect'ians and appurtenant equipment ,tuc'z las rrfeh'rs a art r equF«trars, have been removed or sealed anti pl agged in a safe a irar't2t2c'.r..• E L tilit _t� be \oti#a I `notice Received Batt Received 1 E 3 i'ui U*dot $tfr ��tpna) t t lLalth l� Ytntc�nt_ k Fire y Other-a i i Other - t F a —M — _ .__._ __.._......_._,__....._._...._.._...._.e. 1°7vtT:c)tt t ianitelarh�,I�ruiemr'� T...��C�tYcm�7f tics�nsa�d;' x Sig tvrk� of <\iaph nt Date. Sionaturi (If 0IN110r Date: f This siieet inust be returned to the Inspections Department along with a completed 1 application for a permit, ah site plan, a.rd any other applicable information and fees. E S Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-067871 Construction Supervisor # PAUL T PETRYCKI� 3 RYAN FARM RD ' WINDHAM NH 0304Qvj Expiration: Commissioner 1010712017 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 �y A Home Improvement Contractor Registration Registration: 184621 Type: Corporation Expiration: 2/18/2018 TrN 286448 PATRUM ASSOCIATES E MICHAEL PATRISSO JR. 11 FRANKLINST. SALEM, MA 01970 F . --- -- - - - - Update Address and return card.Mark reason for change. Ij Address (] Renewal I]-j Employment Lost Card SCA 1 0 20M-05/11 ��c Yrn ur urnarnia�/�t�r��ir 4inr�rdr/b _ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only (:COME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: YP egistration: 184621 Type: Office of Consumer Affairs and Business Regulation R Expiration: 2/1-8/2018 Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 PATRUM ASSOCIATES - r DBA SERVPRO OF SALEM/PEABODY/MARBLE HEAD 11 FRANKLIN ST. SALEM, MA 01970 Undersecretary Not valid without signature �' c�® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNYYY) 0 5/2 412 0 1 6 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 pollcy(les)must be endorsed. H 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 endosemen s. PRODUCER CONTACT NAME: Christopher P Kennedy FARQUHAR& BLACK INSURANCE AGENCY INC. °HONE 7a1 sss-zzoo (Al( No: AOOResa: Chrisflifaridbinsurance.com, 85 EXCHANGE STREET-STE.101 INSURER a AFFORDING COVERAGE NAIC S LYNN MA 01901 INSURERA: ACADIA INS CO 31325 INSURED INSURER B: _ PATRUM ASSOCIATES INC INSURERC: DBA SERVPRO OF SALEM INSURER D: 11 FRANKLIN STREET uuluRER E: SALEM MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: 55565 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. LTR ADDLTYPEOPINSURANCE am YAM POUCYNUMa9l y�CY EFF EXF MMRS CO NMERCIALGENERALLUIBIMTY EACH OCCURRENCE $ CWMSPMADE OCCUR PREMISES EE.� e It MED EXP One It N/A PERSONAL&ADV IWURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY 0 JFERCOT LOC PRODUCTS.COMPIOP AGG s OTHER: $ AUTOMOBILELNSILRY E IN N LIMIT $ s a�nt ANYAUTO BODILY INJURY(Perpenon) It ALLOWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Ptraadann $ NON-OWNED PROPERTY DAMAGE It HIREDAUTOS P AUTOS Par a¢i0ent E EACHOCCURRENCE sOUABB OACCSMADE N/A AGGREGATE s DED RETENTION 5 $ WORNERSCOMPENSAIION X PER - AND ENPLOYEW LIABILITY T A FVIFCE"oRYIN miF. 6 0»cLlmEm curNE wA NIA MA WC202000228306 OSM9I2015 09MB/2016 EL.EACH aCGDEW s 500,000 (rrerrtlebrY in NH) E.L.DISEASE-EA EMPLOYEE E 500:020 If yyease tleaaiEe unOer DESCRIPTION OF OPERATIONS tm w E.L.DISEASE-POLICY DMR S S00000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES(ACORD 101,Aeifflo"Rwnarke Se uH,nu,Meae Wff o space M rwtu ) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this Coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mss.gov/hvd/workers-compensationrinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington Street AUTNORI2tn REPRESENTATIVE 1 Salem MA 01970 Daniel M.44,CPCU,Vice President—Residual Market—WCRIBMA 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD