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87 WASHINGTON ST - BUILDING INSPECTION (2) X r The Commonwealth of Massachusetts h j I Department of Public Safety °.F-)f' ••.,.� \1.u>achu.etl.State Building Code(780 CMR)Seventh Edition City of Salem Building Permit Application for any Building other than a 1- or 2-Family Dwelli (This Section Fur icial Use Only) Building Permit Number: - Date Applied: ( O Building Inspector: i SECTION 1: LOCATION (Please indicate Block Nand ILot M•- or locations for which a street address is not availa I No.and Street Cit)- /Town 4" ii Name of Building(if applicable) SECTION 2: PR D WORK If New Construction check he e❑or chlvall that apply in the two rows below Existing Building Vj Repair Alteration Addition ❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes No O Is an Independent Structural Engineering Peer Review required? Yes ❑ No G]' Brief Description of Proposed Work: 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 Use Group(s): •� Proposed Use Group(s): Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR.34: SECTION 4:BUILDING HEIGHT AND AREA ~ Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 2- Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r • A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F H: Hijxh Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 O R-3❑ R-4 ❑ S: Storage S-I ❑ S•2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) n103118 IIA ❑ IIB ❑ IIIA 1118 ❑ IV ❑ VA ❑ VB ❑SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: heckifoutsideFluud Zone❑ Indicate municipal ❑ A trench will not be Licensed Dipusal Site❑or indentifv Zone:_ or on site.vstem ❑ required O or trench or specifv: permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: \I:\ I li,t,-rir t nnmir�i„n Ito+;,• . I'n .N,d ;\pl+licdbly I.Sl nii(u re�cuh In aupnrt.tpproach area' 6lheir revu:w c, mpleted, ,,r Cmilent to Build enclosed ❑ lb. ❑ or No Yes ❑ \o SECTION 8:CONTENT OF CERTIFICA"FE OF OCCUPANCY Fddnn ,d C„de. L,e t;rnupl.c r\pe of Cunstrucuun: OCCLII.dot Load per I luoc IA+r.the buildmg contanan Sprinkler S�,tem.': Yes, Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Al Name and Address of Property Owner /J / r 7 �/ 1""4's r- _ fe1 ; /Pei/ extf K Name(Print) Nu.and Street City/Town y Zip Promo ,arty Owner Contact Information: p Title d waE2 Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the propene owner hereby authorizes Name Street Address Citv/Town State Zip to act on the propertv owner's behalf, in all matters relative to work authorized by this building aermit a )alication. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If building is less than 35,tXx)iu. ft.of encloxd s ace and/or not under Construction Control then check here O and slue Section 10.0 10.1 Registered Professional Responsible for Construction Control �t�N La v�tw�fk R7�?y�_fo2S 529f/ Name (Registrant) Telephone No. e-mail address / R istratioronNNumbek 201 0 [�/lfw/Zf T Sa c d�1 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Na e: a`�i,(D Name )f Person Resptmstyyle fqqr Construction f' V W License No. and Type if Applicable Q Poll I�IJ(!?t 7 !' K M treet Address City/Town State , Zi Telephone No.(business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COWR'ENSATION QJSURANCE 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 i uance 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 Total Construction Cost(from Item 6)=$ and Materials) 1. Building $ 20 OC-3 C7 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ Roi 00 c7 appropriate municipal factor)=S 3. Plumbing $ O ©J Note: Minimum fee=$ (contact municipality) 4. Mechanical (HVAC) $ C, c7 5. Mechanical (Other) $ U Enclose check payable to 6. Total Cost $ c�`Ji 0V 0 (contact municipality)and write c ec number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Please print and si);n name Title Telephone.No. Dale �cntsi. Street Address City/Town ate Lip .Municipal inspector to fill out this section upon application approval: a \a e I ete 05 �� - 57 15 i �� CITY OF SALEM 3 ,( ' I PUBLIC PROPRERTY DEPARTMENT 1�112 K I h.) !•KN ,'•t 1 \I`.l,Ott I ie .\iI11.VG;iL^15rHLCT lit it 11�:I`1�.. 978-740-906 Construction Debris Disposal Aff7davit (I-Cyuired fur 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 N - . - is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c S 150A. The debris will be transported by: ^g L (name of hauler) 'I'Ire debris will be disposed of in -- (name of aci rty) (address of lacility) gnature of permit applicant IZ //0/ Cq date CITY OF SALEM'., MASSACHUSIETTS -" PUBLIC PROPERTY DEPARTMENT 120 WASHI'NGTON STREET, 3Rr1 FLOOR SAL£M. MASS'ACH4US@YTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595-EXT- $aO MAYOR FAX: 970-740-9846 - CONSTRUCTION CONTROL AFFIDAVIT Project Nurnber: C2q 1 t --� Date. I Project Title: �, t-I-� '- a.t-1 TJ Project Location:� � 1LkAh►1 t�-lG��j�� Name of Building: t t.rl S MA l`L tS U L L-p Scope of Project: _64-rw�o Iz- --r-3 Lo - dt-v ]-- IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE;I !+r APµ RpI LwrC-RMo Rao- MASS. REGISTRATION NO. Z13 BEING A REGISTERED PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, :COMPUTATIONS, AND SPECIFICATIONS CONCERNING: Civil Architectural, Structural Mechanical Electrical Fire Protection- Olher(specify). FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOW LEDGE,.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 PRO POSED.PROJECT. I FURTHER CERTIFY THAT 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 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 cor tractor as required by the construction contract documents as submitted for building permit,and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code required control materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specked in the accepted engineering practice standards listed In Appendix I. PURSUANT TO SECTION 116:A, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON-COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO T E ISFA ORY COMP ION AND READINESS OF THE PROJECT FOR OCCUPANCY. Ig SUBSCRIBED AND SWORN TO BEFORE ME THIS a\sf DAY OFS aQr-�5 c T14 0 0 lc rnm - >� My commission Expires: co\-bhp .Notary Public CITY OF S.U.&M, INLASS.-kcfi sEm o &MDLNG OEPARTSMNT +' 120 W.\mmil;T oN STREET, Yet FLOOR TEL (978) 743-9S95 FAX(978) 740-98" K1.-,tl3EUAY DIL SCOLL THohtAs ST.PIERRt MAYOR DmECTOR Or PL aLIC PROPERTY/lIU DOIG COMNOSSION F:R Workers' Compensation Insurance AMilsvit: guilders/Contractors/Electrician%iPlumbers Annllcant Infnrmation Please Print Legibly VsIT1t lausirae.a.drganuatioty lntbvtdualY /"1 ` , ! /�l7/i{,(f• /gyp /-�"ji� �Q ' f /711 /,/1!� Address: r / "`� City/state/zip. Lvejzd, MA a2M Photo M: Are y d): yoou as employer'Cheek the appropriate boa: Type of project(require 1.E3 t am a employer with 5 4. Q t am a Vneral conrtaemr and 1 employees(full and/or part-time).• have hired the sab.com m racto 6. QQ�New canatntctioa 2.Q 1 am a solo proprietor rat partner- listed on the attached sliest : 7 1,_J Remodeling +hip and have no employees These sub-contra toes have S. Q Demolition working for me in any capacity. wtorks i,comp,insumnce, 9. Q Duibling addition I No workers'comp. insurance S. Q We am a corporation and its � rsgddred.l otTleas haw exercised thair IO.Q'Eleet ica)repairs or additions J.Q I am a homeowner doing all work right of exemption per MGL 11.�umbing mpain or additions myself.(No workers'comp. c 132.11(4).and we have no 12.0 Roof repairs insurance requited.)► employees.(No workers' 13.Q Other comp. insurancerequim&j -Any appuoat that diarlu boa et mead alsa na twd ter deaia.bdote abo-iag thdr -01 .•conversation policy infional t► 'I ttttwtu-t-ta who subwas ibis aflhdsve indicating they am Joiner all wart;alai thin hie euaiir caaa non,ttwW alrnk•maw amtk>vil ittdir>tity rte; :C.mttw90 w that ckaek this box twYa anaattsd a a.ldiritw-I ahsp alter-ieg titer tatY err rha aAsMtawlare one their-Wiwi'rantp.policy iwraamaaaa. /one ea employer that b providing bvorbn'rowpetwtlea ltuurrare ja my etup/oy"A dear Ar rbe pal/qr endM slat injorbwwlota Insurance Company Name: Z- 1 Policy M or SelPins. Lie.#* 1 . t Q Expiration Date: l442/ 1 aryenA Job Sim Address: 0 l f a ��1 )T. City/Statr/Zip:�t, zZA .snack a copy of the workers'componsatloa poll"dmlm"lloa page(Showingthe P )6 paltry number and es IraMoa daft )6 to secum coverage 3s required under Section 25A of MGL C. I32 can lead to the imposition of criminal penalties of fine up to S 1.500.00 and/or one-year imprisonment.as wall as civil penalties in the form of a STOP WORK ORDER and a floe Of up to S250.00 a day against the violator. Ile advivxl that a copy of this statement maybe furwardt:d to the Ot7Tce of I n cc,ngadium of ilia MA for insurance coverage vcridieatiow /de herebplr/orrri/y under the pries and pease/des drjpaJury tAer tke intterarst/on provide✓above is true and cerrees �i n note'/!l_l .0 4j r :::1 Phoned• �7- (1 o? 9 - — Offleie/ass att/y. Oe nor write in this area,re be.utnp/ite/by trey a rower n/JJriaL City or town: YrrmitA,lccns a � Issuing Authurtly (circle tinep 1. Iloard of Ilruhh 2. Ruilding Iycparlment I. Citytrown Clerk 4. Electrical Dntpecio► S. Plumbing Impactor 6. Other l.tnlact Person: _ _. Phone a: �_n�TM CERTIFICATE OF LIABILITY INSURANCE i2/23/2 0' PRODUCER (781)729-8770 FAX (781)729-OOS3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION John A. Pierce Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 934 Main St. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Winchester, A 018 90-1994 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED R S Construction & Remode ng Inc INSURER Liberty Mutual Ins Group 0034 17 Fairmont Street INSURER B: Everett, MA 02149 INSURER C: INSURER D: 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, INSR A TYPE OF INSURANCE POLICYNUMSER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTRDATE IMMIDDMI DATE IMWDDIYYI GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGETORENTED $ CLAIMS MADE n OCCUR MEDEXP(Anyoneparson) $ PERSONALS ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ POLICY JEGT LOC AUTOMOBILE LIABILITY COMBINED ANY AUTO (Ea acddeISINGLE LIMIT $ ALL OWNED AUTOS BODILYINJURY $ SCHEDULED AUTOS (Perrpwperson) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Para«idenp PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EAACCIDENT S ANVAUTO EAACC $ OTHER THAN AUTO ONLY: AGO $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ S j DEDUCTIBLE $ RETENTION 3 $ WORKERS COMPENSATION AND WC231S360003029 11/21/2009 11/21/2010 WCSTATU- DTH- LIM EMPLOYERS'LUIBILITY E.L.EACH ACCIDENT $ SOO A ANVCEFUMEMBFRE EXCLUDED? ,�� OY0% eUMEMBEREXCLUDE07 E.L.DISEASE-EA EMPLOYEE $ SOO 000 Syes,dLP OwMer SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMB $ SOD,OOO OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, The Green Land Cafe BUT FAILURE TO MAIL SUCK NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 87 Washington St OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Salem, MA 01970 AUTHORIZED REPRESENTATIVE Kevin Pierce ACORD 26(2001108) ©ACORD CORPORATION 1988