120 WASHINGTON ST - BUILDING INSPECTION (5) PUBLIC PROPERTY
DEPARTMENT
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APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
IA SITE INFORMATION
Location Name. i_ Building:
-propertyAddress.--tJ�l���ii�R���—c��e��
Property is located in a:Conservation Area Y/N Historic DI Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: L LLC K
Address:
ld0 j,Jas�;J�a., s�. �felM � Mq s^4'c , ��' 0oa,4
Telephone: - 9-73-
3.0 COMPLETE THIS SECTION FOR WORK IN FY19TiNG 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 I I New
Beef Description of Proposed Work: P y'
To V'< MWe-- <5?ysf�11S rQAt.� J01.zh46a Uo✓�cbl Sc1oS�K`�C� /ft�
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Mail Permit to: >81 74 - O174'6
tim�a
What is the current use of the Buildin ? ( -
Material of Building? .b6o sU,,If dwelling.how many units?
Will the Building Conform to Law? /1//�- Asbestos? 16114-
Architecfs Name -
Address and Phone
Cty4r�11 Mechanic's ame
Address and Phone
Construction Supervisors License S C73r��t St/ HIC Registration#
Estimated Cost of Project S � Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/111000 Residential
--- - Estimated CosYX$11151000 Commerc'�.'
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to bull to the above stated
specifications. Signed under penalty of perjury X
Date
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The Commonwealth of31assachusetts
Department oflndustrial Accidents
rl Office of Investigations
600 Washington Street
' Boston, ;11A 02111
w- " WWW.111C(SS.g0V1dfa
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leaibly
Name (Business Oreanization'Individuall:
Address: yp CVtC_I S _
City/State/Zip: M� o�eJ HA CQ�55 Phone #: -731 3151tj ?R5q
Are yo n employer? Check the appropriate box: Type of project (required):
I. am a employer with /5 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees (full and/or part-tirne).* have hired the sub-contractors
2.❑ t atn a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for Ine in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Ro f repairs
insurance required.] employees. [No workers' 13. Other
comp. insurance required.]
•Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
-Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infomtation.
I am an employer that is providing workers'compensation insurance for mV employees. Below is the policy and job site
information.
Insurance Company Name:
Policy #or Self-ins. L1icc.. #:_ �` Expiration Date: - q
Job Site Ir�/
.Address: o - lq hit,o�cr� c"l�h City/State/Zip: , -M , (�_I{l
Attach a copy of the workers' compensation policy declaration pa
ge(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 $1,500.00 and/or one-year imprisonment, as well as civil penalties 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 ofthe DIA for insurance coverage verification.
I do hereby certify unde pains and penalties ofper/my that the information provided above is true and correct.
Signature: Date:
Phone #: 3pl
Official use o1r/r. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Information and Instructions
Massachusetts General Lacs chapter 152 requires all emplocers to pros ide workers' coin pen sat ion for their emplo"ees.
Pursuant to this statute. an emploree is defined as "...even person in the service of another under any contact of Itire.
express or implied. oral or written."
An employer is defined as "an individual. partnership. association. corporation or other legal entity. or am two or more
of the foregoing engaged in ajoint enterprise. and including the legal representatkes 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 sr]to resides therein. or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair%\ork on such dwelling house
or on the -rounds 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, §25C(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 number(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 affidavit 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[own may be provided to the
applicant as proof that a valid affidavit is on file for future pen-nits or licenses. A new affidavit must be filled 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The 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-NIASSAFE
_ Revised 5-26-05 Fax # 617-727-7749
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: t HOME D aROVENIENT CONTRACTOR LAW
Permit A' lioatiom
Supplement to P PP
MU 14ZA rquires TJx the ^i sllerarim renove_im mmlr modernimr on pvcr nZ im n but
Of } a don to of acitne ownaomroied bufldma eonaunl
did �+On ne u I�u one but nor more ham
�r owelima s r4 or sn%"d ve x ^�ch restdrna or bu ldfnsa be done b�re�sured marraron w b
��rryy..S5��KK =M7M etcepdoas, .4-Wtth,yJW RgrilreMCnM - ,
{Yj!LY/1t rP•fl, .r Y..ytw• •tij.ts4•tr. tq t'r' ley. . • . + , '� : - '
Location of Pm perry sly r'h.
��
Ow Name and Address: C L
ner -
Date of Permit Application Est Cost: ` ]9'5 -
Type.of Work
I hereby certify that:
REGISTRATION IS NOT REQUIRED FOR.THE FOLLOWn 1G REASONS:
work exchtded,by law
job under S1,000
buiildmg not owner-occupied
77-77-77-7777r777I7Y•'r
owner
Notice is74
veseby given that '
OWNERS PLg11NG THEIR OWN,PERM.r. OR DEALING WTIH UNREGISTERE:'
CONTRACTORS OR APPLYCAB�B HONE WRO,VEMENT WORK DO NOT HAVE _
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND MGL a'142A
Signed under peuat of perjury, I hereby'apPly for a permit as the agent of the owner
Contract r Name (print) Date.I
. . .
Contractor S' Registration tiumber
OP,
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Owner Name (print) Date
Owns Signature
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o�G. -d i� -pra•'t Expiration 7/22/2011
(mm+iLuluan b Tr#: IT732 iG
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Restricted to: 00
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GO- Unrestricted 1
1G-1 2 Family Homes
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Failure to possess a current edition of the
Massachusetts State Sullding Code.:` 1.r.:4
is cause for revocation of Jtt{licpnse t a
Refer to:' WWW.Mas3.Gov/DPS
.,owl
8aard of BulldingReg4latlons,b�„„+J r11s License r r Istraiou valld for indNidul use.onl
I .. o e g t Y
HOME IMP OVEMENT CON7Rg4T4. r. ,before the expiration date. If found return to:
'Board of Building Regulations and Standards -
F Ro6i$ a 135743 � r Y:�r f lG nv' {ram ,' One Ashburton Place Rm 1'301
t 010� do Trry 2680$74+ d y Bo$togr 1�1a 02108
JOSEPH S. SAV T Co.
JOSEPH SAVINI
40 CANAL ST
MEDFORD, MA 02155y r dam'`',d;' . N valid nature -
A olstratvrr „n , - 1.
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• DATE(MMIDDIYYYY)
ACORD,. CERTIFICATE OF LIABILITY INSURANCE 4/29/2009
PRODUCER Phone: 509-651-7700 Fax: 508-653-6009 , THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC -Commercial Lines ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
E as West Central Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Natick MA 01" 60
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA:T e Insurance CO of State PA
Joseph S . Savini, Inc. INSURERS:Max Specialty Insurance Cc
40 Canal Street INSURER C.Hanover Insurance Co. 2292
Med-ford MA 02155
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDi NG. 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 T..
T'RMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY NUMOER POLICYEFFECTIVE POLICYEXPI RATION LIMITS
nATFfmmmniyyj
B GENERALUABIUTY MAX013100001667 10/21/2008 10/21/2009 EACHOCCURRENCE $ 1 000 000
X COMMERCIALGENERAL LIABILITY PREMISES Eao¢uwr $SO OG0
M CLASMADE OCCUR MEDEXP(Anyore iein) $ S 3130
PERSONALS ADV INJURY $ 1 00Q 000
GENERALAGGREGATE $2 000 0130
S
GERI AGGREGATE LIMITAPPLIESPER'. PRODUCT COMPIOPAGG $2 OOO OOO
v POLICY PRO LOC
(• AUTOMOBILE UABILITY AMN870061102 4/25/2009 4/25/2010 COMBINED SINGLE LIMIT(Eaactl 0) $ 1/000 000
ANYAUTO
ALLO'WNEDAUTOS BODILY INJURY S
(Pei Person)
X SCHEDUIEDAUTOS
X HIREDAUTOS BODILY INJURY $
(Pel accitlarn)
X NCNDWNED AUTOS
PROPERTY DAMAGE $
(PeiamC N)
GARAGE UABWTY AUTOONLY EAACCIDENT $
ANYAUTO OTHERTHAN EAACC $
AUTOONLY: AUG $
E%C ESS/UMBRELLA UABILTY EACH OCCURRENCE $
OCCUR CLAJMSMADE AGGREGATE $
S
DEDUCTIBLE $
RETENTION $ $
A WORKERS COMPENSATION AND WC5340642 9/12/2008 9/12/2009 X I
WCSTATU- OTH-
EMPLOYERS'UABWTY E.L EACHACCIDENT $ 500, 0c1S _
ANY PROPRIETORLPARTNE WEXECUTIVE
OFFICEWMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500 OQQ
IYes dIx,urIG9I
S PECIAL FROV ISICNS be EL pSEASE-POUCV LIMIT $ 500 000
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 DATE THEREOF, THE ISSUING INSURER
WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE
CERTIFICATE BOILER NAMED TO THE LEFT, BUT FAILURE TO CO SO
SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND NECK
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORQED REP RESENTATIVE
ACORD 25(2001/08) m ACORD CORPORATION 1988
1
06/17/2009-,12:ra 7813934926 JOSHPH SAVINIINq PAf>t •82
Fixsz
Joseph .Savhti,Tits Mass Builders License#036954
Contractors Registration#135743
Roofing Gutter contractor phone: (781)395-3954
40 Canal St. Fax- (781)393-492�
Medford MA 02155
----------------
Proposal
RCG LL June 17,2009
Attn: x Schnip
17 Ivalo4 P St.
Somervi le,MA 02143
Tel: 61 -625-8315
Fait: 97 -740-0021
Job Ref: 120 Washington St. Salem,Ma 1 Roof over front entrance with big skylight on
it
1. Remove Existing roof down to a workable substrate•
2. To install a new.060 frilly adhered,Versico rubber roofing system.
3. To install I inch insulation as approved by the rubber manufacturer
and rnecbenically fastened using coated plates and screws.
4. Rubber will be run up the brick walls surrounding the roof,as well as
up under the skylight.
5, The roof will be flashed to comply with the roof system
6. We will install all new lead raglets along the brick wall.
7. We will remove the existing drain sleeves and re-install new drain
sleeves.
8. During the roofing process our main objective will be the sealing of
the areas up under and around the large skylight that occupies most of
the roof.We can clearly see the potential for snow and ice damming,
due to the tight quarters of roof around the skylight.Extra attention
will be paid when sealing the area up under the skyliglrts flashing kit
in order to attempt to prevent these potential probierns
9. To remove and dispose of all job related debris
Total Cost of.Work Proposed=$2995.06
This job will carry a ten year warranty,however ice damming is a folne of
nature E nd we eannot•guaradee that it will not occur,therefore leaks tha axe determined
to be adirect result of ice damming will not be covered.
Thank ou, .
Josep Savini' RCG LLClAIex Schnip
't f a•+M kaG t^. !ri a 'A _ r
(y y _
CONTRACT
A.GRFENTNI'wade as of the 6th day.o£Juue,2009.
L CONTRACTING PARTIES
Washington at Derby LLC
C/o RCG LLC
17 Ivaloo St#100
Somerville,MA 01970
And
Joseph S. Savini Inc.
40 Canal Street
Med£ozd,MA 02155
II. PROJECT
a. Peabody Block LLC
b. Project Architect
c. Project Consultants
Project Architect:
III. WORK TO BF. PERFORMED
a. Work Scope
To Furnish and install a,new rubber membrane roof as described in the proposal
dated June 17,2009 attached as exhibit A.
Contract price includes building permit'. /
Work will be scheduled:for a Friday.afternoon and Saturday as to minimize. /
disruption to the 120 Washington Street tenants.
b. Change Orders
Changes to this Contract increasing or,decreasing the Scope of the ozk must be in
writing and signed by the Owner and Contractor.
IV. COMMENCEMYNT AND COMPLETION
i
Date of/Zmencement: 4AW"
Dale of Substantial Completion: iiii"
ate of Final Comp etion:'g J 1/09
The Date of Substantial Completion of the Work is the date when construction is
sufficiently complete so that the Owner can occupy the premises or utilize the Work for
the use for which it is intended.
Final Completion is when all the Work is in place and the final punch list is completed.
TTME IS OF THE ESSENSE 1N THIS CONTRACT,
V, PRICE And TERMS
The Owner shall pay the Contractor the following amount for the Work included in this
Contract:
Ten Thousand Dollars ($2 995.00).
The Contractor shall submit an application for payment in the form of an Invoice to the
I e later than the 15th day of the montJa The Contractor shall only invoice for
Own r no Y
e time the Invoice is resented.
Work complete at the p
The Owner, upon inspection and approval of the completed Work by the Project
Archite t,c will pay the Contractor the approv
ed Invoice amount on the 8th day of.month
following invoice.
VALUES
SCHEDULE OF ALUE
Payments for completed Work shall be made based on the following:
Contract Item Value
I
i
Unit prices, if any are as follows:
Item Dollar Value
VI. INSURANCE PROVISIONS
The Contractor shall inaintain in effect Workman's Compensation Insurance for all of its
employees and General Liability Insurance for the duration of the Work of this Contract.
No Work shall Commence'and no Payments shall be made until a Certificate o
Insurance is issued from Contractor's Insurance Company naming the Owner as a
certificate holder.
I
i
VU. MANNER OF EXECUTION
All Work shall be performed and completed in compliance with all federal, state, city,
and local codes and ordinances.
All Work shall be performed incompliance with OSHA rules and regulations. All OSHA
violations and fines related to the Work of this Contract shall be the responsibility of the
Contractor performing the Work.
All Work shall be performed in a first class workmanlike fashion consistent wit the
highest standards in the construction industry
Vill. CONTRACT DOCUMENTS
The Contract Documents consist of this Agreement and the following Drawings,
Specifications, and Addenda:
AGREED, i ��
Owner Data 0
Contractor Date
it (((