257 WASHINGTON ST - BUILDING INSPECTION The Commonwealth of Massachj�u IVED
Department of Public Safely$FEC OVAL SERVICES
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a `i'wVajily ling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official
�xJ SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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(/�✓ No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2.PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ Alteration 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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ N�
Brief Deption of Proposed Work:
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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): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 5
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❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2 R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U. Utility❑ Special Use ❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a plicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB I IV ❑ 1 VA ❑ VB ❑
SECTION 7:STTE 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❑ Indicate municipal A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system( required i or trench or specify:
permit mit is enclosed❑
Railroad right-of-way: 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❑ No ❑
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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner .sec 6-
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Name(� No.and Street City/Town Zip
Property Owner Contact Information:
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Title e Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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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)
(If building is less than 35,000 cu:ft of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
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�vame(Registrant) Telephone No. a-mail addre Re ' tra on Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Compdny Name
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Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address VCity/Town State Zip
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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 signed Affidavit submitted with this application? Yes No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FtE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ Z 6;) 0 V
1.Building $ 1d d Building Permit Fee=Total Construction Cost x ( (7�yn�'it hSe
4 2.Electrical $ 11 3 t7 appropriate municipal factor)_$ .V a I 0 tI
3.Plumbing $ l k 9 f3 U
4.Mechanical (HVAC) $ , . 510 Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 2 6 006 t d� (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 this
application is true and accurate to the best of my knowledge and understanding.
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Please print and sign r}te Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
PITMAN &
WARDLEY
ARCHITECTS LLC
CONSTRUCTION CONTROL AFFIDAVIT
November 11,2014
Basement Renovation
257 Washington St
Salem,MA 01970
I,Peter F. Pitman,affiliated with Pitman&Wardley,Architects LLC submit that I,or a designated
representative,will perform the following professional services,as specified in the 2009 International
Building Code(including all Massachusetts Amendments) Section 107.3.4:
1. Review for conformance to the design concept,shop drawings,samples,and other submittals,
which are submitted by the contractor in accordance with the requirements of the construction
documents.
2. Review and approve the quality control procedures for all code-required controlled materials.
3. To be present at intervals appropriate to the stage of construction, and complexity of the project,
to become generally familiar with the progress and quality of the work,and determine to the
extent practical and possible the work is being performed in a manner consistent with the
construction documents.
Our observation during site visits will not relieve the Contractor or its Subcontractors of their
responsibilities and obligations for quality control of the work,for any design work which is included in
their scope of services(i.e. design delegation), and for full compliance with the requirements of the
Construction Documents,applicable rules,regulations and building codes. Furthermore, the detection
of,or the failure to detect deficiencies or defects in the work during our site visits does not relieve the
Contractor or their Subcontractors of their responsibility to correct all deficiencies or defects,whether
detected or undetected, in all parts of the work,and to otherwise comply with all requirements of the
Construction Documents.
Peter F. Pitman,Architect
Massachusetts Registration No. 8749
32 CHURCH ST
S AL E M
MASSACHUSETTS
0 1 9 7 0
9 7 8-7 4 4 - 8 9 8 2 CMA )
FAX 978-744-0400
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing(include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Ins ections Program
14 Fire Protection Narrative Report
15 Existinit Building Survey/Investi ation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Designor Construction for which plans are not complete at the time of application submittal must be identified herein.Work
P P PP
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
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Name(Registrant) Telephone No. e-mail address Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address
Registration Number
Street Address City/Town State zip
Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci Town State ZipDiscipline Expiration Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
t` 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,Inc
Address: 58 Glad Valley Dr
City/State/Zip. Billerica, MA 01821 Phone #: 781-953-6036
Are you an employer? Check the appropriate box:
I am a general contractor and I Type of project(required):
2 4.
1.M I am a employer with ❑ g
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New Remodeling
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.❑ 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 a new affidavit indicating such.
tConnacton 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.
I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Travelers
Policy#or Self-ins. Lic. #:7PJUB-4768P16-5-13 Expiration Date: 7/21/15
Job Site Address: 257 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains/�anndd penalties ofperjury that the information provided above is true and correct.
Signature: �f".�— Date:11/20/14
Phone#: 781-9536036
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/Ucense #
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
SUPREA OP ID:JO
;a►coRo CERTIFICATE OF LIABILITY INSURANCE ro312 DATE(
lzsno14
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS li
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and Conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsemen s).
PRODUCER CONTACT
Foeter Sullivan Insurance NAME: John DQ$IBaDIt
163 Main St. PHCN o ,978-686-2266 FAX No:978-686-6410
North Andover,MA 01845 EPAAIL
Michael Lescord ADDRESS:ldussault ostereullivangroup.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:TRAVELERS INSURANCE CO 19046
INSURED Supreme Builders and Design INSURER B:MERCHANTS INSURANCE GROUP 12775
Inc.
58 Glad Valley Drive INSURER C:TRAVELERS INSURANCE CO 19046
Billerica, MA 01821 INSURERD:
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.
ILM TYPE OF INSURANCE POLICY NUMBER POLICY
h NDCDI/YWY �D ID!YNY UNITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
A X COMMERCIALGENERALLIABILITV X 6803D251673 07/09/2014 07/09/2015 PREMISES(Ea occurrence) $ 300,00
CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,00
PERSONAL B ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE UMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00
X POLICY PRO- LOC1 1 $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00
Ee soaderrl $
B ANY AUTO MCA1001684 07/09/2014 07/09/2015 BODILY INJURY(Per person) $
ALL ONMED X SCHEDULED
AUTOS AUTOS BODILY INJURY(PeramkleM) $
X A ED ERPCCE
HIREDAUTOS AUTOS
(PER
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LMB CLAIMSWADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION XAC
STAT LIMU- X OTH-
AND EMPLOYERS'LIABILITY
C ANY PROPRIETOWARTNER/EXECUTIVEYQ NIA 7PJUB-476SP16-5-13 07121/2014 07/2112015 E.L.EACH ACCIDENT $ 1,000,00
OFFICERIMEMSER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00
0 yes,descnbe under
DESCRIPTION OF OPERATIONSW. E.L.DISEASE-POLICY LIMIT 1$ 1,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEMCLES (Anach ACORD 101,AE#Abnal Remarks Schetlule,If more space R required)
CG-LT.0 and RCG Mill Hill LLC are listed as additionally insured on the
General Liability policy as required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
RCG-LLC ACCORDANCE WITH THE POUCY PROVISIONS.
17 Iva loo St.,Suite 100
Somerville, MA 02145 AUTHORIZED REEPRESENTA/TIVE
971----/'--7J
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
![�s -lNassachuSetts 'Department of Public Safety
Board of Building Regulations and Standartt�,
Construc$ob Suo&nitiur
UC&e se CS-069628
�i
-5COTT B AyLIs
58 GLAD VALI.EX DIt, i� t
BILLERICA MA'018
t �
I r �
Expiration
�3mfc" Com_missioper 04/22/2015