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120 WASHINGTON ST - BUILDING INSPECTION (4) CITY OF S.0 EM, KxSSACHUSETTS 130 W.NSHINGTON STREET, 3r FLOOR TEL (978) 745-9595 FAX(978) 740-9846 K[tiLBERI BY DRISCOI L MAYOR THomm ST.PmRRB DTRECTOROF PI:BUC PROPERTY/Bt:m=NG CO..-wN toNER APPLICATION FOR THE CONSTRUCTION,REPAII%RENOVAY104K CHANGE IN USE OR OCCUPANCY,OR DENOUTION OF ANY 13UtiMUG OR STRUCTURE This Section for Offfidat"a Ov* t3uik�ig,-lnsp�ector: Es�ojeCf Oats: Start End: Comments: 1.0 SITE INFORMATION Location Name: /2tJ Gv9sl ,s cS 61dldkW Prop"Address: Assessors IwWffiloac LoUParcet QMMN "INFORMATION 2.1 Owner of land / Nana: ��a6oa/ Q/oc L C Address: R-Ur LL C -,0-V9 100 S S-r Oz/y 3 TeIsPhone: 61} &a S 2.2 Owner or lessee of baltd/nE or structure Name: �'e e�c �c LL C Addresx Sores er v' 0 2 3 3.0 AGENCY OR AUTHORITY AIRHORONG CONSTRUCTION Agency Name: K C� —L L.C _ Address: 17 +�v cos S }r L¢ 0Z ! '3 Agency Projec Number Project Manager Name. y7kx p�_,,,,q Tel: 6 l7 62 S �l S.0 DESIGN AND CONSTRUCTION UTILONG MGL C 112 $ECTt0N 81R EXEMPTIONS (See note below) Cont!ctor Warne: Address: q 0 1 7 o v Area of responsibility: .License Number' C S a� (o) y 3 Date of Expiration: t t / 0 7 Telephone: e.1 6 2 S"-y -4 Fax, Cattractor Name. Address: Area of responsibility: License Number. Date of Expiration: Telephone: Fax Contractor Name: Address: Area of responsibility: License Number Date of Expiration: Telephone: Fax:, Note: For portions of work utilizing exemptions of MGL a 112 s.81R complete the section above.. Use additional sheets if necessary and attach to appkation. F PROFESSIONAL.CONSTRUCTION SERVICES-General Contractor /zG Lw�s L.e ress: -'v s loo Sfk f - Svr- 10D Srk1kierw7/e-� Mom . Calf Telephone: 04 L z12�- B 31 , Fax: 4f-4 G zs g y�- Responoible in Charge of Construction: ✓►b, A=R- cS o g lGe � 64" d es oe06L1--7- 7.0 CONSTRUCTION DOCUMENTS -to be prepared by applicant Item J as Applicable . 7.1 Plans (Note 1 this page) Submitted Incomplete Not Required 7.1.1 Architectural 7.1.2 Foundation 7.1.3 Structural 7.1.4 Fire Suppression s, „ R,;LQ 7.1.5 Fire Alarm �je s;,r r3 ; zi 7.1.6 HVAC 7.1.7 Electrical s; s 7.2 Specifications 7.3 Structural Peer Review 7.4 Structural Tests & Inspections Program 7.5 Fire Protection Narrative Report 7.6 Existing Building Survey 7.7 Workers Compensation Insurance TS Other Documents (Specify) (Energy Narratives, etc.) Note 1 Areas of Design or Construction for which Plans are not complete at the time of this application must be identified herein. Work so identified must not be commenced unfit this application has been amended and proposed construction has been approved by the Department of Public Safety District Building Inspector having Jurisdiction. of Proposed ®®.■.■■.■..®m Mx Mixed Use Sp Special Use 9.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY For new construction comnlete secton 8. Addition Existing Z Renovation ✓ Number of Stories Renovated Changein'Use ✓ New Demolition Existing i ' '3 7 96 Approximate year of I q 4 'Area per floor(sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: ConvGr� q�wX.iw.4•�.ely �{ ��=�� `s,,'� o � 1o �r7cC , S��c�,. fn fD&t USE GROUP AND CONSTRUCTION CLASSIFICATION{ExlstTng,8uildlngs Qniy) " USE Graup(*Y EXiST1i ' PROPOSED Change. 'CONSTRUCTION Use, Hazard Use _ Hazard. Hazard 'CLASSIFICATI (nflte>u+b resao+Y) , Group Index ``group Index Index• " L�as 5pialtea� ? A Assembly 1A ' a Business ✓ 18 E Educational 2A'' F Factory 2* H High Hazard 2C I Institutional 3A M Mercantile 38 R 2 Residential ✓ q S Storage 5A U utility sB Mx Mixed Use Hazard Index Sp Special Use Note: Include Hazard Index Modifier for Construction Type as applicable 9.0 CONSTRUCTION COSTS (Set 780 CMR Appendix L) Total Constructlon Cost Building Permit Fee Check Number (1) _{t)x$041 Z,q(S, , Lqo I I f3: 3 5 5s y 10.0 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR SUMNO PERMIT(when applicable) 1, an behaN of the auduxb V State Agency or Authority, hereby authorizs. apply for the building permit for pmjed number, Signature Date 11.0 SIGNATURE OF BUILDING PERMIT APPLICANT y'1%e�l �-e-✓2�.1' Name Li Signature Date ��' 12. Certificate of Occupancy required on completion of project? v'Yes No Inspector's Noteq r•. CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT )AAvca 12a w,�mac,-no,,sraesr•sn,,,.�e,�aara,�so1970 TW 9711.745-9S9s •FAM 9W4MW Workers' Compensation Insurance Atltdavit: BwdewContmcton/E1eeq{ciaaypbmbers ADp�ant Informaden a kr N r bus Name( i ): Address: 1 -7 y-a Ana City/Stata/Zip: �n Pn v;)Le rnA a z, �1 phone# _ /7 G 2 ,G S 3 7 S Are you as employer!Chech the appropriate boss i.0 1 am a employer with 4. Q 1 am a general connucotr and IJETyperoject(regslr�: employes(1W1 Anwar part time).* have hired the w construction 2.0 1 am a Sole proprietor at partner. listed on the jutwhed sheet,todeling ship and have no employees Thearworking far me in any capacity. workers'comp�mnvaoos7 molition[No wasers'comp insurance 5. ❑ We am a corporation and its t additionreq�e&) Ofikcn have eseraiaed their ctrical repairs or addkime .3.0I am a homeowner do' w mye�CNo workers'tug aU ork right of esempttan per MGL sbing repairs err additionscomp a Is2,41(41,and we have no insurance requiredl• employeon[No workers'CeO1R ioquaop regnhed 1 RWmpain er t Haamso rm.m Sawa m chmdw�rad vit w m an jM as de...etle.edov sea d.a erlr.a tan,compsalw a ply Whrmoles, on rCoaasatom do chsk We bat most nrarJ,w as eddddhrwA Am d.atc err a.hka arsrlde caetraarm rmrrr eo6ma a awe creches hrdlmrhq esi - ehaM4re er acme arse mbmaoagem and their wwrlmm'comp,praq hrttaasatla♦ I ear aw ee yloyer that IMPMVIAwj sort"'COerP"And"lwMFMWe dW Lrjormadma I eT emP/oYeet Jfek w AN airP0147 and jol skr Insurance Company Name l��5 yry✓1 �ZbynJ ' p n C+s S Policy N or Self-ins.Lie.At:__C L a - Ytbt�n +xc�tr 5��', Piracon Job site Address: l Zr� / fi r Za o b City/SftW7 ._0 Attach a copy of the workers'competrsatba palky declaration pap(sit the Failure to secure covers � POBW niter and esp"dea dap} p as required under Section 25A of MGL a 152 can lead to the imposition of criminal penal&s of a fine up to 50.00a d and/or onest th ear imprisonment,as wen as civil penaltia in the form Of a STOP WORK ORDER and a Ron of up to$250.00 a day spinet rho violater Be advised that a copy of this statement may be forwarded to the O@Iq of inveMpnoaa of the DU for insuraace coverage vadCatiod I do berebY resat&under 40Pahn awe/ akin OJPerJsry tAor the 1n �°nwaaewProvldd above 4 raw awI comret flora• IU' '7 PhoneN b / ? (�Ztj 4' o lew use On1L Of nor wire 1w Ab area to beCoarPkW by CiV Or town oOc/aL City or Town: PertdNLleeasa N Issuing Authority(circle one): 1. Board of Health 2.Bundle$Department 3.Cltyfrows Clerk 6.Other 4.Electrical Inspector 5.Plumbing inspector Contact Person: Phone 8: Information and Instructions �tassachtisetts General Lavn chaptac 132 tM emploYet1 tO provide woricas'cotnpeuner a foc their a Ql pursuant to this statute,an enPleyee is defined s"...every person in the service of another under any COR° express Of imPked,oral or written" asaoetanaa wepaatiaa or°�lei eOft'at 8IIy two a mat Anearpfoye►is defined as-as individual•partnasbiR vas of a deceased lOvveav� .(the fo�omg engaged in s joisee"Mpn'%and including it dwwl galesen>sti reviver or truatse of as indivi"Pmcrsbip association or other rentd the o=Ww of the owns of a g hown hsvbg not IDmplwjs persons re that-to do nizioteoaoce.eon°ar rspsir yolk as suele dwel ft ha°M dwelling bouts another tea building apptutensnt veo shall not because of soh employment be deemed to be an®pinYw- MGL Chagos, S1 2.12SC(6)due states testashes"ar local.dr.et b uffo � w wear s ar V ehs sosessswasHh ssiy resewsl of a tlasss or persdt to sPsrab snWtssy of"Mpgaaet with the issursna coverage regtdrad.onwesith nor MY of its political subdivisions shall A dotiaily,MGL cespterappoesse M has met 15 produced�s�ublicwork aveptable evidence "Neither the of eomPea°ce with the WOMMS eare<airamenn of this Chapter presentedbawinto my contract for dw�b to the Cotmac"ll ainhantY•" req ApPNCBRa Mtion affidavit CesWktft.by checking the boxes that aPP1Y to YOM situados and,if Plane Slt out the a s add no and abOOe nutober(s)along with their cudfics*s)of Partnerships(Lisp)wuh no employees o�than the ineccssays s dw �Liability mice(LLC)or Limited Liability mataanaa. If an LLC or LLP does have numbers or parmeea,net not tequi:ed to Carry we elms compensation of Induslc9siThe affidavit_ a� v Be advised that this&Mdevit may be submitted to the Depattmens employees. finsureacgcoverses. AIM les sore to sign lad dsts the affidavit' Dep.rtmesl of Accidents f r �, townapplication--- Am tee parent ar He="is being mPest4 not ou no required to�a wotkatat tndua�al Avidents. Should you haw arty qua listed b slow y sh°uid crams compensation policy,Piesss call tlu line. at the number self-is Man"Uce seas n»mbar an the City or Two Officials »west has provided a ypue at the bottom Please be sure that tht affidavit is Complete and printed legibly. has to Contact you regarding the aPPlicsnt of the affidavit for you to fill out is the event the Offiv of Investigations be used as number. In addition,an applicant Please be sure to fill in the IMMW iCesse number which will be used a.s te&oeace dint must submit multiple permidllCease �) in any even Year.need only mbmit on affidavit indicating Current —(City of policy inforenadon(if newoMY)and under"Job Site Addroa"the applicant should write"ill locations is to the or marled by the City a town may be provided town)."A Copy of the affidavit drat has been officially stamped ac licenses, A now sf"udi.vie must be MW out each applicant ss proof teed s valid affidavit is on file far Amore permW not refitted to any business as Commercial venture Year.Where a bane owner or Citizen is obtaining a)tame or permit to fete this atfidavit (i.e. s dog license at patina to burn leave ow.)said Person is NO required comp The Office of Towedgatioas would lily to thank you in advance for your cooperation and should you have any quesa°°>ti' please do not besitsm to give us a Call. The Dcpar=ces address.telephone and fax numbat: The Comfnonw"A of 11 mach»set s Deputud afb&sMd Accidents OWN edhVediggib s 600 we41109"Scat Bado4 MA 02111 TeL #617-727-4900 Od 406 or 1-&77-MASSAFB Fu N 617-727-7749 RCvised 3-26A5 www.IIli9 Vv/dli Client#:35588 RCGBU DATE ACORDT. CERTIFICATE OF LIABILITY INSURANCE 10113/6 DYYYYI PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE MARKETING AGENCIES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 306 MAIN STREET 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 INSURER B. Associated Employers Insurance Co. C/o RCG-LLC - INSURER C: _ 17 Ivaloo Street,Suite 100 INSURER D: 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. POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE POLICYNUMBER DATE MMIDD/YV DATE MM/DD/Yl' A GENERAL LIABILITY GL0091105 03131106 03/31/07 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY - PREMISES(Fa occurrance) RENTED $50 000 CLAIMS MADE a OCCUR MED EXP(Any one person) $ X BI/PD Ded:15000 PERSONAL&ADV INJURY $1 000 000 GENERALAGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMPIOP AGG $1000000 POLICY JE OT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Par parson) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Peracddenp GARAGE LIABILITY I AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WCC5005531012006 05/10/06 05/10107 X WC IT- 0, EMPLOYERS LIABILITY E.L.EACH ACCIDENT s500,000 ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? EL.DISEASE-EA EMPLOYEE $500,000 If yes.deacnbe under SPECIAL PROVISIONS be. E.L.DISEASE-POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I 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 CIO 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. AUTHORIZED REPRESENTATIVE ACORD 25(2001108)1 of 2 #127562 GCE © ACORD CORPORATION 1988 -suapeq DRIVER S LICENSE " DTTE OFgIgiN C(p$5 pE$T NAM � .,. - 11-01-1964 . EXPINES Y, q �tf BERNIER � MICHAEL ' - t 16 CHANDLER ST NEWTON,MA 02458 'molaeae r Qx �i-. . 9i,-.'x�,y, .%vim �oaxvnxo:,wieall�+. oy✓✓'l�rJ:toclzxcae(` ' f BOARD OF BUILDING REGULATIONS I License: CONSTRUCTION SUPERVISOR % Number: CS 086143 :. Birthdate: 11/01/1964 Expires: 11/01/2007 Tr.no: 86143 Restricted: 00 MICHAEL G BERNIER 16 CHANDLER STD NEWTON, MA 02458 Administrator Pea6ody BCocf qZpsidences BUILDERS _ Peabody Block Residences 120 Washington Street Salem, MA SCHEDULE OF VALUES 13-Oct-06 05500 Miscellaneous Metal $1,174.00 06100 Rough Carpentry $49,141.00 06400 Millwork $10,706.00 07200 Insulation $7,374.00 08110 Doors-Hol-Mtl Frames $1,292.00 08200 Wood and Plastic Doors $8,453.00 09250 Gypsum board $30,139.00 09300 Tile, Marble and Granite $5,025.00 -9550 Wood Flooring r $10,621.00 09650 Resilient Flooring $470.00 09680 Carpet $1,028.00 69900 Painting $11,722.00 10440 Interior Signage $300.00 10520 Fire Extinguishers $750.00 10550 Postal Specialties $500.00 10800 Toilet and Bath Accessories $500.00 11400 Food Service Equipment $18,925.00 12500 Furniture and Accessories $20,031.00 15300 Fire Protection $13,251.00 15400 Plumbing $50,000.00 15500 HVAC $25,000.00 16160 Electrical $30,000.00 TOTAL PROJECT VALUE: $296,401.00 Page 1 of 1 Pages Crry OF SAum PUBLIC PROPE M DEPAR'LMWT awes ts .s,�wx�..oa�sa+ts t�ta►r�w�.ta,.t+n�.►+w Coubvedoo Debris Dlspaal Affidavit A-ORon"I d Ibr d ewmmmmm s.ei isestrMAN Waft 1��000at�eos rrit\��tul.dWos dtbs Stw soildlei Cod,7f0 CSQ aedor lttd pdmy od drpiarWar dIM s 446 i 341 g -pms..Oft"r is bmd to d db wsuw@ Sao :t,is wa�,bd b.dt;o«a otta s pa��lir�wi rsMs dfrp+ s a.Aer by aiap.• ' TtA&Mk*0 be by �S� CoRs� Y-vc�irz� (aar db�IN TIw d&ft will be dispoud d la: (*hkdk ofANO» "" vor"Vold" ±k c> Application for Permit to; Location// l o 6�AVf,474,d S/ Permit Granted /UI,4eC 27, 2607 Approved ,44 �C &L—� ector of Buil ings �ir� / v � � j � q � � � q q $� � y i ��� vvy� �� 3 � S � � �