87 WASHINGTON ST - BUILDING INSPECTION (10) is
The Commonwealth of Massachusetts
Department of Public Safety
4• 'z�j \I.It:.ldm.ctl.State•(Building Cade 1780 C%IR)Seventh Edit wn
City of Salem
Building Permit Application for any Building other than a I- or 24 Dwelling
(This Section For Official Use Onlv)
Budding Permit Number: Date Applted: 2 � Budding Inspector:
SECTION 1:LOCATION(Please indicate Block a and Lot N for locations for which a street address is not air I
;J- 7 WL�S it•`151••arl -Sf. C..J�"tt:'M. Me4
\o.and Street Cite i Tnvn Ap Qwle 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❑ Attention Addition O 1 Demolition ❑ (Please fill out and submit Appendix I)
Changeof Use ❑ I Change of occupancy O 1 Other ❑ Spt'Cify:
Are building plans and/or construction documents bring supplied as pan of this permit application? YesX Nu ❑
is an Independent Structural Engineering Peer Review required? Yes O No p
Brief Description of Pritp,tsed W k:
, , h , t �t► �ro-� �� LOnA unJ s �, '
�-
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): Proposed UseGroup(s): f -
Existing Hazard Index 780 CMR 34: Proposed Haurd Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(N.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A
A: Assembly A-I❑ A•2r ❑ A-2nc❑ A-3 ❑ A ❑ 'A-5❑ 1 B: Business ❑ E: Educational O
F: Facto F-I ❑ F2❑' H: High Hazard. H-1 O H-Z O H-3 ❑ H4❑ H-5❑
I: Institutional 1.1 ❑ Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4 O
S: Stange S-1 ❑ S-2 13 U: Utility O Special Use❑and lease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
' IA O IB O IIA ❑ IIB O IIIA ❑ IIIB ❑ 1 fV ❑ 1 VA ❑ VB ❑
I .SECTION 7:SITE INFORMATION (refer to 760 CMR 111.0 for details on each item)
I Water Supply: '� Flood Zone information; Sewage Disposal: french Permit:
Debris Removal:
A trench
Public ( heiL it out>ate FLr�,I Lon.• bnhc.tte munlapal
r toil not Lae Llirn.ed Site
UisFxt.d
rcyuintl tr trt•nch ..r�pccli v:
I'rltate❑ , .,r mJentric Zona• de,i,tem❑
Rail r ad right-of.way• Hazards to Air Navigation: tin I h.e.r,. t ..,,,o,,.-,.",It,.,•„ 1'r.
\.•t \pl•h. dlc I.�Irv::,uc:. Ihu�.n,)vrl.'ll td,.ova' I.(hcq R•,irtr nnn)`Irh•d• .,N/ti
..rl •mvnt l:•Ilull.l tnGa•aJ❑ lv.❑ ,ir Nit W le•O \a ❑
,
SECTION 8:CONTENT OF CERTIFICA fE OF OCCUPANCY
I..1,1nm.d l'��,lc . .__ l f,l '.�minli L!nn' __�.. t iiuf•a nl L,�a.l)•vr I!....r ._._.... _..__
Ih.r.tho buddinp;nnt.un.m Spru+l.lcr?t�Icm`: ___�p.....d>Ulvda h,.n.
SECTION 9: PROPERTY OWNER AUTHORIZATION
1 o/dyc.i C- QOP'4RT%C �a�4�;t L- ,sT O � 5 N.1 me.11A1 GAddre?s id PfU X'ft1' \'ne(
R1 tit'A-L(.f lvrs %� wJ S r �. '�S L
Name(Print) No.andStreet Cov/Town
PmpvrlyAN n1F Cllnt,ld 1111urm.ition: ! ?dam' `;2�2'O4hDo
tR �a Iclsc�.- .—
Title Telephone No.Ibuemv>sl Telephone No. (cell) c•-mad address
if.,pphc.lble,the l•n+perty owner hereby aulhunzes R —
.Name Street Addrrs.. City/Town Seale Zip
to act un the ny rty ,%%ner,behalf, in all matters rcL\uvr to work authorized by this buddin• +rrmll application.
SECTION 10:CONSTRUCTION CONTROL tPlease fill out Appendix 2)
lit bwldin isk sthin 15MXIl u-n.u(rndovvl s+.xe and/ur nor under Ca•nalrutlrun(:anlrul theneheek hem nJ'Lit,Section lUq
10.1 Registered Professional Responsible far Conatmnion Control
Name(Registrant) Telephone No. e-rmul"address Registration Number
Start Address `,__Citv/Town State;- --Zip Discipline Expiration Date
10.2 General Contractor
pp n
_ 1� cS Co ass�'c.«t'Y lRt o v
Company Name: S�n! j, c S 1.�l(( Rs (�
RP�t 1.I� 1t7 J
Name of Pr��r tm Rrsprmsible for Construction License No. and Type irtU Applicable
ozf cF S
KCTf.twc �t.QO .San f�J 4rt-l"� __l;e.-
Street Address City/Town State Zip
___ I ) i'n:aNw•vt SC' (�4)=rrf2b-�FfSDS"
Telephone No.(business) Telephone No.(cell) e-mail address
SECI JUN 11:WORKEles'COMPENSAT[ INSURANCE AFFIDAVIT(M.G.L.c. 1S2. 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 i ance of the building permit.
Is a sign Affidavit submitted with this application? Yee No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
m
4.Mechanical (HVAC) S A112 J
and Materials) Total Construction Cost(from Item 6)-5
1.Building 9 /O 0 U Building Permit Fee=Total Construction Cost x,(Insert here
2.Electrical 5 SD Q appropriate municipal factor)=S
3.Plumbing S
Note:Minimum fee.S (contact municipality)
5. Mechanical (Other) b A Enclose check payable to
6.Total Cost $ /;SD£,> (contact munici ality)and write check number here
SECTION 13!SIGNATURE OF BUILDING PERMIT APPLICANT
Rv ente,mg my name brluw.I hereby attest under the pains and penalties of pertury that all of the iniormation contained m this
apppkatuyrS+s truerrr''�vvm.�..d a cur.+tr�h1-r`e hCy�sl St my knuwk+IFr and tmd�ln'tand'�in'g.
N `O• Ste" - 0wo-E' -- 7 _�1I9 ��C7
v.i.e +rent and sign name Title relephune No Uate
.. __fR I ten
-�Iwvt Lddre.. tltt:'Toren Lire 1,p
\(umcipal Inspeclur to till out this section upon application approval:
\.one hate
\.
' The Commonwealth of Massachusetts
(T Department of Industrial Accidents
,77
RAW othwWomew
600 Washington Street, 7'Floor
i Boston Mass 02111
r Workers'Compensation insurance Arcdavit: Building/Plumb n EE ctricat Contractors
.
Please'P�IlNT 1 .. - ..
name
address rk C/"` n'1• .S 1"
o
'-Y_ r•Ic_.�' state- dNnA• zip' (DZ ly 5 phone# !�17 - r�'2
work site Imation(full address)' � 7 WhSsi...S}tsn s 1' . St: le �"r e^ A
❑ T am a homeowner performing all work myself. Project Type: ❑New Constructions Remodel
ra 1 e a sole pm rietor and have no one working in any capacity. ❑Building Addition
�I am an employer providing workers'compensation for my employees working on this job.
t
cam nam : 2 . S . � nnSfw.} -s +s F (22Ma.6t.�.
odftWz ? r-� • r . S t-
city: r. anH• 17 — 2 +
ipsurance,co L-y16� L�I ooilcy# WC 2 3 1 S 3 (is 0 0 Q 3 0?-fI .
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
addres_:
city, .phone#:
ins n Dolliev# ..,
add " _. . .
city phone#: _
insurance co. .. . .. .._
Failure to secore coverage as required under Section 25A of MGL 152
Attach hdditioaal' H _ s;.T, s€ U: :;. r: 4 ..
g q can lead to the imposition of criminal penalties of•floe op to SI,500 00 and/or
ont years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that o
copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification,
l do herebv certify under the pains and penalties of perlmy that the information provided above is true an correct.
Signature Res`es .`^c=I�� `•-'a Date )I I 1 0
Print name F, c neL ;az. Phone# (D l 7 P2 9-op
;c,- :"�'+sfCY�tA4D:Y[I�t'GitYJ 4'•i..
olfKin;ase only do not write in this area to be completed by city or town official
city or town: permit/license# []Building Department
❑LIcensing Board
❑check ifimmediale response is required ❑Selectmen's Omce
❑Health Department
contact person: phone#; ❑Other
N (mvi,ni sw unit
VaBillimimritylli:
GAreIMIBDDmwI
CERTIFICATE OF LIABILITY INSURANCE 12/23/z009
►ROMICER (781)729-877( FAX (781)729-0053 THIS CERTIFICATE(S ISSUED AS A MATTER OF INFORMATION
John A. Pierce Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
934 Main St. ALTER THE COVERAGE AFFORDED BY THE POLICIE BELOW.
Winchester, MA 01890-1994
INSURERS AFFORDING COVERAGE NAIC si
INSuRED R S Construction S Remodeling Inc INSURERA: Liberty MUtURI ins Group 0034
17 Fairmont Street _ INSURER B°
Everett, MA 02149 PISUFFRC.
wBIRERR
NSURERE
RAGES —
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 E SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS.
POLLGY EFFE CY LIMITS
SR OLYNUISRN
EACH DCCURRENCE $
GENERALLMBIITY
DAMAGE TORENTED s
BmR
COMMERCIAL OENERAL LNY
L3AMSMADE OOCCUR MED ENP(MYAA.PAI 3
PERSONAL&ADVINJURY 3
GENERAL AGGREGATE f
GERL AGGREGATE
PEP.WT APPLES PE PAODUCTS•COMPJGPAGO 3
POLICY JEC� LOC
AUTOMOBILE LMAUTY COMBINED SINGLE LMn S
(FA wddAN)
ANYAUTO
ALLOWNEDAUTOS �T Lvelw)RY 3
SCHEDLCFDAUTOS
19REDAUTOO BODILYINJURY S
(PRMaddAM)
NOROIMEDAUTOS
(PROS DAMAGE 3
AUTO ONLY-EA ACCIDENT $
GARAGE LIABILITY
ANY AUTO , EAACC 3
AUTO O MNTLYY. AGO S
EACH OCCURRENCE 3
WIBES3AMWLELU UAIRM -
OCCUR CIAMSMADE AGGREGATE S
3
3
DEDUCTIBLE '
3
RIETUMOR S WCSTATV- OTH-
VMmu MCOYPERSADMAND WC23JS360003029 1 //21/ 0009 11/21/2010
EMPLOYOW LMOUTY EL EACH ACCIDENT 3 5UU 0
A OFF PEER�G EL DISEASE-EA EMPLOYE S 5UU DU
BYTna,,�aERHL»,o,dN ELols"-POUCYUMR $ 500 00
SPECULL PRGMSa bWm
OTHER
DEBCNPTILNI OR OPEMTIONS/LacATI0ti3/VE1mCtESREXCLUSIONSADOEOBYEK9DO EMENTJSPEO"PROV18fONS
i
i
SHOULDANYOF THE MM oESCOBEDPOUC ES sECANCELLED BEFORE THE
EI( MIJOHDATE THEREOF,THEIMBUING INSURER PALL ENDEAVOR TO MAIL
10 DAYSWRIYEN NDTLGE TO TLIECERTDTCNTE HOLDER NAMED TO THE LEFT.
The Green Land Cafe OF
FAILURE To MAIL SUCH NORCE MALL IMPOSE NOOSUGATION OR LIABILITY
87 Washington St OF ANY KM UPON THE INSURER ITS AGENTS ON REPRESENTATIVES.
Salem, MA U1970 AuINDWEDREPRESENTATNE
Kevin Pierce
CACORD CORPORATION 1998
ACORD 25(2801/08)
\las.achu>c -Department of Puhlic safet.
Board of Buildin_ Rvuulatilm. :tnd 4r:mdard> _
ff Construction Supervisor License
License: CS 84864 �-
Restricted to: 00
REGINALDO SANTOS
17 FAIRMOUNT ST
EVERETT, MA 02149
y�ilrl� Expiration: 1212=10
( nnmi.+ioncr Tm:
r BdiflFol'Biii , .tQ,a s io7is`aer an
-HOME IMPROVEMENT CONTRAC!°Oft .
Regictradon: 145636
ExpiraGbd:-21162011 Trf 279465
Yypr lrivam Corporation
RS CONST&REMODELMG;INC.
REGINALDO SANtOS _
17 FAIRMOUTN ST.
EVERETT.MA 02146 : Administmtor
Restricted to: 00
00- Unrestricted
1G-1 2 Family Homes
Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
Refer to: VI".Mass.Gov/DPS
_.
License or registration valid for individul use only
before the expiration dale. it found return to:
Board of Building Regulations and Standards
One Ashburton Place Rm 1301 .
Boston,Ma.02103
Tlol valid without signature
Y
E ut ment Schedule
dV` Pcr 1 Bakery Case
�7I �ro (57" x 27")
R I P 2 Wait Station
01 " (4B" x 48" x 26")
3 Casework
(36" x 26")
4 Serving Casework
(57" x 24")
5 Serving Casework
(57" x 32")
6 Display Casework
(32 x 24")
7 Display Casework
(49" x 29")
; I 0 36 36-
36"
Fo
'
Q 4 6 Q 2
36-
000000000
1187
F/7
mil � � - - - - - - - - - - - - - - - - - - - - - - - -
Rumpf Design Group Pr*d
PO lox 4483 Green Land Cafe 10085
57 Wharf Street — Unit 2G 85-87 Washington Street Uu
Salem, Massachusetts 01970 Salem, Massachusetts 10/18/10 Exl
�w
(978) 740-5025 Existing Partial Floor Plan 1/8"= 1'"0"
(978) 607-0045 fax
PnrLit.ion Schedule
Fire
Matr Rnti
p Rang Rattng
eials Descr-i Liam Ei sic Remarks
1/2" A.C. Plywood Screw n/c n/a Typical HOIF Wall Int. Partition
4 5/8" Attach One Side (ShelfSide) Match Existing Top Cap Detail.
2x4 Wood Studs e 12" OC (5-6" A.F.F., Confirm w/ Owner)
5/8" G�Psum Wall Board
Screw Attech One Side
(Bar Side)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,
Match Existing Cep E ut ment Schedule
' And Base Detailing.
+ ; .Al Uncch One Side (ShelFSidel 1 Relocated Bakery Case
i, (57" x 27")
N Shelf ; i2x4 Wood Studs a 12" OC °
io 2 Relocated Waif- Station
5/8' G lum Wall
Bo r (4B" x 48" x 26")
5-2" +/- Screw ttach One Side
(Bar Side] 3 Relocated Casework
-- - - - - - - - - - - - - - - - (36" x 26")
2 I Half Wall PIan, 1/4' = 14- Half Wall Section, 114" 1 L r7
Existing Handsink
L
O 36-
A
J
(V
36" m F FD m 36- 36
2
' in. '
3
Half Wall Construction-
2' x 4' Wood Rude a 12" o.c. 36-
w/ 3/4" Pl wood (Shelf Side1 and 5/8"
Fire Code Well Board
0 0 0 0 0 0 0 0 0
__--_— --770 #8�
O
TT
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1
", Partial First Floor Plan, 1/8 1 -0
Rumpf Design Group o,oren
PO Boa 4493 Green Land Cafe 10085
57 Wharf Street — Unit 2G 85-87 Washington Street am
Salem, Massachusetts 01970 Salem, Massachusetts 10/18/10 Al
�w
(978) 740-5025 Partial Floor Plan As Noted
(978) 607-0045 fax
r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
E ut ment Schedule
1 Bakery Case
(57" x 27")
2 Wait Station
(48" x 48" x 26")
3 Casework
(36" x 26")
4 Serving Casework
(57" x 24")
5 Serving Casework
(57" x 32")
6 Display Casework
132" x 24"1
7 Display Casework
149" x 29"1
36-
FD
36" ;
4 6 2
36-
0 0 0 0 0 0 0 0 0
__-- 77=0 #87
mil - - - - - - - - - - - - - - - - � 0 - - - - - - - - - - FIII
- - - - - - - - - - - - - - - - - - - - - - - - - -
Rumpf Design Group N°j� ,&.
PO Box 4483 Green Land Cafe 10085
57 Wharf Street — Unit 2G 85-87 Washington Street 0
Salem, Massachusetts 01970 Salem, Massachusetts 10118/10
�e
( Exl
978) 740-5025 Existing Partial Floor Plan 1/8"= 1'-0"
(978) 607-0045 fax
PnrLiLiOn Schedule
Materials Descri Lion Fire SLc Remnrks
P Roting Rating
1/2' A.C. Plywood Screw n/o n/e Typical Heli Woll Int. Portition
4 5/8" Attech One Side (ShelfSide) Motch Existing Top Cop Detail.
2x4 Wood Studs a 12" OC (E-6" A.F.F.. Confirm w/ Owner)
5/8" Ggpsum Well Board
Screw RLLnch One Side
(Bor Side)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - -
E ul ment Schedule
Motch Existing Cep
' And Base Detailing.
+ ; .A tech One Suede (�ShelfStdel71 1 Relocated Bakery Case
i.: (57" x 27")
N Shelf ; i2x4 Wood Studs a 2' OC °
o 2 Relocated Wait Station
1:::::::::. ::.:::::. 5/8" Oum Well Boer Ln (48" x 48" x 26")
5-2" +/- Screw
r Ste Mach One Side 3
Relocated Casework
� (36" x 26"1
I I Half Wall Plam, 1/4" = 1'-1" 13 I Half Wall Section, 1/4' 1
Existing Hondsink
0 7.-0" 36 36-
�jI N
i
36" m FD m 36 36
Mina 3 2
Half Well ConsLrucUQn-
2' x 4" Wood Studs a 12" o.c 36-
w/ 3/4' Plywood (Shelf Side) and 5/8'
Fire Code Gyp. Well Board '
O O O O O O O O O
10 u87
0
- - - - - - - - - - - - - - _ - - - 1
1 Partial First Floor Plan, 1/8" - 1'-0"
Rumpf Design Group Pr*"
PO Box 4493 Green Land Cafe 10085
57 Wharf Street — Unit 2G 85-87 Washington Street o.W
Salem, Massachusetts 01970 Salem, Massachusetts 10/18/10 Al
( �w
(978) 607-0045 fax Partial Floor Plan As Noted