120 WASHINGTON ST - BUILDING INSPECTION What is the current use of the Building? �_
Material of Building?
fir,C _ If dwelling.how many units? —
Wig the Building Conform to Law?_�� 5 - Asbestos?
Jp
Archited's Name ?
Address and Phone
s
Mechank:'s Name
Address and phone
Construction Supervisors License HIC Registration 0
E,*natsd Cost of Projed S c o a PermM Fee CakxOagon
Permit Fee: Esgmated Cost X$71$1000 Residential
Es*nated Coe<X S11/S1o00 CommercW----
An Addidonal$6.00 is added ae an
Administrable charge.
Make sure that all fields are PrOPedY 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 parJury x
ate
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PUBLIC PROPERTY
DEPARTbI&NT
IaSOMM"DInCA ,
•'&- 4nsuansh-jis 01970
TM-97 IMS"•FAX V&740A146
APPLICATION FOR TSE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION OR CAANGE OF USE OR OCCUPANCY FOR ANY EXISTIN
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name (4- Ca Building:Property �JrwLL oe�„'x ac o
ate_
(' �? C )CAS LtK S-1-4,
PrW&V is located In a;Coneervatlon AM YIN Historic Disttkx Y/N
2.0 OWNERSHIP INFORMATION
2.i Owner of Land
Name: KC —
Address: Qco C'3cack,,,O , S-t-
�tl e,, 1n4
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EYLBIINIG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Y New
Demolition Existing
Approximate year of Area per floor(sn Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Lxt�r.. WW c� �Ov
Sw;l�
�jfn�I� d�✓l`�!� ue,J� e y�/.�aS?+esr/'7 Cyw .— 0-icic
far..-fi'� S �atu�•�.l"�iztGe.n 5/�e�
Mail Permit to:
"CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\1.t1 O1c 120 WAS111XG":ON STREET 1 SALF.M.MASSACHI.iL CIS 019/C
TF1:978.745-4595 * F.,-X:978-7+G9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CMR section 111.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit ft _,__ __ 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
1 11,S 1.50A.
The debris will be transported by:
— — � tname of hauler
Hie debris will be disposed of in
(name of facility)
address offaci lily)
_ \hl!atuCc of 1mmit apimciat -
Gatti —.
CrrY of SALEM
PUBLIC PROPRERTY
DEPARTMENT
w►,raa IIO��nnnreToa,ststasr•serat,'dAmeat�aTraoI970
nk" WSM•FAX:97W,*9W
Worilena Compensation Imortiset AfAdaft Ba&rWCo
AnaNnat Intor>madon Please Print r AIM
Name
Adds@ I J (5- / ) ALP 14- S-1- Lya;vy
City/ /96 PboneN 7F'l SryS- �73
AN you u empisyert Cheek the appropriate b9af
1.p 1 eta a eo4byer with 4. 01 sm a Ymad contractor.esd I Type edtpN)ew(N9uirse
amployess(fib andler part-time).• haw hired the whocc atr@a me & p Near case mcdoe
2.0 1 em.Main proprkoor er parsec. Had an the aeached chest: 7. 016modeling
ship and have no employeas Thws ab catmaatp,haw L p DemoHdan
wasting for me in my Capadty. werlmrs'Camp.ioOMOM 9. p .ddh[en
(No arerhm@'Camp.inaaata s. p We ere a otrparamn end is
m4uiret] oAlcm@ hew eaaeiaed their 10 �sccaical3.❑ I owsar repairs or addition@
doing a8 work right otcum3Pd a per MOL 11.[ repairs or addition
myaeit(No wnrkars'Comp, a 152.il(4) and we have no es required.) goof mpain
insurance t employees,(No wocim 1 kownsc�) 13.p Other
'Any WdmWftdeftraetwutfa002drewtlas dowlag�
xae,.oa..a who.6.rai.tea,ear@cryewdeieyd.t sed see Usego"
rCa.a.wwn ore ab"sW box wet ANAW a adMa d screw Am**so aeta erne M640aaaaot ad dtfr was>ns'mew Pow ra�t..fa�.
fn o rAat b pro�j worAera'eesepenradowf larwanee paldep owf s41r
f �'sy esrployeaa Bdora 4 rAa /�
inswance Company Name:
Policy N or Self-ins.Lie.N_f� f- / �S U r c,a Expiration Datr 40
Job site Address CirylSotdZip
Attach a copy of thi workan'eompsassebn policy deeLratlea Pap(showing the policy somber said nplradon date).
Psikm to secure coverage as required under Section 25A of MOL e. 152 Can lead to the imposition of erimiad penalyaa of a
Ron up to g 1,500.00 and/or one-year imprisconumR as wag u civil penalties is the form of a STOP WORK ORDER and a Arse
of up to$250.00 a day against the violet.` &advised-hat a copy of-his staoemers maybe forwarded to the Oflia of
Investigations of the DIA for inaurenn coverage vaiAeuien
/do hereby cord*ender tAe paW and penakAw ofpojJwy tAw fAe lnyoresedaw provided @bow 4 trw and correct
Da� s'/i//��o�)
phone t
?77
Of eve use on/p De no/wdW In this area,to be eoarpkw by C4 or fovea o,QleAd
City or Tows: PermWCleeasf t►
Issuing Authority(circl@ one):
I. Board of Health I.Building Department 1.Citylrown Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person Phase M:
11/06/06 RON 09:36 FAX 17815982423 WOODWARD INS. Z001
ACO CERTIFICATE OF LIA131LITY INSURANCE DATE(MNl00IYYTY)
I
11/06/2006 PROOUCE0. (781)598-30SO FAX (781)S98-2423 THIS CERTIFICATE*ISSUEDASAMATTEROFINFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Woodward, Wilkens and Foy Insurance LLC HOLDER.THIS CERTIFICATE DOES NOTAMEND,EXTEND OR
156 Broad St - Suite 202
ALTERTHE COVERAGE AFFORDED BY THE POLICIES BELOW.
Lynn, M.A 01901 INSURERS AFFORDING COVERAGE NAICN
WBUR® Everett McKechnie INSURERA CNA
OBA:Mack's Painting, Carpentry & Wallpapering INSURERS; -
185 Walnut Street MEURER C:
Lynn. MA 01905 INBURERD: '�—
• 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 RAVE BEEN REDUCED BY PAID CLAIMS.
TYPE W - LICYCIFFECTIV.URANCE POUCYNUMBER PO
-jIfijEJMEEo2MU PDATru IPIRATIDN URITS
GENERAL UABU DY EACH OCCURRENCE 1
CDMMERCUL GENERAL LIABILITY OAMAGETO RENTED S
CLANS MADE aOCCUR MEOEUP(AIAy ,*N ) L'
.PERSONALBADYAMRV S
GENERAL AGGREGATE S
GENL AGGRECATELBAR APPLIES PER; PRODUCTS-COMPIOP AGO S
POLICY n
jER LOC
AUTDIIDIME LITBIIIR COMBINED SINGLE LIMB
ANY AUTO (EF PLddol) S
ALL OWNED AUTOS
SCHEDULED AUTOS BODILY INJURY
S
LY NJ
HIRED AUTOS
B M;Id S
NON.OYMED AIrt05 (Po'AcddPnD
PROPERTY DAMAGE - S !
GARAGE UABNr AUTO ONLY_EA ACCIOBNT S
ANY AUTO OTHER THAN FA ACC S
AUTO ONLY; AGG S Ftyl,
EXCE9DUMBREUAUA80lr! EACH OCCURRENCE 1
OCCUR ❑CLAIMS MADE AGGREGATE S
1 I
DEDUCTIBLE S
RETENTION 1 S 1
WORKERS COMPENSATION AND WC4S59U8-5647C483 09/02/2006 09/02/2007 X WC STATV- 0T I.
EMPLOYERS'RALSIUTY Ok
g ANY PROPRIETORMARTNEAIFRECUTNE EA.EACHACCIOEM S 100 OO
OFFICERIMEMBER EXCLUDEOT EL DISEASE-EA EMPLOYEE S
4 yyeeee dmfts der - 100,00
SPECIAL PROVISIONS t» EA OMSEASE-POUCYLNIT 1 SOO 00
OTHER
(
DESCRIPTION OF OPERATIDII9llDd1T10N91 YENICLEB I UCLUSUM AOOEO BY ENOORSEMENT/SPECIAL PROWSIONS !
Painting, Carpentry and Wallpapering
• I
ERTIFICA
TE tjOLDER CANG&LATION
SHOULD ANY OF THE ABOVE BESCRIBEO POLICIES BE CANCELLEO BEFORE THE
EXPIRATION DATE THEREOF,THE MHARNO INSURER WILL ENDEAVOR TO MAIL
10 OATS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
-BUT FAILURE TO MAIL SUCH SHALL IMPOSE NO OBLIGATION OR UABRITY
OF ANY MM INSU ITS OR REPRESENTATNES.
RUTNDP¢E P
ACORD 25(2001100) .. ACORD CORPORATION ieBB
I
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HUB International New England HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR
299 Ballardvale St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Wilmington MA 01887
Phone: 978-657-5100 Fax:978-658-9185 INSURERS AFFORDING COVERAGE NAIC#
INSURED IIEURFRA oa[Toml bran9e fKlmat inc. to
If EIF,EF,171
Mack Paintinq,Carpentry & Wall
185 Walnut Street
Lynn MA 01905 uhllRrr D
mrorer<E_ "
COVERAGES
RIF FOq aN;LwAII r LI- FO PEL •W HAVF HEEH IG6UEL r,THr-ImGDFn NUMLr neon;FOR TtE r'nc.PFPloe Ilvlcal D.NonvITlETnnv-rN--
ARYREa.AREMENT, 6THEr' RE IsaFD car
MAY PERTAIN,THE IHKJJFMLFF AFF0RVFD F,Y RiE FiiLIGE$fiFiiHIDF.D tIFREIiN IS S(iE•IECT TOAIL TILE TERMS,EXCLLIgViHS AHIi COr NIi10rIS OF SL iCH
POLICE?A.3GREG.4IE UMU9 GigWN LU,Y HAVE!?EEH REUIXEIi FiY P810 fLA1DA.5_
nJSR' Doti POLICY EXPIRATION-.
LTR NSR TYPE OF INSURANCE POLICY UUMER DATE(MM/DDIYY) DATE IMI.VDD1Y1') HIPP S
GENERAL LIABLITY EAf.11 CrrUL'FENME 11000000
A X 1- - -r:NF;r_ . TVA'"E'fLr rer>RD ------
.onn,JEr.�,va I r a lwilLIT'i MP059295 01/30/07 01/30/08 rpi s(E-71n r•,v;} 'i 500000
�X�,' a: M[o L;n>in c ".r o_ t 10000 .__--_
J PFR Rr+ ALP/INILRi 11000000
_ :r"N2rv.n:._r•r:nn" s2000000
Ell Ai:,dFEGAIE 1114f fYPLIES'PER. PRODUCT'S-COMr'101>PSG :42000000 _.__
RC9.IC:' •16.T In'.
AWOMOBILE LIABILITY
ri iMgINEC•8141GLE LIMN
—I AD't AUTC, (Ge aaJ:•nll
Al 1. 011E U^:UTiS __.._... _.__..
BOU0.'l IHILgY1 1 -
SCNEDULEDAPOS (Pni O•'-.52n1
I WED A)TO$
eOEnci a+JI IF:r
HL416WHEC•AtN rg lFnr'.l!rirl.-rAl
PFY:PERT(CVGAACE ( _
4Fel'ceL1_-nNI
GARAGE LIABILITY - A0IO!li'P_'1 MAP- CLI I Y
Apy hJ Irf -
4THERTIUV,I EA Arr x
. P.1100LLY' itC3 4 "
EXCESSIULiBRELLA LIABILITY - EAU I VJJIJRI'EI ICE
jOCCUR I___I 1I.AIM4 L:1"Dr. A!i1RE4ATF i
-- DFUJIJ IDLF.
-... r.EinanoH 1 �7.
WORKERS COMPENSATION AND ''-
EMPLOYERS'LIABILITY ��_IYlRY 1I141IS__.ER_
EL.Ef1C"Al'CINK t
!J•1'lfRCtl�IiIEfGRII Ntl Paii£iHYECHIIVIS ______.D_E. __ _�_. .
OFFlCEA/M1IR.ii&EF IF:LIJDFii^ EL EP16U>E"EAEN.IPIAYEE —
It4'c5,rl::q{nlrY
$FECIAL EL DIFEAiE-Pi1LV�Y LIMN # -
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS -
CERTIFICATE HOLDER - - CANCELLATION
BRIDGEW SHOULD A14Y OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF.THE ISSUIRG INSURER WILL ENDEAVOR TO,NAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
BIPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR -
REPRESENTATIVES.
AL T
ACORD 25(2001108) 0ACORD CORPORATION 1988
2007-03-2713:16 HUB International NeHUB International Ne Paget
OULAGULA
CAFE
118 Washington Street
r IENT
......... RC(;LLC
....,.....
I.11, 1.- T,%
KHALSA DESIGN INC.
it
PROPOSED
STANCHIONSt
AND CABLES —PLANTERS
Sd
5,1
It
_j z
SEATING INSH)F=80
SEATING,OUTSIDE=14
1-0 1 AL SIA I IN(j=9 4
First Floor
A103
' PROIECi M6tlE
GULA 4lt1 A
CAFE
TPPpIECTPpME%
'I I IS W.Aingwn Street is
. xrM, SRleny ltasvnrbuvelk �
fr, rve*• i � rCnEM -
°" RCG 1 I C
- • '. • n.c!- -PROn1iEOT�
tKNALSA DESIGN INC
41
iot
® i77
Ira a i
I
717
—♦ �' _ wxs�x n��EtMn�� ,��
\ 6.a
A
e/S
A! use
a
a o-
��
v
9 mw,
1
m
PROPOSED ;
STANCHIONS
R AND CABLES LANTERS.
a _
r � I �
SEATING INSIDE:-80 P
+mnscnx! vam,uw SEATING OUTSIDE=14 -" - —
! c . ..,cw - cccurn.�• un�,�,.. TOTAL SEATING=94
14,11
First Floor
�i-
A103
Az-
- BOARD 05 BUILDING REGUF.ATIONS
License: CONSTRUCTION SUPERVISOW,"--,
Numbet;', 085399�
Tr no 57.0 =
JOHN PER + - ;F,x +ip� _ a,
3 76 PITMAN
1 MARBLEH MAI 0 •Cwnmisalomr'