120 WASHINGTON ST - BUILDING INSPECTION (9) The Commonwealth of Massachusetts (pl 2[ �� ✓o
# Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only) - -
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
120 Washington St., Salem
n No.and Street City/Town Zip Code Name of Building(if applicable)
-- SECTION 2:PROPOSED WORK
Edition of MA State Code used 8t If New Construction check here❑ or check all that apply in the two rows below
Existing Building i Repair❑ Alteration 4b 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No a
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
ange contractor on permit tor worK In the garage at 12U Washington St
Permit # B-2013-0890
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) O
Existing Use Group(s): Proposed Use Group(s):
-:SECTION 4:BUILDING HEIGHT.AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
- SECTION 5:USE GROUP(Check as applicable)
A. Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile ❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB Ib IV ❑ 1 VA ❑ VB ❑
- .. SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone& Indicate municipal M A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑ or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: 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 Q Yes❑ No 10
- 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 System?: Special Stipulations:
YtlAk0-Eo trj 24:k
9: PROPERTY OWNER AUTHORIZATION n 6ECTIOL�, � .
Name and Address of Property Owner
RCG 17 Ivaloo St Somerville 02143
Name (Print) No.and Street City/Town Zip
Property Owner Contact Information:
Jim Gagnon 617-B25_8315 617 512 2286 Jgagnon@rcg-Ilc.com
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Scott Allison 58 Glad Valley Dr Billerica MA 01821
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix.2)' '-
buildin is less than 35,000 cu'ft.of enclosed space and/or not under.Cons truction Control then check here 0 and ski. Section 10.1 "
10.1 Registered Professional Responsible for Construction Control'':
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractorf:' '
Supreme Builders
Company Name
Scott Allison CS 069628 Unrestricted
Name of Person Responsible for Construction License No. and Type if Applicable
58 Glad Valley Dr Billerica 01821
Street Address City/Town State Zip
781-953.6036 scott@)supremebuiIder.net
Telephone No. (business) Telephone No. cell e-mail address
-::- ' - • -SECTION.11:WORKERS`COMPENSA'110N INSURANCE.AFFIDAVIT'(M.G.L,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 signed Affidavit submitted with this application? Yes■ No 0
SECTION 12 CONSTRUCTIONS COSTS AND PERMIT FEE "
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing. $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
5 . SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
Scott Allison C"ivf/�/-, Cd,?'a' tJe% - 781-953-6036
Please print and si name Title Telephone No. Date
58 Glad Valrey Dr Billerica 01821
Street Address City/Town /f State Zip /
Municipal Inspector to fill out this section upon application approval.
s <- ,. . ,.
.f a e� Name," <.= , :Date
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
a d 1 Congress Street, Suite 100
s' Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Supreme Builders & Design,lnc
Address: 58 Glad Valley Dr
City/State/Zip: Billerica, MA 01821 Phone #: 781-953-6036
Are you an employer? Check the appropriate box: Type of project(required):
1.9 I am a employer with 3 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑■ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.#
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 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 anew affidavit indicating such.
tContmctors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Travelers
Policy#or Self-ins. Lic. #:7PJUB-47681`16-5-13 Expiration Date: 7/21/16
Job Site Address: 120 Washington St City/State/Zip: Salem
Attach 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 $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 of the DIA for insurance coverage verification.
I do hereby cerirfy under the pains and enaldes of perjury that the information provided above is true and correct
Sienature: �,/ Date:
6/20/16
Phone#: 781-9536036
Official use only. 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
Contact Person: Phone #:
Commonwealth of Massachusetts
OONOLpI
City of Salem
3e t
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
PERMIT REPORT BY ADDRESS
PIN Permit For Parcel ID Occupancy Type Building Type Work Description Construct. Fee Paid
Cost
J B-2013-0649 ALTERATIONS 35-0004 Commercial Commercial/Res MOVE PLUMBING FOR BAR 15500 170
AREA FROM EXISTING
LOCATION APPROX 10 FEET TO
NEW BAR LOCATION,NEW
PAINT AND REFINISH FLOOR jbh
B-2013-0890 REPAIR/REPLACE 35-0004 Commercial Commercial/Res DEMO FLOOR POUR NEW 130360 1435
CONCRETE,NEW FLOOR
DRAINS,AND NEW OIL
SEPARATOR,VENTALATION AS
PER PLANS (996-13)
See comments below regarding
change of contractors from Roger
Tremblay to Dan Tremblay dated
04/30/2014
B-2014-0622 RENOVATIONS 35-0004 Commercial Commercial/Res FRESH TASTE OF ASIA 46500 511
RENOVATION(SEE PLANS FOR
DETAILS) #605-14
TB-16-653 Repair/Replace 35-0004 Commercial Commercial/Res RENOVATE BATHROOMS 15000 165
TB-16-655 Renovation 35-0004 Commercial Commercial/Res test 0 0
BT-16-9 Oil Burner Installation 35-0004 test 0 0
TBT-16-10 Oil Burner Installation 35-0004 test 0 0
E-14-286 Other 35-0004 Commercial Commercial/Res REPLACE DEFECTIVE 1ST FL 0 15
LED DROP IN FIXTURE IN
FRONT OF THE ELEVATOR
E-14-55 New Construction or Renovation-Electrical 35-0004 Commercial Commercial/Res INTERIOR REMODELING 5000 209
TE-16-549 Other 35-0004 Commercial Commercial/Res REPLACE 8 CEILING FANS/9 0 50
RECESSED TRIMS/2 BATH
EXHAUST FANS/2 BATH HAND
DRYERS
FS-16-6 Special Supression Systems 35-0004 Commercial Commercial/Res lest 0 0
TFL-16-24 LP Gas Cylinders Storage 35-0004 test 0 0
TFL-16-25 Fuel Storage 35-0004 test 0 0
G-14-646 Initial Permit-Gas 35-0004 Commercial Commercial/Res CO VALVE 0 60
G-14-653 Piping Only 35-0004 Commercial Commercial/Res BSMT:REPLACE 0 85
DETERIOTADED 4'GAS PIPE
G-16-144 Remodel and Repair 35-0004 Commercial Commercial/Res 1ST FL: 1 GRILLE 0 170
3 of
Commonwealth of Massachusetts
�pN➢Ip,�
City of Salem
a 'm
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
° PERMIT REPORT BY ADDRESS
PIN Permit For Parcel ID Occupancy Type Building Type Work Description Construct. Fee Paid
Cost
G-16-95 Range 35-0004 Commercial Commercial/Res REPLACE RANGE @ THE UGLY 0 85
MUG @ 122 WASHINGTONST.
1ST FL.
(G76)
G-2001-0002 -35-0004 Commercial Commercial/Res ONEIL'S PUB 0 100
G-2001-0073 35-0004 Commercial Commercial/Res Sub-bsmt-9 roof top units, 0 160
basement-2 heating boilers
G-2001-0191 35-0004 Commercial Commercial/Res Basement-1 heating boiler. 4th 0 240
floor-7 roof top units
G-2002-0394 35-0004 Commercial Commercial/Res 1st floor-1 oven/Transylvania 0 20
Pizza
G-2006-0384 GAS 35-0004 Commercial Commercial/Res G373-06 0 825
RAN GE/OVEN/G RI LLENVATER
H EAT ER/FRYOLATORS/RIC E
COOKER/BBQ DR
G-2008-0042 GAS 35-0004 Commercial Commercial/Res 3 ROOF TOP UNITS 0 90
G-2010-0119 GAS 35-0004 Commercial Commercial/Res (1)WATER HEATER jbh 0 85
G-2011-0157 GAS 35-0004 Commercial Commercial/Res 2"LINE 0 10
G-2012-0348 GAS 35-0004 Commercial Commercial/Res 1 test 0 20
G-2012-0449 GAS 35-0004 Commercial Commercial/Res 2 boilers 0 110
G-2012-0963 GAS 35-0004 Commercial Commercial/Res 4 ovens,1 roof top unit 0 185
G-2013-0489 GAS 35-0004 Commercial Commercial/Res bsmt:1 2"line 0 10
G-2013-0548 GAS 35-0004 Commercial Commercial/Res 1st fl: 1 convection oven 0 85
GF-16-102 Fire Inspection Day Care or Camping 35-0004 Commercial Commercial/Res test 0 0
GF-16-103 Black Powder Storage 35-0004 Commercial Commercial/Res test 0 0
GF-16-104 Application for Standard Permit 35-0004 Commercial Commercial/Res test 0 0
GF-16-105 Application for Standard Permit 35-0004 Commercial Commercial/Res test 0 0
GF-16-106 Application for Standard Permit 35-0004 Commercial Commercial/Res test 0 0
GF-16-107 Application for Standard Permit 35-0004 Commercial Commercial/Res test 0 0
GF-16-99 Cutting and Welding(Annual) 35-0004 Commercial Commercial/Res iot works to be done on second floor 0 70
TGF-16-100 Fire Inspection Day Care or Camping 35-0004 Commercial Commercial/Res This work will be done correctly. 400000 50
Notify when done correctly.
4 of
Commonwealth of Massachusetts
LON➢IT
: g
City of Salem
120 W ashington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
PERMIT REPORT BY ADDRESS '
PIN Permit For Parcel ID Occupancy Type Building Type Work Description Construct. Fee Paid
Cost
P-2006-0099 PLUMBING 35-0004 Commercial Commercial/Res P94-06 FIXTURES DR 0 160
P-2006-0265 PLUMBING 35-0004 Commercial Commercial/Res P266-06 WATER 0 540
CLOSETS/LAVATORIES/DISH W A
SHER/FLOOR
DRAINS/U R I N A LSNV AT E R
PIPING/GREASE TRAPS/SINKS
DR
P-2008-0052 PLUMBING 35-0004 Commercial Commercial/Res 5 WATER CLOSETS,3 KITCHEN 0 230
SINKS,5 LAVATORIES,4
BATHTUBS,1 SHOWER STALL,3
DISHWASHERS,3 DISPOSERS,3
LAUNDRYTRAYS
P-2008-0069 PLUMBING 35-0004 Commercial Commercial/Res TIE IN RAIN LEADERS TO 0 80
EXISTING STORM,DYE TEST
P-2008-0110 PLUMBING 35-0004 Commercial Commercial/Res 1 HOT WATER TANK,WATER 0 200
PIPING,3 BAY SINK,GREASE
TRAP,2 CUP DRAINS, 1 HAND
SINK
P-2008-0237 PLUMBING 35-0004 Commercial Commercial/Res (2)WATER CLOSETS/(2) 0 140
LAVATORIES jhb
P-2010-0136 PLUMBING 35-0004 Commercial Commercial/Res (1)HOT WATER TANK jbh 0 80
P-2011-0164 PLUMBING 35-0004 Commercial Commercial/Res 1 4"DRAIN,1 1 1/2 WATER LINE 0 20
P-2012-0473 PLUMBING 35-0004 Commercial Commercial/Res 2backflow prev 0 80
P-2012-0509 PLUMBING 35-0004 Commercial Commercial/Res 1 water piping, 1 drain piping- 0 100
underground
P-2012-0918 PLUMBING 35-0004 Commercial Commercial/Res 1 hand sink, 1 indirect waste 0 100
P-2012-0934 PLUMBING 35-0004 Commercial Commercial/Res 2 water closets,2 lavatories 0 140
P-2013-0472 PLUMBING 35-0004 Commercial Commercial/Res bsmt:1 dishwasher, 1 grease trap, 1 0 100
hand sink, 1st fl: 1 dishwasher
P-2013-0487 PLUMBING 35-0004 Commercial Commercial/Res bsmt 1 4"drain,1 1 1/2"waterline 0 20
P-2013-0803 PLUMBING 35-0004 Commercial Commercial/Res 1 st fl:2 lavatories,1 dishwasher, 1 0 180
backflow,prev,2 floor sinks
P-2014-0096 PLUMBING 35-0004 Commercial Commercial/Res tat fl:1 dishwasher,1 backflow, 0 120
prev, 1 floor sink
P-2014-0413 PLUMBING 35-0004 Commercial Commercial/Res bsmt: 1 hot water tank,1 water 0 100
piping
P-2014-0414 PLUMBING 35-0004 Commercial Commercial/Res bsmt:1 hot water tank, 1 water 0 100
piping
6 of
NDIp� Commonwealth of Massachusetts
OO
City of Salem
j
120 Washington St,3rd Floor Salem,MA01970(978)745-9595 z5641PERMIT REPORT BY ADDRESS
PIN Permit For Parcel ID Occupancy Type Building Type Work Description Construct. Fee Paid
Cost
TGF-16-101 Cutting and Welding(Annual) 35-0004 Commercial Commercial/Res 0 0
M-2001-0026 35-0004 Roof-5 roof top units 0 0
M-2001-0028 35-0004 5 Rooftop units 0 0
M-2002-0002 35-0004 Sign for Transylvania Pizza per 500 0
drawing submitted. P.S.
M-2004-0007 35-0004 S123-2004 ERECT TWO(2) 1000 0
SIGNS FOR SALEM YMCA)1/24"
X 36"WOOD HANGING SIGN
WITH METAL BRACKET. 2) 24"
X24"WALL SIGN. TJS
M-2004-0038 35-0004 - 912-2004 SIGN PERMIT TJS 500 0
M-2006-0027 35-0004 697-06 SIGN PERMIT TJS - 0 0
M-2007-0058 35-0004 ERECT 3 SIGNS TO GULU GULA 1500 0
CAFE AS SUBMITTED
M-2008-0018 35-0004 INSTALL SIGN FOR UPPER 1000 0
CRUST PIZZA
M-2008-0049 35-0004 ERECT SIGN FOR SACRED 2669 0
GEAR
M-2008-0058 35-0004 SIGN PERMIT AS APPROVED 200 0
FOR(GULU-GULU CORP)
P-14-507 New Construction Plumbing Permit 35-0004 Commercial Commercial/Res 6 FLOOR DRAINS,1 GAS TRAP 0 340
P462(at 118 Washington St,
garage,under building)
P-14-638 Remodel Kitchen or Bath 35-0004 Commercial Commercial/Res 2 floor drains, 1 kitchen sink/bar 0 360
sink,4lavatories,3 toilets,1 urinal,
2 water heaters, 1 water piping,2
hand sinks
P-14-784 Existing Construction Plumbing Permit 35-0004 Commercial Commercial/Res RENOVATIONS 0 280
P-16-120 1 Plumbing Fixture 35-0004 Commercial Commercial/Res BSMT:6 FLOOR/AREA DRAINS, 0 0
1 GAS TRAP
P-2001-0238 35-0004 Commercial Commercial/Res 2nd flr-3 water closets,4 0 220
lavatories,) urinal/3rd fir-3 water
closets,4 lavatories,l urinal/4th flr-3
water closets,2 kitchen sinks,4
lavatories,1 hot water tank,2 floor
drains,) urinal
P-2002-0236 35-0004 Commercial Commercial/Res 2nd floor-1 lavatorie, 1 drinking 0 100
fountain.3rd floor-8 lavatories
5 of
Commonwealth of Massachusetts
�OONOIT� .
City of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Uz
PERMIT REPORT BY ADDRESS
PIN Permit For Parcel ID Occupancy Type Building Type Work Description Construct. Fee Paid
Cost
TP-14-497 Existing Construction Plumbing Permit 35-0004 Commercial Commercial/Res 1 MOP SINK, 1 HANDWASHING 0 100
SINK P453
FM-15-64 Food Establishment 25-99 seats @ParceIID 0 280
FM-16-73 Food Establishment 25-99 seats @ParceIID 0 280
Total Permits: 104 2089172 24810
7 of
Commonwealth of Massachusetts
City of Salem
q
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
PERMIT REPORT BY ADDRESS
Address: 120-b1dg3 WASHINGTON STREET
PIN Permit For Parcel ID Occupancy Type Building Type Work Description Construct. Fee Paid
Cost
B-14-1199 Other Building Permit 35-0004 Commercial Commercial/Res SHEET METAL PERMIT: 7000 77
INSTALLING EXHAUST FAN&
DUCTS INTO THE BASEMENT
FROM THE GARAGE AREA @
120 WASHINGTON ST.
B-14-1634 Signs 35-0004 Commercial Commercial/Res SIGN PERMIT,AS APPROVED, 0 0
FOR: THE UGLY MUG
(WINDOW DECALS&A-FRAME)
@ 122 WASHINGTON ST
B-15-707 Signs 35-0004 Commercial Commercial/Res SIGN PERMIT AS APPROVED 0 0
FOR: BISTRO 118 @ 118
WASHINGTON ST
B-16-354 Other Building Permit 35-0004 Commercial Commercial/Res SHEET METAL PERMIT FOR THE 9836 77
UGLY MUG @ 122 WASHINGTON
ST.:
EXTEND EXISTING KITCHEN
EXHAUST HOOD TO MEET
CODE.
B-2000-0101 437 Nonresidential:additions,alterations,conv. 35-0004 Commercial Commercial/Res Renovations as per plans submitted. 490000 4900
P.S.
B-2000-0177 437 Nonresidential:additions,alterations,conv. 35-0004 Commercial Commercial/Res Restaurant fit out per plans 20000 205
submitted."A New Place in Thyme".
F.R.D.
B-2001-0513 437 Nonresidential:additions,alterations,conv. 35-0004 Commercial Commercial/Res Renovations to YMCA per plans 120000 1205
submitted.F.R.D.
B-2001-0515 437 Nonresidential:additions,alterations,conv. 35-0004 Commercial Commercial/Res Tennant buildout for City offices. 173000 1735
F.R.D.
B-2001-0742 REPAIR/REPLACE 35-0004 Commercial Commercial/Res Stucco front&rear connector 27500 285
elevations. F.R.D.
B-2003-0069 437 Nonresidential:additions,alterations,conv. 35-0004 Commercial Commercial/Res 66-2003 CITY OF SALEM 1500 20
PLANNING DEPT SPACE
CHANGE. DEMOLISH
APPROXIMATELY 20'OF
DRYWALL PETITION. ERECT 16'
OF PARTITION. METAL STUDS&
5/8"FIRE CODE SHEET ROCK.
TSP
B-2003-0463 REPAIR/REPLACE 35-0004 Commercial Commercial/Res 462-2003 REPLACE SKY-LIGHT 2000 20
@ CITY HALL ANNEX. 120
WASHINGTON ST. TJS
1 of 7
Commonwealth of Massachusetts
�➢N➢1P��
City of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 z5641
N PERMIT REPORT BY ADDRESS }�
PIN Permit For Parcel ID Occupancy Type Building Type Work Description Construct. Fee Paid
Cost
B-2006-0221 REPAIR/REPLACE 35-0004 Commercial Commercial/Res 234-06 KITCHEN CABINETS TJS 1000 25
B-2006-0602 TENNANT FIT OUT 35-0004 Commercial Commercial/Res 626-06 TENANT FIT UP FOR 95000 955
RESTAURANT TJS
B-2006-0867 35-0004 Commercial Commercial/Res Tennant Fit Out 9000 104
B-2007-0527 DEMO 35-0004 Commercial Commercial/Res INTERIOR DEMO ONLY T.J.S 1000 100
B-2007-0750 REPAIRIREPLACE 35-0004 Commercial Commercial/Res MINOR INTERIOR PARTITIONS 0 0
WORK 4TH FLOOR T.J.S.
B-2007-0803 REPAIR/REPLACE 35-0004 Commercial Commercial/Res CONSTRUCT DEMISING WALL 47561 505
FOR COMMON CORE
BATHROOMS
B-2007-0804 REPAIR/REPLACE 35-0004 Commercial Commercial/Res CREATE(5)RESIDENTIAL 296401 3305
CONDOS
B-2007-1064 TENANT FIT-OUT 35-0004 Commercial Commercial/Res TENANT FIT UP FOR GULA 8000 93
GULA J.B.
B-2007-1100 REMODEL 35-0004 Commercial Commercial/Res TENNANT FIT-OUT 81450 896
B-2008-0074 REPAIRIREPLACE 35-0004 Commercial Commercial/Res CREATE EGRESS CORRIDOR 6000 71
SERVING TWO BUSINESS
B-2008-0744 TENNANT FIT OUT 35-0004 Commercial Commercial/Res TENANT FIT-OUT INCLUDING 27200 299
HANDICAP ENTRANCE,RAISED
FLOOR RETAIL STORE UNIT C
jhb
B-2008-0762 REPAIR/REPLACE 35-0004 Commercial Commercial/Res ADD CHANGING ROOM AND 1000 20
OFFICE TO EXISTING RETAIL
SPACE
B-2010-0110 REROOF 35-0004 Commercial Commercial/Res EXTERIOR REPAIRS,RUBBER 2995 25
ROOF
B-2010-0877 TENANT FIT-OUT 35-0004 Commercial Commercial/Res TENANT FIT OUT FOR(NEW 27000 302
RESTAURANT)AS PER PLANS
jbh
B-2012-0873 ALTERATIONS 35-0004 Commercial Commercial/Res ADD ONE NEW WALL,PAINT 6000 66
AND EXPOSE BRICK @(TWO
PLACES)jbh
B-2012-0890 ALTERATIONS 35-0004 Commercial Commercial/Res BUILD DIVIDING WALLS IN 1500 25
OFFICE jbh
B-2013-0515 DEMO 35-0004 Commercial Commercial/Res DEMO ONLY AT(118 7500 30
WASHINGTON STREET)jbh
2 of
SUPRE-1 OP ID: JM
ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE
os/0812016ofi/2o16
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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 endomement(s).
PRODUCER CONTACT
Foster Sullivan Insuranceii NAME: Ryan Arsenault
163 Main St.L L AI ONE Ell::978-686-2266 FAX
No): 978-686-6410
North Andover,MA 01845�� E-MAIL certificates fostlli com
Foster Sullivan Insurance LLC ADDRESS: ersuvan 9roU p•
INSURER(S)AFFORDING COVERAGE NAICIf
INSURER A:TRAVELERS CASUALTY INS 19046
INSURED Supreme Builders &Design Inc-1 F1 INSURER13:Merchants Mutual Ins. Co. 23329
58 Glad Valley Drivel Billerica, MA 01821 INSURER C:TRAVELERS INSURANCE CO 19046 Billerica,
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 15 TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY EFF POLICY EXP
TYPE OF INSURANCE
LTR POLICY NUMBER MMIDO MMIDD LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
CLAIMS-MADE N occuR X 6803D251673 07/09/2015 07109/2016 PREMISES Ea occurrence $ 300,00
MED EXP(Any one person) $ 5,00
PERSONAL&ADV INJURY $ 1,000,0001
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00
POLICY 0JET LOC PRODUCTS-COMP/OP AGG $ 2,000,00
OTHER $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
B ANY AUTO MCA1001684 07/09/2015 07/09/2016 BODILY INJURY(Par person) $
ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
X X NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per a.d%t
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $ -
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY STATUTE Eft
C ANYPROPRIETORFARTNERIEXECUTIVE YIN 7PJUB-4768P16-5-14 07/21/2015 07121/2016 E.L.EACH ACCIDENT $ 1,000,000
OFFICERMIEMBER EXCLUDED? N I A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000
If yes,deacnbe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I $ 1,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe atleched N more apace Is mQulred)
120 Washington St &RCG-LLC are listed as additional insureds on nF
the General Liability policy as required by written contract. L_
uu
❑❑
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
RCG-LLCuu
17 Ivaloo Streetu❑ AUTHORIZED REPRESENTATIVE
Somerville, MA 02143 _0
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD