0164 REAR BOSTON STREET- TBA-14-772lI>— -=1 z S f'o . `
o 2-
f — 1 3 c T as,— „, .=:..
The Commonwealth of NlassachuseEtse
Department of Public Safety
Mussachuse[ts S[a[e 6uilding Code(780 CMR)
r'_., _ 6uilding.Peimit Application for any Building other than a One-or Two-Family Dwe 'ng
Chis Section For Official Use Onl ).
Building Permit Nwnber: DaM Applied: Buildi
SECfION 1:LOCAT[ON(Please indicate 6lock k and Lot#for loca4ions fot rvhich 5 street ad'dre availab(e) •-.
S-n._ r c' /9 hb«.Fy 3+` :e6c.oi9Go 4+G S ans'
No.and Street City/Tosvn Zip Code Name oi Building(if applicable)
SECTION2PROPOSED.WORK .
Edition uf Mr\Statc Cude used_ ff New Cunstructiun dieck hcre or dieck all that apply in[he hvu rows belnw
EsisCingBuildingO` .Repair' .Alteration=O r'- •Additiun O, Demolitioii O (Plcasifi llou[ainlsubmit nppendisl)w'-z';+F ,
ChmigG of Use., ti ,Change.of Occupanry.. O . _,.,,.s O[her Specify; E
Are building plans and/or construc[ion ducumcnts being supplied as part of this permit applicatiim? Yes Q "No
fs an[ndependent Structural Engincering Pcer Revicw rcyuimd? Yes Cd' Nu
Bricf Desc ip[ion of Proposed 4Vork: // q(
fa1..' l}yeQ (27eq / BJ'e9
r
P ra/ L ii-.oa..S l_Ba—LY i r r.s b¢C--.tG+.=Y ,-kjGh a'`L`'
14 c
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDINGUNDERGOING RENOVA7'ION,ADDITION,p
L' • , - "'`' CHANGE IN USE 02 OCCUPANCY - .y Y"'.r% 3.
Check here if an Exisfing Building[nvestigation and Evaluation is encloscd(See 7S0 CMR 3 4) a
rn
Ezitting Use Group(s} f+`- - Proposed Use Group(s):z '
SECT[ON 4:BUILDING HEIGHT AND AREA
Existing P ose
No.of Ploo s/Sturies(include basement levcl.$)&Arm Per Floor(sq. ft.) U 0
Tutal Arca(sy.ft)and Total Height(ft.)
SECCION 5:USE CROUP(Check as applicable) O n
A: As`sembly A-t>A-2 Nightdub A-J A--4 A-5 B: I3usiness E:E atio b
F: Facto F-1 F2 H: Hi h Flazud H-L H-2 .H3 H-d HS
I: Institutional 1-1 l-2 f-3 I-4 M: Mercantile R: Residential R-1 R-2 R-3 R-1
S: Storage S-1 S-2 U: Utility Special Use O and vlease describc beluw:
Speci.il Usc. 5- "*;+
SECTION 6:CONSTRUCT(ON'I'YPE(Check as.a,licable)-
IA l6-O ..» • ,.,. IGC'•0 1[0 yI[Ii\ 0 '.•,.111U ' IV Vr\ - ' V6 -
SECTION 7:SITE INFORb1ATION(refer to 780 CMR t11A for dekaits on each item)
4Vater Supply: F ood Zone InformaHon:Sewage Disposal:Trench Permit: Debris Removal:
Public Check if outside Flood Zune Indicate municipol
A trench will not be Licensed Dispusal Site
required O or trench or specify:
Private,O`,.,,:; :, qr indtntify Zone: or on site system rmit is endoseJ t >c.
Ruilroad righFof-way: Hazards to Air Navigation: In ih tr u 'unnv v n itr cu i r ;.5:. _.
Not Applirnbfe O Is Structure within airport approach area? Is thcir review cumpleted?
or Consent to Build ciidus d Yes o Nu O . Ycs No O
SECTION 8:CONTENT OF CERTIFfCA'CE OF OCCUPANCY
i
Edi[ion uf Cudc: Usc Croup(s): CYVe of Construction: Ocu pant Load per Flooc .
Dues the building cuntain,n Sprinkler System?: Special Stipulations:
1 -o ' P-a,(d l r -[ / H
i
SECT[ON 9: PROPER'fY OLVNE2 AU'fFIOBIZATION
Namc und Addretis of Property Owncr 4
o a 3 •c 3SC"s96.xacl c 74 c.oy_i'Z
Name(Print) Na and Street City/Town Zip II
Property Owner Contact Information:
G/7-_ N - 7c d.Sfs' c r-t
Ti[le MC(' Tclephone Na (business) Telephone Ya (mll) e-mail address I
If applicable,the property uwner hereUy authorizes
oS+lEr-,FS'e'2 1b.d
Nvne Street Address City/Town State Zip
to ad un che ro er 'owner's behalf, imall mat[ers rel'ativc tb.work authurized U-this Guildin ermi[ar lica[ion.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2).
f buildin is less than 35,000 cu.Ct.of e iclosed s ace and or not undcr Construction Control then check here and ski Section 10.1
101 Re istered.Professional Res onsible for Construction.Conhol
tcS ib.n..s.I .Z---_i$5._,'.sG/afh 03s.sL •l.am ('Q -a/70.g'7
XN a me^(Re istrant) Telephone Nu.
t
e-m.iil address , ,y Registmtion Number
f.L12G C.i A/ L.K4 uF7-a.0 nS02c vCifC 17 /
Street Address Cty/Tuwn State Zip Discipline Ezpiration Date I
t0.2 Ceneral Conhactor
7/Y i. G»fJnui,iaj , .
Compviy Name
lr, s'1'/.r S-a oa r9
Na ie of Person Responsible for Cunstruc[ian License No. and Type if Applicable
ysy // Wav w,cLz y3
Stmet Addres City/Town , State Zip
r's- 1- s i. %.-r
Tele hune No.` 'usiness Tcic hone No. ccll c-nivl address
r,=': SECTION 11:ivor.tiF:ts'conarr 5,crio in sul::wc'ki nrFin vrr M.G.L.c.152. -25C 6
A.4Viirkers'Compensation Insunnce Affidavit from the MA Department of[ndustrid Accidents must be completed md
subniitted with this applicatioa Failure to provide this affidavit will result in the denia(of[he issuance of the building permit.
Is a si ned Affiduvit submitted with this a licatiun? Yes No
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE -
T-. "'Estimated Costs: Labor O p y pItemTohilConstruc[ion Cost from R m 6 =.`S /o.ra0[.O/und Matcrials)
K 7 07 Building Permi[Fce=Tu[al Constmction Cusl x_(Insert here
2. Electrical appropriate municipal factor)_$
3. Plumbing
I. Icchanical (HVAC) Note:Minimumfee=$.OV(mntadmunicip:ility)
5.hlechanical Other py" clbsk'chik payable to
6.Total Cost 5 ` contact municipality)and write chec iber hem
SECTION 13:S[GNATURE OF 6UILDING PERh1IT APPLICANT
By entering my name bclow,I heceby attest undcr the pains nnd penalties of perjury that all of the infonnatiom m tained in Ihis
applica ion is true and accunte to the best uf my knowledge and understanding.
G/ 689 y8-2O
C.?,1! 7 0' .,..y--1—--- y /l
Ieise prin[and sign n,me Pitle Telephune No.Date
i S- .-.--s-5, arv
Strcet Address Ci[ 'own State Zip
hlunicipal Inspector to fill nut this section upon application approval:
Name Date
I`
aoa `-''01 -4 S'nUt '.GCS
SHAWMUT METAL PRODUCTS, INC.
1914 G.A.R. Hwy. sHeerno. C oF_._.
SWANSEA, MASSACHUSETfS 02777
cai.cuuTEoev onre 2 3 / 508) 379•0803
FAX (508) 379-08].0 CHECKE68Y OATE 2G i
SK
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SHAWMUT METAL PRODUCTS, INC.
1914 G.A.R, Hwy. stteerrao. (2 oF
SWANSEA, MASSACHUSETfS 02777 ca cuuTeoev — onre Zle y
508) 379-0803
FAX (508) 379-0830 cxEc o ev DATE 3 w i
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aco CERTIFICATE OF LIABILITY INSURANCE
OATE MMIDOIYVYV) I
1/15/2014 I
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGA7IVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POIICIES
BELOW: THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: I(the certificate holder is an ADDITIONAL INSURED,the policy ies)must 6e 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
certifiwte holder in iieu of such enuarse r eni's.
PRODUCER CONTACTNFME:
AII12flt If15Uf2f1CB SBNICRS, If1C., PHONE FA%
131 Oliver Street,4th Floor C o Ext 'I- - NC No: - -]
E-MAIL
Boston MA 02110 aoortess:
INSURER 5 HFFORDING COVERAGE NAIC k
IN5URERA:
INSURED
INSURERB: (aff If1dERlfllt &Lia il an
Baltic Trail Engineering, LLC INSURERC:N vi rs nsurance Com an 2307
72 Sumner Street
INSURER D:
Milford MA 01757
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:qg p q527 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00
INDICATED. NOiVNTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IMTH 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 SHONIN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
TypE0FIN5URANCE POLICYEFF POLICYE%P
LTR INSR WVD POLICYNUMBER MMIDOIYYYY MM/DD/YYYY M TS
A GENERnLLIABIUTY Y 2DG96831304 2/30/2013 2/30/2014 EACHOCCURRENCE 1,000,000
X COMMERCIAL GENERAL LIABILITV PREMISES Ea ocwrrence 5100,000
CLAIMS-MADE OCCUR MEDE%P Anyonepereon) E10,000
PERSONAL&ADVINJURY $1,000,000
GENERALAGGREGATE E2,000,000
GEN'IAGGREGATELIMITAPPLIESPER: PRO UCTS-COMP/OPAGG E2,000,000
POLICY X PRO- X LOC PefOccurrence Detl.E50,000
A AUTOMOBILELInBILITY Y A2CA96841304(AOS) 2/30/2013 2/30/2014 Eaaccitlent g1,000,000AxA2CA96831304(MA) 2/30I2013 2/30/20'14
ANY AUTO BODILY INJURY(Per person) §
ALLOVJNED SCHEOULED
BODILVINJURY(Pereccitlenp $AUTOS AUTOS
HIREDAUTOS
NON-0NMED PROPERTYDAMAGE
AUTOS Pe accitlent
E
B X UMBRELu uAB X OCCUR Y 1000020599 2/30/2013 2/30/2014 EqCH OCCURRENCE E10,000,000
EXCE55 LInB
BE 8766155 2/30/2013 2/30/20'14
CLAIMS-MADE AGGREGATE 510,000,000
DED RETENTION$
q WORKERSCOMPENSATON 2DW9fi831304 2/30/2013 2/30/2014 X STATU- OTH-
ANDEMPLOYERS'LIABILITV YIN
ANYPROPRIETOR/PARTNERIEXECUTIVE E.LEACHACCIDENT 1,000,000
OFFICER/MEMBEREXCLUDED'!N A
ManCatorylnNX) E.L.OISEASE-EAEMPlOYE $1,000,000
If yes,tlescnEe urMer
DESCftIPTIONOFOPERATI0NS0elow E.L.[JISEASE-POLICYLIMIT $1,000,000
DESCRIPTION OF OPERATION51 LOCATION51 VEHICLES (Attach ACORD 101,AEtlltlonal Remarks Sc etlule,I/more epaee is requlretl)
Ahold U.S.A., Inc.and Its Subsidiaries and Affiliates are included as Additional Insureds as required by written contract and executed prior to
a loss, but limited to the operations of the Insured under said contract,with respect to the Automobile, General Liability and Umbrella/Excess
Liability policies.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRAiION DATE THEREOF, NOTICE WILL BE DELIVERED IN
AhOld U.S.A., InG ACCORDANCE WITH THE POLICY PROVISIONS.
do MAC Risk Management, Inc.
P.O. Box 200001
AUTHOR EO REVRESENTATIVE
Woadstock, GA 30189-0400
GU L
OO 1989•2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010I05) The ACORD name and logo are registered marks of ACORD
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8` edition of the
Massachusetts State Building Code, 780 CMR, Section 107.6.2
Project Title: O', 9 jy0 OS Date: 3 Z.f
Property Address: ("/ Nd W 1 C y T Cc/r r D y M.A, G 6
Project: Check one or both as applicable: New construction 0 Existing Construction
Project description: 'QE cr E{Z cc 5,ti T
I RFAtiI I.las(fn/ MA Registration Number: 4 L14 L Expiration date: G 3d 2+am aregistereddesignprofessional, and hereby certify that I have prepared or directly supervised the preparahon of all designplans,computations and specifications conceming:
Entire Project Architectural Structural Mechanical
Fire Protection Electrical Other
for the above named project and that 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 theconstructionsiteonaregularandperiodicbasisto:
1. Review, for confonnarice to this code and the design concept,shop drawings,samples and other submittals by thecontractorinaccordancewiththerequirementsoftheconstructiondocuments.
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 prog5ess!andx,,yqualityoftheworkandtodetermineiftheworkisbeingperformedinamannerconsistentwiththeaioVed -"'' ',construction documents and this code. ppF.` r Mqs J .
When required by the building official, I shall submit field/progress reports (see item 3.)together with pertinem s9'
i,comments, in a form acceptable to the building official. i &Rl N J. ro
i Kavar;?o4H $
Upon completion of the work, I shall submit to the building official a `Final Construction Control Docum nt°.
SrRUCTU;t'lL
y 0.41 42 o
2.A, ir r'ST . .k.i .
Enter in the space to the right a"weY'or SS
electronic signature and seal:
zti:.t- a '
Phone number: Q{p O OT Email:_ yq/y,µf}V(py C g CC N
Building Official Use Only
3uilding Official Name: Permit No.: Date:
rial Version 10 09 2012
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Cuns[ructiun Supen isor
License: CS-072849
t i:.
E
JAMES E HAI.LO}YAN
202 COUNTRY CLifli '`
IPSWICH MA Of938 Fa
J y j,,.>" Expiration
Commissioner 02/17/2016
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(991m')of
enclosed space. i
Failure to passess a current edition of the Massachusetts
State euilding Code is cause for revocMion of[his license.
For DPS Licensing information visit: www.Mass.Gov/DPS
ry ;,
CITY OF 5 1LEl,f, C-15.1CHUSETTS
i . C(LDL 1G DEA R'I1tErT
I O 1V.ISHCYGTON S'CAEgT, 3AD.pp2
i a 7 s-5 s
F.ti c»a aa sas
1Cl1tHE1tLEY D2ISCOLL
L YO:t Tt-toaL s ST.PisRnB
D(ZECTOR UF P BLIC PROpERTY HCiLDL(G CO\L(ISSiOVER
t,'onstructiun Debris ,isposal At'tidavit
requirad tor all dcmolition and renuvation work)
In accordance with tlie sixtlt editiun of the State Building Coda, 730 CNfR section l I I.5Debris, ittd die provisions uf fGL c 40, 5 54;
Huilding PeRnit # is issued with the condition that the lcbris resuJting Fromthisworkshallbedisposcdofinaproperlylicensedwastedisposaifacilityasd6ncdby IGL clll, S ISOA.
I'he debris will be transportcd by:
y
y
name aFltauler)
Che dcbris will be disposed ot in :
nama ot Facility)
address oF taeility)
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The Stop & Shop Supermarket Company LLC
Apri12, 2014
Michael E. Lutrzykowski
Assistant Building Inspector
City of Salem
120 Washington Street
Salem, MA 01970
RE: Super Stop & Shop #005
164 Boston Street, Salem, Massachusetts
Dear Mr. Lutrzykowski:
The undersigned, The Stop & Shop Supermarket Company LLC ("TenanY'), is the tenant
of the entire property containing the above store and associated parking pursuant to a
financing Sublease dated February 12, 2001 entered into with Ahold Lease U.S.A., Inc,
an affiliate of Tenant), as landlord ("Landlord"). Pursuant to the provisions of said
Sublease, the Tenant, as master tenant, has the right to apply for any and all variances,
special permits, zoning changes or other federal, state or municipal permits, approvals
and the like, in its name or, if required, in the name of the Landlord.
This will confirm that Baltic Trail Engineering ("Contractor") has our consent and is
authorized to file application(s) for any and all permits necessary to perform the produce
cooler box rebuilding work to be performed by Contractor at this location.
Should you have any questions require any further information, please do not hesitate
contact our representative, Rhonda Torcoletti, Manager—Vendor Sourcing, Maintenance,
at 617-770-8846.
Sincerely,
The Stop & Shop Supermarket Company
LLC
By
Name:
Title:
Ahold USA, Inc.
1385 Hancock Street
Quincy, MA 02169
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