118 WASHINGTON ST - BUILDING INSPECTION (14) cK 0 v>
1LL—AP I S 'FIL En The Commonwealth of Massachusetts
Ulf I N i=-1 `C, . Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Famil Dw in
E. .,o-s (This Section For Official Use Only)
Building Permit Number ;Date Applied '=i ''i`1 Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is av Ie)�
118 Washington St Ist Fl. Salem 01970
No.and Street City/Town Zip Code Name of Building(if applicable)
°SECTION 2:PROPOSEDWORK a,''"w ; - T
Edition of MA State Code used 8th If New Construction check here❑or check all that apply I in the two rows below
Existing Building❑ Repair❑ Alteration 10 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ® Other ❑ Sec
Specify:
Are building plans and/or corstructlon documents being.supplied as part of this permit application? Yes 12 No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work: Interior remodeling at an existing restaurant including relocating the woman's toilet,
service bars& equipment, adding an urinal in men's toilet room replacing artial dininiz area flooring. remove entry
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION;OR=
-'-""CHANGE IN USE OR OCCUPANCY " :? "
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s) A-2 restaurant Proposed Use Group(s): A-2 restaurant no chan�ne)
HEIGHT AND AREA: ur -
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3 38,127+/ 3
38,127+/-
Total Area(sq.ft.)and Total Height(ft.) 3 38,127+/ 3 38,127+/-
'' ' SECTION 5:USE GROUP(Check as applicable), r
A Assembly A-1 ❑ A 2® Nightclub ❑ A-3 ❑ A4❑ A-5❑
B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ I U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION;TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA IN IIIB ❑ IV ❑ VA ❑ VB ❑
s4*• x °_5 .,:;SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item).. „e .
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public® Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site IM
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad ri t-of-wa
P y: Hazards to Air Navigation: T—MA Historic Commission Review Process:
Not Applicable® Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes ❑ or No M Yes ❑ No
-----------------
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY ,?
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System7: Special Stipulations*
CITY OF SM.E;tit, MASSACHUSETTS
' BI:II.DLNG DEPARn[L-4T
120 WASHINGTON STREET, Ya FLOOR
TEL (978)745-9595
FAX(978)740-9M
KIMBERLEY DRISCOLL
MAYOR THOMAs ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONDMIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anpiicant Information PI age Print Le ihly
Name(Businesr.OrganizarioNindividual): Wayip Construction Inc
Address: 26 Harbor Villa Ave
City/State/Zip: Braintree, MA 02184 Phone 1'1: 617-899-2892
Are you an employer?Check the appropriate box:
LEI i am a employer with 2 4. ❑ 1 am s general contractor and I Type of project(required):employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance.
[No workers'comp. insurance 5. ❑ We are a corporation and its 9• ❑Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL t l-El Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12❑ Roof repairs
insurance required.) employees.(No workers
comp. insurance required.1 13•0 Other
'Any apparua that checks box#1 most also rill uo the maim below showing their workaa'compensation polity infomration,
♦I ranxowmas who submit this affidavit indicating they an doing all work and then hire outside connector,u must submit a now andavit indicating such.
=CwnrsYon that check this-- mint anached an additional sheet showing the mite of the arb>cmveclors and their workers'camp,pen y inf ennatim.
!am an employer that Lr providing worriers'compensation Insurance for my employees Beiuw Is the polity and jab site
information
Insurance Company dame: Western World Insurance
Policy#or Self-ins.Lic.#: NPP8183545
Expiration Date:
Job Site Address: 118 Washington St City/StawZip: Salem, MA
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a foe
of up to$250.00 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 under the pains and penalties of perjury that thb information provided above is true and carried
Signature'
Date
Phone q: 617-899-2892
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/Lkense#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Persoa:
Phone#:
SECTION 9'. PROPERTY OWNER'AUTHORIZATION
Name and Address of Property Owner
Peabody Block,LLC 120 Washington St Salem 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the vroperty owner's behalf,in all matters relative to work authorized by this building permit ap2lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
f buildin is less than 35,000 m.ft.of enclosed space and/or not under Construction Control then check here Eland skip Section 10.1 k d.
Fr,n
'stered Professional Responsiblep for Construction Control �" ' ' _;; -
t Berliner 617. 277. 6158 bbbberina,aol.com 1300
gistrant) Telephone No. e-mail address Registration Number
nt Paul St. Brookline MA 02446 8/31/2014
dress City/Town State Zip Discipline Expiration Date
ral Contractor:= `?4_ E ,. i- " •-'::F..,r' ,_;g' - .,,5.
Company Name
Bonnie Tan CS082141, unrestricted
Name of Person Responsible for Construction License No. and Type if Applicable
16 Chesterfield St Readville MA 02136
Street Address City/Town State Zip
617.899. 2892 617. 899.2892 design.bt(c)gmaiLcom
Telephone No. business Telephone No. cell e-mail address
"N�A.�r,,QiL `?.'4<,. SECTION 11:.WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.Lt 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 issuance of the building permit.
Is a si ed Affidavit submitted with this a lication? Yes® No ❑
4h'
SECTION 12.CONSTRUCTION COSTS AND PERMIT.FEE "" 4,J[ _
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
1.Building $ 38,000
2.Electrical $ Building Permit Fee=Total Construction Cost x_(Insert here
3,500 appropriate municipal factor)=$
3.Plumbing $ 4100
rBy
al (HVAC) $ Note:Minimum fee=$ (contact municipality)
al Other $ 5 I Q \
t $ 45,600 Enclose check payable to y
(contact municipality)and write check number here
„ ,'¢ ` - ECTIONI3:SIGNATUREOFBUILDINGPERMITAPPLIC2 NT ' -`;' 'my name below,I hereby attest under the pains and penalties of perjury that all of the information contained m this
pis true and accurate to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town
State Zip
Municipal Inspector to fill out this section upon application approval:' G '«f"« ••r
't m ..it.. %•m '
Name .� ..
Date ;
Appendix 1
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.
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.
Property Location (Please indicate Block # and Lot # for locations for which a street address is not
available)
No. and Street City /Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
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
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.
Checklist for Construction Documents*
Mark'Y'where applicable
No. Item Submitted Incom lete Not Required
1 Architectural X
2 Foundation
3 Structural X
4 Fire Su ression
5 Fire Alarm ma re uire re eaters x
6 HVAC
7 Electrical x
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other X
10 Surveyed Site Plan Utilities,Wetland,etc.) X
11 S ecifications -
12 Structural Peer Review X
13 StructurMOther
l Tests&Ins ections Program
otection Narrative Report x
Building Survey/Investigation
X
Conservation Report X
ctural Access Review 521 s Com ensation Insuranceous Material Miti ation Do X
S eci
21 Other(Specify)
22 Other(Specify)
-Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction. Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Barnett Berliner 617- 277-6158 bbbberlgaol.com 1300
Name(Registrant) Telephone No. e-mail address Registration Number
265 Saint Paul St. Brookline MA 02446 8/31/2014
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State IF
Discipline Expiration Date
i CITY OF SM.&M, NLkssAcHusms
BUILDING DEPARTMENT
120 WASHINGTON STREET,Yn FLOOR
TEL (978) 745-9595
KIMBERL.EY DRISCOLL FAX(978) 740-9846
MAYOR THOMAs ST.PfERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO.'X%MIONER
Construction Debris Disposal Affidavit
(required for 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 ofMGL 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 MGL c
111, S 150A.
The debris will be transported by:
Doctor Disposal
(name of hauler)
The debris will be disposed of in :
Doctor Disposal
(name of facility)
1071 Washington St. Weymouth, MA 02189
(address of facility)
signature of permit applicant
date
debri.aff dw
STOCK COMPANY COMMERCIALI-WES''POLICY
Zt� IWestern World POLICY NUMBER: NPP8183545
INS URANCE CROUP Prior Policy Number: NPP8113327
AI WESTERN WORLD INSURANCE COMPANY E] TUDOR INSURANCE COMPANY STRATFORD INSURANCE COMPANY
COMMON POLICY DECLARATIONS Agent/Broker#04302
Named Insured and Mailing Address:
Wayip Construction Inc This policy is insured by a company which is
not admitted to transact insurance in the
26 Harbor Villa Ave Commonwealth, is not supervised by the .
Braintree,MA 02184 commissioner of insurance and, in the event
of an insolvency of such company, a loss
shay not be paid by the Massachusetts
Producer: Insurers Insolvency Fund under chapter
Conexco Insurance Agency;Inc, 175D.
114 Turnpike:Rd;Suite 109
Westborough,MA 01581
Policy Period: (Mo./Day/Yr.) ed
From: 07/03/2013 To:07/03/2014'. 12:01 AM,standard time at your mailing address shown above.
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND.SUBJECT TO ALL THE TERMS OF THIS POLICY, WE
AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
THIS POLICY CONSISTS OF THE FOLLOWING 66VERAGES FOR WHICH A PREMIUM IS INDICATED.
THIS PREMIUM MAYBE SUBJECT TO ADJUSTMENT.
Commercial Property Coverage.Part $ NOT COVERED
Commercial General Liability Coverage Part $ 2 117000
Commercial Auto Coverage Part $ NOT COVERED
Other Coverages: Terrorism Risk Insurance Act ilk-
il NOT COVERED'
$
m $ r
TOTAL ADVANCE PREMIUM $ 2,117,00
Policy Fee $ 60.00
SL Tau $ 84.E
Forms and endorsernents applying to this policy and $
attached at time of issuer $
See Applicabl®Schedule Of Forms And Endorsements. $
GRANDTOTAL $ 2,261.68
INSURED Page 1 of 2 W W230(08/11)
Wayip,Construction
;
Wayip
ti tm oay.com Jae
xs ; -JHM®MM. T R
aAve Braintree _'. _'
M
Tel: (617)899-2892
DATE: JAN 2, 2014
TO Fresh Taste of Asia
118 Washington St.
Salem, MA
kiat�E-DATE[01:251 PAYMENT TERMS'
Remodeling
E 120MY"I imi maiar ii�%wggg--
umtc
M-
Interior Remodeling per plan dated 1/10/14:
• Demo entry vestibule and repair GWB.
• Relocate woman's toilet room.
• Add 1 urinal in men's toilet room.
• Remove existing service bar and sushi bar.
• Install new service bar and existing equipment.
• Replace damage flooring.
• Install low wall.
• Paint and repair dining room partitions.
38,000
SUBTOTAL 38,000.00
SALES TAX
TOTAL 38,000.00
s The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code (780 CMR)
Building Permit Application to Construct,Repair, Renovate or Demolish any
Building other than a One-or Two-Family Dwelling
Code and Other Requirements for Building Permits
The Department of Public Safety has issued these building permit application forms so that municipalities
across the state can move toward use of a single permit form and consistent permit application process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised to
review and be familiar with these requirements in order to avoid some of the common permit application
problems. Likewise the applicant should be aware that some municipalities require that the owner confirm,
even prior to acceptance of the building permit application, that no outstanding property taxes, water fees,
etc. exist.
Filing Instructions
1.Please contact the city or town where the work will be done to ensure that the city or town will accept
this application form and if any additional information is required, and obtain the correct mailing
address. After doing so, print the application, fill in completely and then submit to the local city or
town where the work will be done.
2.All applications shall be considered complete and will be reviewed if construction documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Application are included with the application.
3.Please include a check for the Building Permit fee. The fee may be calculated using the information to
be supplied in section 12 of the Building Permit Application. The check is to be made payable to the
local city or town where the work will be done.