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118 WASHINGTON ST - BUILDING INSPECTION (10) /` CITY OF SALEM ' i PUBLIC PROPRERTY DEPARTMENT \(.\tiIN 110 Wail IINI�:ON6:REET •S.* .%-X: 78-7 C-984iL 6{'R 717tC "CFL:978-7ii9i95 �f.Vc:)78.7iG98i6 Construction Debris Disposal Affidavit (required for all demolition aad renovation work) In accordance with the sixth edition of the State Building Code, 730 CNIR section 111.5 Debris, and the provisions of vIGL 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 vIGL c 111. S 1.50A. The debris will be transported by: __-- fG(St COosl ame ht^ ( kI � Umme ut haulerar) J The debris will be disposed of in (name of facility) tad.tresa of IaciLty) Z1 --- ,:aft ._ -.. CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT MAYOR M.WASHINCIONS-mrtor 4 SALEVI,MASSACIllisF] ISO 197' 11,1.:9/8-MS-9D9:> *FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaiblv Name (BLIsiileqs/Or-,aniZatiODIIiidividual): 9 plo,rAwdy A16CA_ e/ Address: 1 lyCt� n SaL&L.. ....S U(Le a) city/stare/zip:_ 04-143 Phone P: (Gm) (.I-< ....... Are you an employer?Check the it pproprisap box: Type of project(required): 1.0 1 am a employer with A. 1 ant it general contractor and 1 6. El New construction employees(full and/or part-tirne).* have hired the sub-contractors 7. (611crriodcling 2.0 1 ant a sole proprietor or partner- listed on the attached sheet. , Ship and have no employceS, These sub-contractors have 8. [] Demolition working for me in any capacity. workers' comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. 0 We are it corporation and its 10,E] Electrical repairs or additions required.) officers have exercised their 3.El I am a homeowner doing all work right of exemption per MGL II.E] Plumbing repairs or additions myself. (No workers' comp. c. 152,§1(4),and we have no 12.E] Roof repairs insurance required.] t employees.tNo workers' 13.E:1 Other comp. insurance rt:quircd] 'Any apphc.nt that checks box 41 must also III[Oul the section GUIOW showinghei,wink.W conipernation policy minrmution- T I I()Menw.C,,. who Sidanni this affidavit indicating they are doing all work and then hire oulsidt contraclors njitst djjbmjq;t new affidavit indicating such. 'Contractors that check this box must anacFxd an additional Aiecl showing me name of the sub-contractors and their workers'comp.policy information. I ain an employer that is providing workers'compensation insurance far my,employees. Below is the policy and job site information. Policy 9 or SQII'-irts. Lic. Expiration Dane: Job Site Address: City/State/Zip:_ Attach it copy of the workers' compensation policy declaration page (showing the policy number and expiration date). l-'ailime to secure coverage as required under Section 25A ofiV[GL c. 152 can lead to the imposition of criminal penalties of a fine tip to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of Lip to$230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ul r the pains rand penalties of perjury that the information provided above is trite and correct. Sitanature: Datc7 c,11�471 pholic-r. 61--7 rag< Ofjicial rise only. Do not write in this area, to be completed by city or town official City or Torn: Permit/License# Issuing Authority. (circle one): 1. Board of Health 2. Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5.plumbing Inspector 6. Other Contact Person: Phone ff: 'I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an enployee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, r25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have Been presented to the contracting authority." - Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es)and phone nurtber(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial .Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The aff irlavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address'the applicant should write "all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. - 'rbe Office of.Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NlASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Client#: 35588 RCGBU ACORD,. CERTIFICATE OF LIABILITY INSURANCE 06/21/07 A"""' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE MARKETING AGENCIES - ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 306 MAIN STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. WORCESTER, MA 01608 508 753-7233 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER Associated Employers Insurance Co. 11104 K(;G Builders LLC INSURER B: c/o RCG-LLC INSURER C. 17 Ivaloo Street,Suite 100 Somerville,MA 02143 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER PDATEYMMIDDEFFECTIVE POLICY DATE MMIDDI ) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES(Ed occurrence) $ CLAIMS MADE OCCUR MED EXP(Any one Person) S PERSONAL B ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOG EDT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO (Ea accident) 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 S AUTO ONLY. AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR 71 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND WCC5005531012007 05/10/07 05/10/08 X I WC STATITTORYIMITS orH- FIR EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT 1$500,000 OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE1 s500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1 s500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Peabody Block LLC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1_ DAYS WRITTEN c/o RCG LLC NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 17 Ivaloo Street,Suite 100 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Somerville,MA 02143 REPRESENTATIVES. AUTHORRED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #135822 GCE 0 ACORD 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-S(2001/08) 2 of 2 #135822 n t I Gulu Gulu Cafe . r I o - - --- - I P U CORRIDOR t BATH �- I i 1 t ; - - -- - - - - - - tLappinPark k( Of v II _ I —; CORRIDOR BATH I i RErAIL1 l i I I Existing entrance door and ...i / adjacent storefront windows I STORAG � I i I \� / - -- - if f BATH I k c`° / I ; New egress door ; i l �6N Existing entrance door and - - - - - _ -- adjacent storefront windows p BATH 0• - Extent of work L - - - - - -- - - - - - - -- - - - - - - - - - � \ T I I 1 � • I + er • I �m.m NEW EGRESS CORRIDOR f II s � • II r li, 7 •. • Align ® T-3"• 2' • I EV S© • i 0" in. -S I SD Existing Ceilings to J • '� 6� j remain,typical h S FL• )� 4� CP • 36 3" Q�e�j Vao' • RETAIL 2 • • J \ T New 1 hour tenant separation pil walls: UL#U465, 1 layer 5/8" gypsum board each side on 3 5/8"metal studs. Seal wall Ij assembly to underside of �! structural deck. RESIDENTIAL ,..... -_ - I STE OF ASIA Existing Parking First Floor Demising Walls LIFE SAFETY LEGEND CODE SUMMARY: Symbol Description Use Group:M �see� LIMIT OF WORK Number of exits:2 Space is sprinklered ® CEILING MOUNTED SINGLE FACE EXIT SIGN. 780 CMR Section 1010.2"MINIMUM NUMBER OF EXITS FOR OCCUPANT LOAD" WALL MOUNTED EMERGENCY LIGHTS -Maximum occupant load:500,actual occupant load:59 Per 780 CMR Table 1006.5"LENGTH OF EXIT ACCESS TRAVEL" -Maximum travel distance:250 feet with sprinkler system,actual travel distance:80'-8" SD SMOKE DETECTOR Actual Occupant load:Per 780 CMR Table 1008.1.2-First oo-Mercant e per s SF FIRE ALARM SPEAKER WITH FLASHING LIGHT flil 1 30f gross FL 1,774 sf/30=59 occupants MANUAL FIRE ALARM STATION 780 CMR Section 1006.4.1 "REMOTENESS"of egress exits Exception: Buildings with a sprinkler system shall have a minimum separation distance of 1/4"of the length of the maximum overall diagonal dimension. -Retail Space 1:69'474=1T-3"allowed,3VAT actual;Retail Space 2:76-674= 16-10"allowed,37-11"actual Note: Drawing scale may change when copied or faxed f Proposed Egress Door to La in Park /7\ ER STREET ARCHITECTS p 9 pp ,- .,,SOD tt//JJ r 06/21/07 118 Washington Street _ -�- Salem, N% a ;J'tr he n 0232.004 To- t Y r l J 0 A m .,. . ITI. i,._'RE r .F. -- __ Gulu Gulu Cafet ED Apt i ' PAUL R. c CORRIDOR U BATH I -- - Lappin Park - - � r � � I CORRIDOR !' o i -- I BATH I RETAIL - -- -- - - - - - - - - - - - - - Existing entrance door and adjacent storefront windows iSTO GE C f II I BATH @ xrory / r - - - - - - - - - - - - - - - - - - - - - - - - - - - - O�c New egress door 7 I i `D gx \ / i adjacent storefront windows i BATH / I } • I Extent of work �s�d4 j I NEW EGRESS CORRIDOR ] \ V4 see Align ® 1'-3.0 3" SFL I / 1 i � r I i 0 '-0" in. = I SD ,Existing Ceilings to — _ J SF FLO 5`%�^ yAls, remain,typical �� ova\ ? o pa0 RETAIL 2 ( ` I Align 13 i j 1 i� � • • � Ti��o/ ' ,,' I s � Os�oc I New 1 hour tenant separation walls: UL#U465, 1 layer 5/8" gypsum board each side on 3 5/8"metal studs. Seal wall assembly to underside ofj structural deck. j RESIDENTIAL "- STE OF ASIA Existing Parking 1 First Floor Demising Walls A-1 1/8" = 1'-0" LIFE SAFETY LEGEND CODE SUMMARY: Symbol Description Use Group: M �oos� LIMITOFWORK Number of Ja7ts:2 Space is sprinklered ® CEILING MOUNTED SINGLE FACE EXIT SIGN. 780 CMR Section 1010.2"MINIMUM NUMBER OF EXITS FOR OCCUPANT LOAD" WALL MOUNTED EMERGENCY LIGHTS - Maximum occupant load:500,actual occupant load: 59 Per 780 CMR Table 1006.5"LENGTH OF EXIT ACCESS TRAVEL" - Maximum travel distance:250 feet with sprinkler system,actual travel distance: 80'-8" SD SMOKE DETECTOR Actual Occupant load: Per 780 CMR Table 1008.1.2 SF FIRE ALARM SPEAKER WITH FLASHING LIGHT - First floor Mercantile 1 per 30sf gross FL 1,774 sf/30=59 occupants MANUAL FIRE ALARM STATION 780 CMR Section 1006.4.1 "REMOTENESS"of egress exits Exception: Buildings with a sprinkler system shall have a minimum separation distance of 1/4"of th4'le xi um overall diagonal dimension. -Retail Space 1:69'-2"/4= 17'-3"allowed, 30'-10"actual; Retail Space 2:75'-6"/4= 18'-10" II a ual -rr:3t .:.J ^ Note: Drawing scale may change when copied or faxed - �xrc�cn Proposed Egress Door to Lappin Park ,�T WINTER STREET ARCHITECTS L 06/19/07 118 Washington Street a ,, Salem, MA { r 0232.004 EIT�`oFgXLE1G --'Q" PUBLIC PROPERTY DEPARTIVIF.,�1T 91NOSERLEY DRISC AL MAYOR 130 WAsmN-mN srREEr♦c"LxK,%L%A CHLst„s 0197o TEL'978-7+5-9595•FAx:97b7ie-9W APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: - 1-c5.5 Coi^r4of Building: — — Property Address.—, ---- - - l astil-n- fates St. Property Is located in a;Conservation Area YM Historic District YM 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: - Address: J.CL-/,,a D -101 r..,t p !t NA Telephone: C I? I yi 3.0 COMPLETE THIS SECTION FOR WORK IN EXISIING 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: 2 � I Jf el�t-c85 f�"ridor �rJt.1r1 ai s�oc�u-S Mail Permit to: - -_ -- What is the current use of the Building? �- " • • Material of Building? b J ,tC If dwelling•how man units? Will the Building Conform to Law? Asbestos? — Archhect's Name 11� tKkz.� ,-i e,l AV c]nna�. fn �, 4 '73r1q Address and Phons 9 nA ESse�c S 5�12w• ( ) --�7 `l^ Mechanic's Name Address and Phone Construction Supervisors License# 1'S Mid 12 _—HIC Registration# Estimated Cost of Project$ fl•o Permit Fee Cakwlatbn Permit Fee$ Estimated Cost X$7/$1000 Residential -----_--__- -- -- -____- --- Estimated Cost X$11/$1000 Commercial— - An Additional$5.00 is added as an Administrative charge. Make sure that all fields are property and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of penury Date 4 N 9 �°' V y `0 3 •• ao F a t- tlw Is° - i�