211 WASHINGTON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
•�,, L�;f � Department of Public Safety
.\lassachusetls State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family D 4ellin4
(This Section For Official Use Only)
I) i-Iding Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a stri t address is no av I le)
B mac. f Cd FFeE
No. and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
/ If New Construction check here O or check all that apply in the two rows below
Existing Building❑ Ri Alteration ❑ 1 Addition ❑ 1 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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief
/nDescription f Pro used o
`QS C/ I Yi zi eD I
/ Id! 1111
i✓l — All — cF
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑ '
Existing Use Group(s): Z Proposed Use Group(s):
Existing.Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area ("I ft.)and Total Height(ft.)
SECTION 5: USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: BusinessMR-313
l O
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2 ❑ H-3
1: Institutional 1-7 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-1❑Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use ❑and plea
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA ❑ Ill ❑ IIA ❑ IIB )d IIIA ❑ IIIB ❑ IV ❑ 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�, Check if outside Flood Zone ❑ Indiorte municipal (� \ trench will nut be Licensed Diapusal hite_x
PI kale ❑ or indentifk Zone:_ or on site svrtem ❑ required ❑ur trench Or.pecilc:
permit is enclosed ❑
Railroad right-of-wa_Y: Hazards to Air.Navigation: VA 11"I.o..r Cnnmi��iin Kvcir++ i'n�r,.,; _
\nl :\pl+likable ❑ I.tilruklure�cithin airport appn ach area' I.thco rek icw cmilplelvd'
.a'l un.cnl 6l Build CoClo.ed ❑ Ye.< ❑ nr\'o❑ Yes ❑ \n ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
1[.iunm ,dC ode: L.c•Gawp!>1: rk pe.d( on.trukhun: l)crtt pant Load per Fk,m
I)-', thc•bmldml;conlainan Sprinkler tikHcm': Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
_.
dame and Address of Pru perh'Owner
_/91'c UZ 17 ZvaLaosf 5re IGo SomF✓z�
:Name(Print)
No.and Street Cit,'/Town Lip
Property O%N ner Contact Information:����rr77
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 pru periv owner's behalf, in all matters relative to work authorized by this building permit a > >lication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,1R10 cu. ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10 1)
10.1 Re istered Professional Responsible for Construction Control
t
Name(Registrant) Telephone No. _ e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
o/Ln,4 onl SQ ui ✓/ T L
Co7j}in��VVName:
/Ca{1(r 2�`
Na e of Per , Respons bit or Cunstntctiun License No. and Type if Applicable
3 LYRE /�ii� _S6o,#I"gry _ -Zzw- av
Str et A d gess City/Town State Zip
- �iGO =—
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION 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 si ned Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ od Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ 010 appropriate municipal factor)_$
3. Plumbing $ Sd0
Note: Minimum fee=$ (contact' unicipality)
4. Mechanical (HVAC) $
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ ^jg (contact municipality)and write check number here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby atte. der t e pains and penalties of perjury that allot the information contained in this
application is truee/and accurate to . t of in wledge and understanding.
052AG-(4 W- -o-cq-7.
Please print and n l nai e Title Telephone No. Date
97
<Iieel Address ) City/Town tote
Municipal Inspector to fill out this section upon application approval: 0
Ime Dale
CELL:(401)-338.7597
- TEL: (508)-679.2500
FAX: (508)-679-2600
MANN BRAGA
Project Consultant .1
CORNERSTONE
lill
DESIGN/BUILD SERVICES, INC.
163 GRAND ARMY HIGHWAY-SWANSEA,MASSACHUSETTS 02777
mbroga@iwon.com
CITY OF S.U.EM, ANSSACHUSETTS
KI DING DEPART\ ENT
120 WASHINGTON STREET, r F100R
'a TM (978) 745-959S
FAX(978) 74CI-98U
lV.(BFjUEY DRISCOLL THoms ST.PtEm
MAYOR
DIRECTOR OF Pl:BCIC PROPERTY/gl'QDING COSMRSS10NElt
Workers' Compensation Insurance AlTtdavit: Builders/Contractors/Electrictans/Plumbers
A ) Ilcant Information i I Print e
G '
Valnt tdvsirwv.Orgmsizmion.In�LviduahY�� /G 7rJ O/f� ✓ • lG�!/ G
c-i Address: Z61 64A
City/State/Zip: Phone H:
Are you as employer?Cheek the appropriate boa: Type of project(required):
1.W I am a employe with /1 4. 0 1 am a general contractor and I
employees(full and/or part-tie).• have hired the sub-contractors 6. ❑New construction
m
2.0 1 am a sole proprietor or partner. listed on the attached shceL : 7. 0 Remodeling
ship and have no employees These sub-contractors have V. 0 Demolition
workingfor me in an capacity. workers'comp.insurantx
Y P tY• 9. 0 DuiWing addition
(No workers'comp. insurance S. 0 We are a corporation and its 10.❑Electripl repair of additions
required.] offices have exercised their
3.0 i am a homeowner doing all work right of exemption per MOL I I.0 Plumbing repairs or additions
myself.[No workers'comp. C.
152.41(4),and we have no 12.0 Roof repairs
insurance required.] t employees.[No workers' 13.0 Othe
comp. insurance requited.]
•Any 4pplirant this Chocks Eon rl mull JIM fill out the srctian belotr showing their worken'wngenrylun policy infunnaeua
'i h neuwnua who subnd this aflhtwB indicating they an,doing all work and than him outside contractors mans sultsnh a n na anidevil indicatitg suck
{',mtra•ton thin chock this has mud attached an sklitival shows showing do osser of do au►-canUactom and their ww%m•comp.policy infommause.
/um an employer that Is prov/dlnR workers' onepereredoe lasturanee for my employets, at/ow/s rht polfly and fob sUe
injormwion. / _
Insurance Company Name: _! L T2/fof, �125 1ti p
Policy 4 or Self-ins. Lic. p: X64C/2-LA-9 ZY C - -G Expiration Date: 7 I-7 BEd
Job Sire Address: Cz/1 City/Stawzip:
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 S 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 5250,00 a day against the violator. Ile advised that a copy of this statement may be rurwarded to the Office of
Invnitg4tiona ul'oui nIA for insuran ovcr •rificafion.
/Jo hereby arnij=Iimsper/ury`rear the 'formurlow provided
qu y/r is rut and currtreY
,zno i i r ' / L ? f
hone A' e Dutet % �-7 09
P J` �2 10
iOff7ciul use duly. Dd nor write in this urea,to be:umpleted by city or town o/f eial
I
City or Tuwn: _- _ Permit/l.lcense
Issuing Awhonly (circle one): -- -- - -
I. Huard of livAlh 2. Ruilding Department J.City/town Clerk 4. Electrical inspector 5. Plumbing Inipeetor
6.Other
Guuact Person:__ ._. _. Phone ill:
FROM newport insurance (WED)JUL 29 2009 8:45/ST, 8:44/No.7500000601 P 1
A WRA CERTIFICATE OF LIABILITY INSURANCE I `7/Agj091
PRODUCER (401)619-1660 FAX (401)619-2689 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Newport Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Admiral 's Gate Tower HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
221 Third Street
Newport, RI 02840 INSURERS AFFORDING COVERAGE NAIC e
wsuReD Cornerstone Design/Build Services, Inc INSURERA: St. Paul/Travelers Ins. Co. TPC001
163 WR Hwy INSURERB:
Swansea. MA 02777 INSURERC:
INSURER D;
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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.
.INSR 400-1. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
DATE IMMInDNYI GATE IMMMONY1
GENERAL LIABILITY DT-CO-978K7S18-COF-08 07/19/2009 07/19/2010 EACH OCCURRENCE S 1,000.00
X COMMERCAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,00
PRFMIql`q IF,
CLAIMS MADE O OCCUR MED EXP(Any One person) E 10,00
A PERSONAL S ADV INJURY 9 1,000,000
GENERAL AGGREGATE S 31000,00
GENL AGGREGATE LIMIT APPLIES PF,R: PRODUCTS-COMPIOP AGO S 3,000 00
POLICY M PIEOOT LOC
AUTOMOBILE LIABILITY UT 0-810-978K7518-COF-08 07/19/2009 07/19/2010 COMBINED SINGLE LIMIT
X ANY AUTO IEe accident $ 1,000,000
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per Person)
A HIRED AUTOS
tlOUILY INJURY E
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE S
(Per,cu00n1)
GARAGE LIABILITY ALTO ONLY-EA ACCIDENT S
ANY AUTO OTHERTHAN FAACC S
AUTO ONLY: AGO $
EXCES9NMBRELLA LABILITY DT M-CUP-4217L829-TIL-08 07/19/2009 07/19/2010 EACH OCCURRENCE E S 000,0001
OCCUR ❑CLAIMS MADE AGGREGATE $ _ _ S1000,OQ
A E
DEDUCTIBLE S
X RETENTION S 10,00 E
WORKERS COMPENSATION AND OTACR-US-97SK751-8-08 07/19/2009 07/19/2010 wc; TATU- X oTH-
EMPLOYER9'LABILITY
,A ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 11000,000
0WICERIMEMBER EXCLUDED? E.L.DISEASE.FA FMPI OYF. E 11000,00
II ym%.no%cri0e under
SPECIAL PROVISIONS 0910w I I E.I.DISEASE-POLICY LIMIT E 1,000,00(4
OTHER
DESCRIPTION OF OPERATIONS 1 LOCAnON9 I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
ERTIFICATE HOLDER ANCELLkTION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE 15BUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILRY
OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
AUTHORITFn REPRESENTATIVE )
Lauren Gillis/NEWLGI
ACORD 25(2001108) BACORO CORPORATION 1988
Starbucks Coffee
211 Washington Street—Salem, MA
Cosmetic facility maintenance of existing Starbucks,
Existing space contains 1,200 Sq. Ft with 17 Interior Seats
Occupancy A2,Type of Construction 2B
No changes to basic layout, egress, seating,fire safety systems.
11
Scope of work—Narrative—9/14/09
Cosmetic remodel to introduce new design elements, repairs to existing conditions, replace worn-out
elements as required (Furniture, Fixtures, Equipment, Lighting, Wall & Floor finishes)
1. Remove selected casework and replace with new design G2,AO,A7,7.1,7.2,7.3
2. Construction Plan A2,2.1,A3,3.1,5.1,5.2,5.3,5.4,A7,7.1,7.2,7.3,7.4 includes casework&details
3. Remove specific Plumbing& Electrical connections from existing equipment in casework
G2,AO,A2,A2.1, P2, P3, E2, E3 and replace in new casework
4. Patch& repair existing Soffits as required to match revised casework layout G2
5. Remove and relocate existing or new lighting fixtures, per design G2,AO,A3, E2,E3
6. Repairs to flooring in Backroom areas and in Common&work area AO,A4,4.1
7. Replace all Tables, Chairs, Furnishings with new design elements G2, A8,A8.1
8. Paint all walls&soffits as required G2,A5,5.1,5.2,5.3,5.4
9. Remove& replace plumbing connections as required G2,A2,A8,8.1, P2, P3
10. Life&Safety review Gi
11. Existing Equipment Legend AO,A5.3,A8.0,A8.1, P2, E2.0
Contacts:
Starbucks: Rich McLivene—617-694-8204 cell—rmcilven@starbucks.com
Permitting: Mann Braga —401-338-7597 cell—mbraga@cornerstonedesignbuild.com
Contractor: Cornerstone—508-679-2500—rsanford@cornerstonedesignbuild.com
Proposed Construction timeline:
Projected Start: 11/2/09
Projected Completion: 11/13/09
Punch List/Add List TBD
CITY OF SALEM
PUBLIC PROPRERTY
.V DEPARTMENT
is C,I IL RI El I'HNA''1 I.
M 120 W.N.I 11NGION$fHLLT 0$.\I FM, MASS%( If SI I 1S 3"'—
1F1: 178-'43-9595 • I'AX:978-74C✓)846
�-u
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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The
eeJdebris wwill be
transported/by:
Iname of hauler)
The debris will be disposed of in
(address or Facility)
signature of lxnnit applic t
date
,Iola ra(I d,k -
CS1 New England
Construction Support
10/15/09
City of Salem
Public Property Department
120 Washington Street
Salem, Massachusetts 01970
Attn:Joyce Bilodeau
RE: Change of Licensed Builder- Permit#0287-10
Starbucks remodel
191-211 Washington Street
Salem, Massachusetts 01970
Dear Mrs. Bilodeau
Starbucks has elected to hire another general contractor for this project based on work schedule and
project timing.
The attached documents are being submitted to replace Cornerstone Design/Build Services, Inc. and
provide the documents for the new contractor:Timberline Construction, construction supervisor will be
Robert J.Zeuli and a copy of his license is enclosed along with all of the required documents from
Timberline Construction to include:Agent authorization, Letter of Intent for construction budget set by
Starbucks, Mass Workers Comp.Affidavit,Certificate of Insurance, Debris Disposal Affidavit.
Feel free to contact me with any questions.
Regards,
z 2- i:: ,-- , President
Mann Braga
20 Commerce Way
Suite 12 - PMR 305
Seekonk, MA02771
Cell 401-338-7597
Fax 508-336-4837
191-211 WASHINGTON STREET 287-10
G 779 COMMONWEALTH OF MASSACHUSETTS
Map: 34
Block: ;^ CITY OF SALEM
t: 0a 1 s
Category: REPAMIREPLACE
1perntit# f287-10 --. BUILDING PERMIT
!Project# 13S-2010-000409
Est. Cost: 5S33,500.00
Pee Charged: S423.00
Balanf-- a Due: {S.00 PERMISSION IS HEREBY GRANTED TO:
jConst Class: Contractor: License: Expires
EUse Group: iCornerstone Design/Build Services Inc.
Lot Size(sq. ft.): 33349.9716 —j owner: DODGE AREA,LLC,C/O RCG LLC
Zoning: B5
Units Gained: 1Applicant: Cornerstone Design/Build Services Inc.
Units Lost: iAT: 191-211 WASHINGTON STREET
IDig Safe#: 1
ISSUED ON: 13-Oct-2009 AMENDED ON: EXPIRES ON: 13-Mar-2010
TO PERFORM THE FOLLOWING WORK:
MAINTENANCE WORK TO INCLUDE PAINTING,REPAIRS TO EXISTING CONDITIONS REPLACE WORN OUT
ELEMENTS AS REQUIRED NEW TABLES&CHAIRS LIGHT FIXTURES& SOME COUNTER TOPS&WALL FINISHES
&FLOOR REPAIRS NO CHANGE TO#OF SEATS,EGRESS,jbh
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Buildin
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chinmey:
D.P.W. Fire Health
Institution:
Meter: Oil:
Final:
House# Smoke:
Rater: Alarm:
Assessor Treasury:
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOL AT N ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
f BOILDINGj : An lrSr,r't.;(iC<p� 1 R C$2010-000499'.itREI) 13-Oct-09 29 1 . 5423.00
upon COmp,etron of work pease f _ Call for Permit to Occupy
978-619-5641
C.eoTMS®2009 Des Lauriers Municipal Solutions,Inc.
CORNERSTONE
DESIGN/BUILD SERVICES, INC.
10/15/09
City of Salem
Public Property Department
120 Washington Street
Salem, Massachusetts 01970
Attn: Thomas St. Pierre
Building Commissioner
RE: Change of Licensed Builder - Permit # 0287-10
Starbucks remodel
191-211 Washington Street
Salem, Massachusetts 01970
Dear Mr. St. Pierre
Please be advised that on or after October 15, 2009 I will not be in charge and control of the work at the above
referenced project. Starbucks has elected to hire another general contractor for this project.
Feel free to contact me with any questions.
Regards,
Cornerstone Design/Build Services, Inc.
sp^�
Bv: I %1 President
Robert Sanford
CS License Number 053393
License Expires: 12/30/2009
163 Grand Army Highway—Swansea,MA 02777
508.679.2500 Phone 508.679.2600 Fax
www.comerstonedesignbuild.com
} — '". Ala�ti ichuutt� Dyt u'tmcnt of Public S it'ctc
/! Board tit-Budthn , Regulations and tit inil.u•tls,.
-Construction Supervisor-License.
License: CS 92477
Restricted to: 00
ROBERT J ZEULI c,
26 DONNA ST
PEABODY, MA 01960
Expiration: 1118/2010 t
(5nnmi>simu•c' Trp: 6397
r '
o
10/15/09
To whom it may concern,
This letter is to authorize Mann Braga to act as Representative/Agent for Timberline Construction for Construction Support
Services to include Permitting required for Building Permits for various projects within the State of Massachusetts and
Rhode Island..
Representative's Name: Mann Braga—CSI New England
Business address: 20 Commerce Way, Suite 12
Seekonk, MA 02771
Personal Address: 2 Mt. Hope Avenue
Swansea, MA 02777
Phone: 401-338-7597
11
7U-
Rdbert Z ul
Field Superintendent
Timberline Construction
MA-CS#92477
Date: 10/15/09
State of: Massachusetts
County of: Norfolk
Then personally appeared the above named Robert Zeuli and acknowledged the foregoing instrument to be
his/her free act and deed, before me.
Notary Public Signa re
My commission expires: 1/21/2016 A SHARON C MOWRY
NdWPrA ;c
COMY
Print name: Sharon C Mowry NNWEWN.OF vaSSACNJ$Errs
. My Ca+rtmission Expires
Jamzary_: 2U16
We 00 Mwoof
0
10/15/09
City of Salem
Public Property Department
120 Washington Street
Salem, Massachusetts 01970
RE: Starbucks remodel
191-211 Washington Street
Salem, Massachusetts 01970
LETTER OF INTENT
Please be advised that the intent of the construction services shall be to alter an existing space per construction
documents provided by Cubellis, dated 9/10/09 with a proposed budget of$38.500.00
The proposed budget allowances for the purposes of permitting are as follow:
Building $ 25,500
Electrical $ 6,500
Plumbing $ 6,500
Mechanical N/A
Fire Protection N/A
The terms of this agreement will be submitted in the form of an AIA Contract between the parties prior to the start of
construction.
r/b
41
X-
Robert Z li
Field Superi tendent
Timberline Construction
The Commonwealth oflllassachaselts
Department of Indrrsh ial Accidents
Office of Investigations
600 Tfashington Street
Boston, DI t 02111
tilt vir.nrass.gov/din
Workers' Compensation Insurance AffidaNzt: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Le bly
Name (ButsinessrOrganiz tion/Indi< (hnl): Timberline Construction Coro
:Address: 300 Pine Street
City/State/Zip: Ca to 0?02 Phone #: 3 39-502-5000
_Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am employer with .70 4. ❑ I am a general contractor and I
6. ❑ New construction
employees(fall and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ®Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
%vorkiug for me 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.❑ I am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or additions
myself. [No workers' comp. c. 152, y 1(4), and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 1''❑
;Any applicant that checks box A must also fill out the section below shouting 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 indication such.
lCoutramors that check this box must attached an additional sheet showine the name of the sub-coatmeton and their workers'comp.policy information.
I ant an employer Dial is providing workers'conrperrsotion insriraitee for n{r employees. Below is the policy and job site
Information.
Insurance Company Name: Commerce&Indusily
Policy#or Self-ins.Lic.#:_WC5317492 Expiration Date: 3112/1/10
Job Site Address: 191-211 Washington St City/State/Zip: Salem, MA
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 aud/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 a ;&ander Utep is nd penaliles ofperfary that the information provided above is trite and correcl.
Sie tatlre: Contract Manager Date: 10 15/0 9
Phone#: 339-502-5000
Official rise only. Do not virile try this area,to be completed by eity or tolvit 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#:
Client#: 23415 •TIMCO1
ACOR& CERTIFICATE OF LIABILITY INSURANCE 1DATE 0061200M/�9 n
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Sullivan Insurance Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
One Chestnut Place HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
10 Chestnut Street
Worcester,MA 01608-2804 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER& First Specialty Insurance Corp.
Timberline Construction Corporation INSURERB. North River Insurance Company
300 Pine Street INSURER O: Commerce&Industry
Canton,MA 02021
INSURER D: Travelers
NSURER 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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.
POLICYEFFECTIVE POLICY EXPIRATION
LTR INSRE TYPE OF INSURANCE POLICY NUMBER DATE iMMIDDIYYI DATE D LIMITS
A GENERAL LIABILITY IRG996113 06/20/09 06/20/1 O EACH OCCURRENCE 211.000.000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $50 OOO
CLAIMS MADE a OCCUR MED EXP(Arty one Person) $
X Deductible$10,000 PERSONAL B ADV INJURY $1 00O 000
Per Claim GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000
POLICY j Co- LOC
D AUTOMOBILE LIABILITY 810977KB104 08/23/09 06/20/10 COMBINED SINGLE UMIT
X ANY AUTO (Eaacndenl) $1,000,000
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per pers)n)
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGO $
B EXCESS/UMBRELLA LIABILITY 55330924467 06/20/09 06/20/10 EACH OCCURRENCE $10 000 000
X OCCUR CLAIMS MADE AGGREGATE s20,000,000
DEDUCTIBLE $
RETENTION $$O 1 Is
C WORKERS COMPENSATION AND WC5317492 03/12/09 03/12/10 WC STATU- OTH-
EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $1 000 000
OFFICERIMEMSER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1 000 000
If yes,descdbe under
SPECIAL PROVISIONS be. E.L.DISEASE-POLICY LIMIT $1 000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
RE:Evidedence of Insurance for obtaining building permit
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Evidence of Insurance DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL An DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SMALL
IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE_
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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 endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
CITY OF SALEM
,. 1 PUBLIC PRO PUBLICPRERTY
DEPARTMENT
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Construction Debris Disposal Affidavit
(required fur 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 It ._ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
11, S 150A.
The debris will be transported
by:
(name of hauler)
The debris will be disposed of in
(flame of facility)
laddrcss ul'licilny)
signature of lxnnit applic t
date