120 WASHINGTON ST - BUILDING INSPECTION (2) Crr -OF --
PUBLIC PROPERTY
DEPARTM&NT
&MAK Wu,.«cst„s 01970 O
'Ri 978-745-959S•FAx 97s.74o.9g"
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
r STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address: / 20 4w is1f f�o 7-on) T T.
r Property is located in a;Conservation Area Y/N Historic District Y/N
r
2.0 OWNERSHIP INFORMATION
,
2.1 Owner of Land c f}3O 1 !3 L0-Lk-
L LL
Name:
Address: C D 4C6 TZ 27
l D i1��0 c s i A- t>2
y Telephone: f 7 — f
F
3.0 COMPLETE THIS SECTION FOR WORK IN EX13I1l,IG BUILDINGS ONLY
fl
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
t Brief Description of Proposed Work: �) r
�6/L/.✓bs— /`t'9/LE t< let-c- 2fooc
---------- Mail Permit to:
a
What is the current use of the Building? If dwelling.how many un'lts?_�--
Material of Building?L2A)c w°
Will the Building Conform to Law? Asbestos?
Architeas Name I✓tN7ra- � Itac11. 7c�y_ 7375
Address and Phone
�� s lSSE>< tT- S7�on
Mechanles Name
Address and Phone f168o HIC Registration# ---
Construction Supervisors License# C S og(o r
Estimated Cost of Prolect S —
Pemm�Fes Calculation 0 0 p t7 Estimated Coat X$71$100o Residential
Permit Fee S , Estimated Cost X$11/51000 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 perjury —
Date 10-16
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Client#: 35588 RCGBU
ACORD,., CERTIFICATE OF LIABILITY INSURANCE DATE(MMND/YYYY)
10113/06
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 A: Crum&Forster 42471
RCG Builders LLC INSURERS: Associated Employers Insurance Co.
c/o RCG-LLC INSURER Q
17 Ivaloo Street,Suite 100
INSURER 0:
Somerville,MA 02143
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 WO'LTR NSR TYPE OF IN POLICY NUMBER OATEYIEFFEDt DATE EXPIRATION
M ODJM LIMITS
A GENERAL LIABILITY GL0091105 03/31/06 03/31/07 EACH OCCURRENCE $1000000
PCOMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $5O 000
CLAIMSMADE �OCCUR MED EXP(Any one person) $
PD Ded:15000 PERSONAL BADV INJURY $1 000 000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1000000
POLICY JEo- LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Eeac6denU $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY $
-O NONWNED AUTOS (Per acddeot)dentl
PROPERTY DAMAGE $
(Per eCGdent)
GARAOE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
FXCESSNMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION AND WCC5005531012006 05/10/06 05/10/07 X WCSTATu- OTH-
ORY LIMITS ER
EMPLOYERS'LIABILITY
ANY PROPRIETOMPARTNERIEXECUTIVE E.L.EACH ACCIDENT s500,000
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000
UN yyes,descnbe under
SPECIAL f ROVISIONS b.., E.L:DISEASE-POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
Peabody Block LLC and RCG LLC are named as an additional insureds where required by
contract or written agreement with respects to general liability coverage for the poject
know as Peabody Block(encompassing 120 Washington Street,247 Essex Street,8-10 Barton
Square),Salem,MA.
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 In DAYS WRITTEN
c/o RCG LLC NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
171valoo Street, Suite 100 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Somerville,MA 02143 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001/08)1 of 2 #127562 GCE 0 ACORD CORPORATION 1988
t �
t
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 25S(2001/08) 2 of 2 #127562
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR
120 WA21WGTONSTREET a SA UM,MASSACIjUSErn01970
Workers' Compensation Insurance Affidavit Bullders/C ntractors/Electr(clans/Plumbers
ADDHcant Informado
Please Print Le
Name(Business/Organiration/Indivi&W): /`»e 6 L e /
hft
Address:_ 17 /t/1 too S f ,
city/state/Zip: V AE 6 )
-----� 2 one #:
Famn
mployer?Check the appropriate boss:
mployer with 4. I am a general contractor and I Type of protect(required):
es(full and/or part-time).• � have hired the subcontractors 6. ❑New construction
ole proprietor or partner- listed on the attached sheet t 7. Q Remodeling
have no employees These sub contractors have for me in any capacity. workers co g' Demolition
workers'comp. insurance 5. ❑ We are a corporation itiottand i 9. Building rpora .on and its Q 8 addition
3.❑ required) officers have exentised their 10.❑Electrical
I am a homeowner doing all work right repairsor additions
myself. ght of exemption per Mr
11.❑Plumb'ng repairs y [No workers'comp. c. 152. §1(4),and we have no °f rdO°6
insurance required.]t employees [No workers' 12.❑Roof repairs
comp,insurance required) 13.0 Other.
'MY appticant that thesis box NI ntttp also till otu
t Homeowmn who submit tail afl9dava' the section below showing their.wodta t eompeoation policy infamatloa.
tContrecton that check this boa mmt mdica n they am W.hM all work and tine hire ouaide emtraetosa mush almit a new afthhvit'
attached an edditiorW sheet showing the nano of the abcon
lley litioneadoni
I an an employer that is providing workers'compensation inst nee jar my em/o Below a�information p yp icy ani site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers'cmpensation 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
.00 and/or one-year imprisonment,as well as civil penalti
fine up to S 1,500 es in the form of a STOP WORK ORDER and a fine
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.
f do hereby terrify under the pains and penalties of perjury that the information provided above is true and correct
Signature-
Phone
UJjleia::7
t write in this area,to be completed by city or town oJjlcfaL
City orPermit/I icetue#Issuing one):1. Boaruilding Department 3.City/rown Clerk 4. Electrical Inspector S. Plumbing Inspector6.OtheContact
Phone#•
Information and Instructions
Laws chapt
er 152 requires all employers to provide workers' compensation for their employees.
Massachuse
le a is defined as"...every Person in the service of another under any contract of hire,
tts General
pursuant to this statute,an amp ye
express or implied,oral or written." two to more
individual,Partnership,association,corporation or other a e entity,or loy er or the
An employer is defined as"anoint and including the legal rePresentadves of a deceased employer-
en ed in a joint a �P assoc who or other legal entity,employing employees. However the
re the foregoing engage, or the occupant of the
receiver or trustee of an individual,P than thin apartments and who resides therein.
owner of a dwelling house having not more cc�ctioa or repair work on such dwelling YM"
dwelling house of another who employs persons to do maintenance, to ens be deemed to be an employer.
or on the grounds or building appurtenant thereto shall not because of such emp yin
MGL chapter 152,§25C(6)also states that"every state or local Iteensfas agency shall withhold the thforissua s or
renewal of a license or permit to operate a business or to construct buiidings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance With the insuranceof itscoverage political subdivisions s�
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwwe Ieth any
of compliance with the insurance
enter into any contract for the performance of public work until arc�iithori "
requirements of this chapter have bien presented to the contracting authority'
Applicants 1 to our situation and.if
'on affidavit completely,by checking the bones that apply Y
Please fill out the workers' compensation es and phone number(s)along with their certificate(s)of
1 sub-cont" ies (s) )oe* ) Partnerships(LLP)with no employees other than the
necessary.supply Companies�I or Limited Liability
insurance. Limited Liability d to carry worker' compensation insurance. If an LLC or ent does have
members or partners,are not to ge that this affidavit may be submitted to the Department of Industrial
employuld
ees,a policy is required. Be advisedbe sure to
Accidents for confirmation of insurance coucanon for the permit or license is beingsrequested,not the Departme The affidavit nt of
be returned to the city or town that the application
regarding the law or if you are required to obtain a workers'
Industrial Accidents. Should you have any qua c should enter their
compensation policy,please call the Department>�number listed below. Self insured companies
self-insurance license numbs on the a
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Departions ha to c has Provided a space at the bosom
the applicant
rmidlithe event
somber which will a used as a reference number. In addition,an applicant
of the affidavit for you to fill our in the event the Office of Investigadons has to contact you regarding PP
Please be sure to fill in the pe locations in any given year.need only submit one
affidavit indicating current
that must submit multiple permit/license aPP " a licant should write"all locations in (city or
policy information(if necessary)and under"job Site Address PP the city or town may be provided to the
town):' A czpy of the affidavit that has been officially stamped or marked by t5
applicant as proof that a valid affidavit is on file for future permits or licences. Anew atusine r must m filled out each
a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
year. Where t to brim leaves etc.)said person is NOT required to complete this affidavit.:
(i.e. a dog license or Perms uestion%
The Office of Investigations would like to thank you in advance for your cooperation and should Y ou have any 4
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Contonweaith of Massachusetts
Depadnnent of Industrial Accidents
Office of Invesdgadons
600 Washington Street
Boston.MA 02111
Tel.#617-727-4900 W 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 wwwxam.gov/dia
CrrY OF SALEM
'., PUBLIC PROPERTY
DEPARTMENT
NAraa 130 WASiat+G"sls7M•sjUEK.MM&ACft=M 01970
IVL-MUS-M o FAm.M7449"
Consimcdon Debris Disposal Affidavit
(required,for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code.780 CMX section 111.3
Debris,and the provisions of MCM c 40.S A
Building Permit M is issued with the condition that the debris resulting e m
this work shtl)be disposed of in s properly Heensed waste disposal hicility as defined by MGL a
1 11.S 150A.
The debris will be transported by:
/b! �9SS P�iv�la✓6
(ttstw o[tttaalsd
The debris will be disposed of in
(namt of Wity)
(addrm of facility) I
siyaamre olpamtit applicant
due
i
,;e6ri,m7Jua