211 WASHINGTON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts RECEIVED
Department of Public Safety INSPECTIONAL SERVICES
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-F ' 9A 1451
(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)
W a o
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK
Edition of MA States Code used-0— If New Construction check here❑or check all that apply in the two rows below
Existing Building fir Repair Mr I Alteration N( I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) -
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes W No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work
�f
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) ❑
Existing Use Group(s): A JL Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area-Per Floor(sq.ft.). 7
Total Area(sq.R.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A. Assembly A-1❑ A-2 Je Nightclub ❑ A-3 ❑ All❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ 1- Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION&CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ ILA ❑ IIB ❑ IHA ❑ IHB ❑ 1 IV ❑ 1 VA ❑ VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Sup; Flood Zone Information: Sewage unicipa. A trench not be Licensed Disposal Site❑
Public Check if outside Flood Zone� Indicate municipal
Private❑ or indentify Zone: or on site system❑ required for trench or specify:
permit is enclosed❑
Railroad rightof-of . Hazards to Air Navigation MA Historic Commission Review Process:
Not Applicable Is Structure within airport ap roach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Yes O No ILA
SECPION 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:
l
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
RGG L.LG aaf w :—i,4y AevB Sa, n► IM
Name(Print) No.ah&Street City/Town Zip
Property Owner Contact hformation: -
3;.t, &n?-(VAr-
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application.
SECTION 10,CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 ca.ft of enclosed spaoe and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
t �Ittin tw7-.n 7
Name(Re istr t) elep one No. __ e-mail ad - I Rggis a 'or} umber
-as �V
1 � -<��� i- N
Street Address City/Town State Zip Discipline Expiration Date
102 General Contrado
assoG�dtis
Company Name
Dt>1 KM
N e of Person Responsible for Construction License No. and Type if A fieable
t oSt--S Z UVW., ram► Q
Street Address en e'' City/Town,,.v,A,1 ��Sllutte� Zi C0.A
Tele hone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS COWENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents most 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 O No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$ .
1.Building $ b 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
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 tiffs
application is true and accurate h s my knowledge and understanding.
Please print sr' e r �Q ,�A� A 1 _GTftle Telephone No. Date
s0 No/� ��r/1U7 V6/ lY( !/J�YJetaV // /� G/Y/Q
Street Address - City/Town State Zip
Municipal Inspector to fill out this section upon application approval: 1-
Name Date
a� T�-
i CITY OF &UY.M. NViSSACHUSETTS
• BUMD04G DEPART.%MNT
P 120 WASHINGTON STREET, r FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KI\IBERLEY DIUSCOLL
MAYOR T HOmAS ST.FIFAR6
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
CONSTRUCTION CONTROL DOCUMENT
Projeetritle: Salem - Dodge Street Date: Dec 18, 2014
Project Location: 211 Washington St, Salem MA, 01970
Scope of Project: Commercial tenant improvements to existing building
In accordance with SECTION 116.0-116*2 of the 8th edition of the Massachusetts State Building Code
1, Michael Coleman Mass.Registration Number 20016
being a registered professional EngineerlArchitect hereby CERTIFY that I have prepared or directly supervised
the preparation of all design plans,computations and specifications concerning:
( ] Entire Project DQ Architectural [ ] Structural [ ] Mechanical
( ] Fire Protection [ ] Electrical [ ] Other(specify)
for the above named project and that to the best of my knowledge,such plans,computations and specifications meet
the applicable provisions of the Massachusetts State Building Code,all acceptable engineering practices and all
applicable laws for the proposed project.
Furthermore,I understand and AGREE that I shall perform the necessary professional services and be present on
the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the
documents approved by the building permit and shall be responsible for the following as specified in section
116.2.2:
1. Review of shop drawings,samples and other submittals of the contractor as required by the construction
contract documents as submitted for the building permit,and approval for the conformance to the design
concept.
2. Review and approval of the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress,and quality of the work and to determine,in general,if the work is being performed in
a manner consistent with the construction documents.
I shall submit periodically,in a form acceptable to the building official,a progress report together with pertinent
continents. Upon completion of the work,I shall submit to the building official a final report as to the
satisfactory completion and readiness of the project for occupancy.
Signature and Seal of registered professional: Phone Number: 617-357-7171
Email: mcoleman@beaconarch.com
IcSVRED Apo
rFCIA
No.20a16 y yt
005 Z C
3RC g u
OF P.iP'r'gP/n
CITY OF S.U.&N4 ANLUSACHUSETTS
BUUMLNG DEP-Mn- 04-17
• P• 120 WASmNGTON STREET,r FLOOR
-0j T m (978)745-9595
FAX(978)740-9846
KIa1BERLEY DRISCOLL
MAYOR Itlotuas ST.FtERRs
DIRECTOR OF PUBLIC PROPERTY/Bt aMINGCON5115SIONER
CONSTRUCTION CONTROL DOCUMENT
ProjectTitle: STA( f(1LS Date: t%j►a tLf
Project Location: [I
ScopeofProject: _ lAf i tr"h a+e�s
In accordance with SECTION 116.0-116.4.2 of the 8th edition of the Massachusetts State Building Code
I �.,r4 V�sr±� Mass.Registration Number
being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised
the preparation of all design plans,computations and specifications concerning:
[ ] Entire Project ( ] Architectural ( ) Structural [ ] Mechanical
j ] Fire Protection [ ] Electrical K Other(specify) TLL*V_ t &
far the above named project and that to the best of my knowledge,such plans,computations and specifications meet
the applicable provisions of the Massachusetts State Building Code,all acceptable engineering practices and all
applicable laws for the proposed project.
Furthermon,I understand and AGREE that I shall perform the necessary professional services and be present on
the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the
documents approved by the building permit and shall be responsible for the following as specified in section
116.2.2:
1. Review of shop drawings,samples and other submittals of the contractor as required by the construction
contract documents as submitted for the building permit,and approval for the conformance to the design
concept.
2. Review and approval of the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine,in general,if the work is being performed in
a manner consistent with the construction documents.
I shall submit periodically,in a form acceptable to the building official,a progress report together with pertinent
comments. Upon completion of the work,I shall submit to the building of SN OF,yq art as to the
satisfactory completion and readiness of the project for occupancy. -44
gOa' JEFFREY R. CyN
Signature and Seal of registered professional: WHITE
WHITE m
MECHANICAL m
No.41477
�'0 9FG/S7ER��C
.gsslOry � '
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8`h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: 7 GTr sIeSOCKS Date:
Property Address: Z 1 I W SHM.-Toil 5T . SA L-e" HA 019 70
Project: Check one or both as applicable: 0 New construction Existing Construction
Project description: t°nloD�e�(/D6?/ pf /� ifL LKj Ns Rowe [ SYs MS
I RONaLD W,'BU 114 MA Registration Number: Expiration date: 6/�/ am a
registered design professional, and I have prepared or directly supervised the preparation of all-design plans,
'
computations and specifications concerning:
[ ] Architectural ( ] Structural [ ] Mechanical
[ ] Fire Protection ,T'fJ�[ Electrical [ ] Other
for the above named project and that to the best of my knowledge,information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR), and accepted
engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progrem reports(see item 3.)together with pertinent
comments,in a form acceptable to the buildin official.
Upon completion of the work,I sha 'submit to t I a'Final C nstruction Control Document'.
Enter in the space to the right a"we"or Vv"�
electronic signature and seal:
�7 �roAt Eli
Phone number. q78-� { 5—S1$4. Email: f�13Ui#���U�AENc�[Iueet�NG� CaM
Building Official Use Only
Building Official Name: Pennit No.: Date:
Version 06 11 2013
i CITY OF S� .EM, NIASSACHL'SEM
BuHMING DEPARnIENT
P• 120 WASHINGTON STREET,Ye FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KL%IBERI$Y DRISCOLL
MAYOR THoh1As ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIO:iER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business Organt:adoNlnd vidual):
Address: y4�� ��,,��yy�� tom $
City/State/Zip:La/1A� L I$AQ Meff 1 Phone to -4ffl '1b=
Are you as employer?Check the appropriates: Type of project(required):
I.❑ 1 am a employer with 4. I am a general contractor and 1 6. ❑ ew constrncdou
employees(full and/or pan-tithe)* have hired the sub-contractors
2_❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7. Remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance.
9. ❑building addition
(No workers'comp. insurance 5. ❑ We area corporation and its
required.) officers have exercised their IO.❑ Electrical repairs or additions
3.El t am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'romp, c. 152,§1(4),and we have no 12,❑Roof repairs
insurance required.)t employees.[No workers' D❑Other
comp.insurance required.]
•Any applicasa that chocks box NI must also till out the sectim below showing their workm'compensation policy information,
r I hxnatwnua who submit this affidavit indicating they are doing ail work and then his outside ,mr sm must submit a stew,amdavil indicating such
:Commnon that cheek this bent must attached an a.Witiami aheet showing the name of the sub racron and their woken'comp.policy inib maim.
/am an employer that is providing workers'compensation insurance for ray employees. Below is the policy and fob site
Information. AA'' AA��y� .�
Insurance Company Name: AJCAU N M
Policy it or Self-ins.Lic.#: lS'1b�L Expiration Datea '10�5 `
Job Site AtWrcss:V1 1 0 �+k• City/State/Zip.-4aa-m a#.% OI a 10
Attach a copy of the workers'compeos . a policy declaration page(showing the policy number and expiration state).
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 S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Be advised that a copy of this statement may tx forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
[do 1 u)i the
1ppaiins en/a//(Jes o'jperjary that the information provided b/ow is True gad correct
S1mlhtfe___-J�1[c�!r�S Z Date. Z�;tics
Ehunc 1; TO
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permiti'Llcense# _
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#:
VOTZE-1 OP ID: BC
CERTIFICATE OF LIABILITY INSURANCE DA10/06/D014
10IO6I2014
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 endorsements.
PRODUCER N0 EpCT Brian Clancy
Foster Sullivan Insurance
163 Main St. 'HONE .978-686.2266 ac No:978-686-6410
North Andover,MA 01 B45 E-MAIL
Michael J.Foster ADDREss:bclancy@fostersullivangroup.com
INSURE S AFFORDING COVERAGE I NAICd
INSURERA:ACADIA INSURANCE 131325
INSURED Vot2e, Butler&Associates, In INSURER B:THE HANOVER INSURANCE COMPANY 122292
44 Stedman Street Suite 8 Lowell, MA 01851 INSURER C:ST PAUL SURPLUS LINES INS CO 130481
INSURER D
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS 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 SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER IMMIDENYYYYI tMMMPJYYYYiLIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
DAMAGE TO RENTED
A X COMMERCIAL GENERAL LIABILITY X X CPA5157597 0513012014 0513012015 PREMISES Ea ocanencel �$ 250,00
CLAIMS-MADE 1K OCCUR MED EXP(My one person) $ 5,00
X CONTRACTUAL CLA5158800 05/3012014 05130/2015 PERSONAL B ADV INJURY $ 1,000,00
X XCU COVERAGE GENERALAGGREGATE $ 2,000,00
1�GEEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00
POLICY X PRO-
IFCT LOC $
AUTOMOBILE LIABILITY EOMacoNdentSINGLE LIMIT $ 1,000,00
A ANY AUTO X MAA5157598 0513012014 05/30/2015 BODILY INJURr(Per person) $
ALL OWNED X SCHEDULED BODILYINJURY Per acddenl $
AUTOS AUTOS ( )
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS _(PER ACCIDENT)
Is
J( UMBRELLA LAB I X OCCUR EACH OCCURRENCE Is 9,000,00
A EXCESS LAB 17CLAMS-MADE X X CUA5157600 0513012014 05130/2015 AGGREGATE $ 9,000,00
OED I I RETENTION $
WORKERS COMPENSATION X WC STATU- OTH-
AND EMPLOYERS'LIABILITY TORY LIMITS ER
A ANY PROPRIETOWARTNEWEXECUTIVE YIN X WCA5157602 05/3012014 05/3012015 E.L.EACH ACCIDENT $ 1,000,00
OFFICERIMEMBER EXCLUDED? NIA
(Mandatory In NH) E.L.DISEASE-FA EMPLOYEE$ 1,000,00
Use,describe under
DESCRIPTION OF OPERATIONSbel. E.L.DISEASE-POLICY LIMIT $ 1,000,00
B CRIME BDNIS51786 03/0912014 0310912015 LIMIT 2,000,00
C POLLUTION LIAB 21N17469 04/20/2014 04/20/2015 LIMIT 1,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
Additional inured with Primary And Noncontrib GL/UMB
WOS G1/Auto/Um/WC
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Sample ACCORDANCE WITH THE POLICY PROVISIONS.
EVIDENCE PURPOSE
AUTHORIZED REPRESENTATIVE
1K�
@ 1988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
CITY OF S UX..Nl, NLxSSACHUSETTS
• BuMDING DEP.sRTxL&NT
120 WASHNGTON STREET,YD FLOOR
0 TeL (978) 745-9595
FAX(978) 740-9846
KIttBERLEY DRISCOLL
MAYOR THo"ST.PIEm
DIRECTOR OF PUBLIC PROPERTY/BUILDING COND(ISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit# 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
111, S 150A.
The debris will be transported by:
CAA'o 1X*0 "VISPOWAke
(name of hauler)
The debris will be disposed of in
rSoop �c�p►1,E
(name of facility)
�°t�' �• -�� ,r, 1AA °I9bb
(address of facility)
signature of permit applicant
2Iy I2bC5
date
�cbrivll'.Jx
EEi
i0 �
d -pb CONSULTING SER VICES
50 Holt Road,Andover,MA (508)380-8460
December 31, 2014
City of Salem Inspectional Services
Attn: Plan Review
120 Washington St., 3rd Floor
Salem, MA 01970
978) 745-9595 x5641
Re: Starbucks Coffee Renovation—211 Washington Street, Salem MA
To whom it may concern,
Please enclosed plans and specs for of proposed Starbucks Coffee renovation for plan review for
a building permit approval. This is a routine renovation to give an updated appearance.
Enclosed
2 Full Set of Stamped Plans
Application
Construction Control Documents
Check for fee=$770.00
If you have any questions or require any additional information please do not hesitate to call.
Cell 603-505-5633
Sincerel
D ergrennidIr
dpb Design Consultants
50 Holt Road, Andover MA 01810
603-505-5633
danbrennan07@comcast.net
u�