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29 WINTER ISLAND RD - BUILDING INSPECTION (4) ARCHITECTURAL SERVICES d -pb24 Rockridge Road, Hopedale, MA 01747 (508)380-8460 January 23, 2007 City of Salem Building Department 120 Washington Street Salem, MA 01970 RE: Starbucks Coffee, 262 Highland Ave, Salem, MA To whom it may concern, In accordance with section 116.0 of the Massachusetts Building State Code, I, Kevin T. Triplett, Registration No 4530, 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 the tenant fit-up for the above referenced location, and that to the best of my knowledge such plans, computations and specifications meet all applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and applicable laws and ordinances for the proposed use and occupancy. Please do not hesitate to call myself or Daniel Brennan, Project Manager, if you need any additional information. Sincerely, �5<ti ©pR�yir Q�t> 5.TRP�F FpT No. 530 o STON, Kevin T. Triplett Fq<TH OF MPS�P Date Notary Public My commission expires: EILEEN P.DONOVAN 999 qA Notary Public 11M�Y618y Commonwealth s on Expires Massachusetts My Commission Expires June 15,2012 CSI New England 1 Mann Braga Cell 401-338-7597 Fax 508-336-4837 mbraga@iwon.com `, ro. h° . .,gip 'T`r q.:• n, a. _. or Permitting-"sSite Visits - Meetings & Reports As-Built Docume_ntation'- Photo Documentation ,Owner/A&E Iritt rface-Verid'or Selection N. Concept Development Renderings` ` Materials & Finishes Specifications & Resources tRestaurant Equipment Specifications v&tures, Equipment,Signage_& Graphics. Procurement ,` • N-�,-A - CITY OF SALEM �• PUBLIC PROPERTY DEPARTMENT KISntERLEY DIUSCOLL MAYOR 12o WAININ TON STREEY•S L cu,AfAS'SACHCSE'M 01970 TIeL 978-745-959S• FAX:979-740-9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) 1n accordance with the sixth edition o�he State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40. . 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 dis 1L1,S150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : �aDk S . �' Gi ilc+ �z 7'j (name offaclht (address of facility) signature of per applicaat date .Ie6iis�17.dut ice:', .+• y ?CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT t KIMBERLEY DRISCOLL MAYOR 120 WASHINGTON STREET♦SALEM,MASSACHUSETTS 01970 TEL:978-745-9595 +FAx:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apiffleant Information Please Print Le ibl Name (Business/Orgmization/Individual):_ Lyct/ O Address:—If 5 n 10 P� .5-� City/State/Zip: Y �r Co �c� 114 Phone #: Are ypu an employer? Check the appropriate box: 1. I am a employer with H 4. Q 1 am a general contractor and IFyP e of project(required): employees(full and/or part-time)—me).+ have hired the sub-contractors ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 1 ❑ Remodelingshipandhave no employees These sub-contractors have DemolitionErEquired.] g for me in any capacity, workers' comp. insurance.orkers' comp. insurance 5. ❑ We are a corporation and its ❑ Building addition officers have exercised their 10.❑ Electrical repairs or additions homeowner doing all work right of exemption per MGL 11.0 plumbing repairs or additions [No workers'comp, c. 152, §1(4), and we have noce required.] r employees. 12• oofrepairs [No workers' comp. insurance required-] 13•0 Other •Any applicant that checks box#1 most 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 than hire outside contractors must submit a new affidavit indicating such. [Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I an;art employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1 4/24/2L 2_i/� Policy#or Self-ins. Lic. #: Z? (' 'ZC�rjC= 3 9n/ ��•I Expiration Date:_��G 7 ' Job Site Address: 222 W1,7 e - ::[S oel( City/State!Zip:_.�/Jf�c_�t- 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 tine 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$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 D1A for insurance coverage verification. I do hereby certify under the pains and penalties ajperjury that the information provided above is true and correct. Sit�nahire: , Date: Phone#: — —ff. L 770nly. Doonly. Do not write in this area, to be completed by city or town offrciaLn: Permit/License# hority(circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son:_ Phone#: - -AUG.`23-. 2006 9:10AM ASSOCIATED INSURANCE NO. 8650—P. 1 YIfERTIFICATE OF INSURANCE IS °"'Z""°°"" PRODUCpa ' IN TION OHI,Y AND c�oPSIFEas xo alGz s tmox�%caRru lcATc IroLDEa TBms ceer¢ncAT� Prestige Insurance Agency DOLj NOT BELOW,1 EXTEND oA ALTFR[ COvFBAGE AFFORDED sY 7 HE 14 North Main Street COMPANIES AFFORDING COVERAGE Middleton. MA 01949 INSURED Salvatore Guarino Lima`Y A A.T.M. Mutual Insurance CO dba S Guarino Company 115 River Street Middleton, MA 01949 COVERAGES RAGES IS TO CERTTFYTH E AT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 65USD TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUDUENWNT,TERM OR CONDTTION OF ANY CONTRACTOR OTHERD000MLN r WITH RESPECI 10 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRJBSD HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES- LDSl't'S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. RVXCY EFFECTIVE POLICY E%YOtA LDA1's COTYF&OII DdUR11NC6 POLICY Nu6[BfiA DATBIMMIDDIYT) DATE(MMAMNY) GENERAL AGGREGATE S L[ADNTY COMMERCIAL GENERAL LIABILITY PRODGCTSSOMP/OP AGO. S AIMS MAOE E mfl RMNAL d nM INIURY ! WNER'S 6 CONTRACTOR'S MOT. EACH OCCURRENCE f FIRE DAMAGE(AA m fire) S FD,EXPENSE UM om{cr S VIOMORDE ANY A LIADILTIY COMBINED MOLE f MIT ILL OWNED AIIfOS OORLY_Y TnIIL'ICY y Rr SCHEDULED AUTOS i ED AUTOS ODRY INJURY S YCihN) NON.OWNED ALTOS GARAGE LIABILITY ROPERTY DAMAGE S ACH OCCURRENCE S LESS LLABILITY AGGREGAtE f 'MBREW.A FORM I I THEN THAN UMBRELLA FORM W ATU• WF- WORKER'S COMPENSATION AND EMPLOYERS'LIABILITY f ' 7008319012000 06/23/200G i 06/23/2007 5D0 UUo A THE MOPRIETON INCL 1 DISEA E- 1 WnS1 S M PARTNERSMKSCUTIVE x ELDIS nA"EAEM YEE f 100.Oa0 OFFC PA ARE ODREX ESCRIPITON OF OPER nONSHACATIONS'YEBTCLESISPEOAL ITEMS CERT IFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DFSCRJBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO City Of Salem MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO TIME LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Erry`OL S __ PUBLIC PROPERTY DEPARTMENT Kimanu.EY DRISCOL L MAYOR M WASHINGTON STRFFr•S ALA MAISACHl:5h1lS 01970 - . 1Fi 978-745-9595• F=978-740-98" APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: I ; Building: Property Address: jt�,2, 1vt a v y'i ✓� Property idiocated in a; Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: y z L Address: p pp /79 4�, �W o%f Or/ Ve, --- 7a 50TCJ A),T 09ns Z Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use ` ) ( � New Demolition Existing .• Approximate year of Area per floor (so Renovated construction or renovation of existing building New J Brief eDdelscriptnf Proposed Work: 9n ` ��fv Gi �v� 1fU N -For yvc—, r 3llz>c- �fi�r vtcXa c7 Mail Permit to: Z-54 Zy�66 1 1f4;,q OIL )-- What is the current use of the Building? Material of Building? *sari If dwelling, how many units? Will the Building Conform to Law? Asbestos? Architect's Name ptT7J Address and Phone Z O Mechanic's Name Address and Phone Constriction Supervisors License# HIC Registration#_--- Estimated Cost of Project$ ``� U i7 Permit Fee Calculation Permit Fee $ Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercial i An Additional $5.00 is added as an 0 Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building�P[ermit bu I t the ove stated specifications. Signed under penalty of perjury /� Date Y 3 4'�1 v o NJ _ C - O, tJ L G ,