25-27 BRIGGS ST - BUILDING INSPECTION a /6
The Commonwealth of Massachusetts
Department of Public Safety
f A:,_„✓
Maslduuetts State Building Code 1780 CNIR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
(This Section For Official Use Only)
Budding permit Number: Date Applied: Budding Inspector:
SECTION l:LOCATION (Please indicate Block s and Lot N for locations for which a street address is not available)
No.and Street Cite /Town Zip Cote Name of Building 01'applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repairy I Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
Changeof Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No tGK/
i Is an Independent Structural Engineering Peer Review required? Yes ❑ No tY
Brief Description of Proposed Work:
CS-
_.
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) O
Existing Use Group(s): Proposed Use Group(s): f
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A. Assembly A-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional 1-1 ❑ I-2 ❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-t❑ R-2❑ .R-3❑ R-4❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 111 IIA ❑ IIB ❑ 111A 13 [118 ❑ 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❑ C hvcl, if uublde 171ood Zone❑ Indicate mumapal❑ \ trench will not la: Licensed Disposal Site❑
I'] nr mdenufc Zone._ or on.de,v,tem❑ regwred ❑ur trench or�pca/v:
permit is enclosed Cl _
Railroad right-of-way: Hazards to Air Navigation: \I:\ 16d�•r., c-,•nnni��nn It.,i,., ('r.",..:
\at 1 ii.)blc❑ I.Sfruaurc..rthm air rtt,� wach arra' 1.their rr.iew cmpuIclyd'
f i )" pp'
. r C 1 mvnl to Budd vndo'ed Cl I }r.❑ or.\u❑ }'c•.❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I.,Llwil I kde _..__ LC, f.pvot CanNnictam: OCCoF+ant Load per f6u,r
Uuo� thr buddu,�;:ont.un an SpnnAler».tcm' >praal?upulauuns
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
95 ?3 tmc S�(?D LlL 2s-�1 Ti9lS S4reai- SCtoflxw MA
Name(Print) No.and Street Cite/Town Lip
Properly Ch%ner Contact Information:
Sylnnn�or- Se� !-�tl�vrar��j��:- y4=_.
Title Telephone No. (business) Telephone No. (cell) a-mad address
If applicable,the properly owner hereby authorizes
Name Stmel Address Citv/Town State Zip
to ocl on the property owner's behalf, in all matters rclatiee to work authorized by this building ermit a +plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cu.it.of endoad s pica andlor not water Con anwhon Control then check here O and skAp SLS tion RUT
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town titate Zip Discipline Expiration Date
10.2 General Contractor
puiA Cortt sla)ri loy-V
Nat+ye,of Person Rrsptmsible(or Construction License No. and Type if�Applicable
�' 2pezc�: t2yr, t Day 6)cfob
Street�Add resCsf Cit own State Zip
`6- err 17h
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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'ssuance of the building permit.
Is a signed Affidavit submitted with this application? YeAg No 0
SECTION 12:CONSTRUCT70N COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from(tem 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact munici alily)
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 this
applic((ittion is true and acc rate o the best of m - kn twledge and undemanding..���,"� p'1 p'np
fico., pool .mdwig name Title t/ Telephone +. Date
9 9hQr�su t�
Nivct Addires C ih own State G +
Slunwipal Inspector to fill out this section upon application approval: (
\a e Date
CITY OF S.Uy., I, NIASSACHUSETTS
BL:ILDING DEPAitTNIENT
'f 130 WASHINGTON STREET,3w FLOOR
a
TEL (978)745-9595
FAX(978)740-9846
KlxfBF.RLF-Y DRISCOLL
MAYOR T HoMAs ST.PiERRB
DIRECTOR OF PCBLIG PROPERTY/HCIICIING CONMaSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information Please Print Letribly
Vatlle(Business(Or�ganizatiorVlndividual): �-� t ( v
Addrass:Z 3Y�Co saa Pi V\ 1�Ywe (7
City///State/Zip: Phone #: q Dg— ?)�-7�5
Aron an employer?Cheek the appropriate box: Type of project(required):
1 I am a employer with 4. ❑ I am a general contractor and 1
employees(full and/or part-date).
+ have hired the sub contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers'comp. insurance 5. ❑ We area corporation and its (0❑Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I i.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12. Roof repairs
insurance required.]t employees.[No workers' 13.0 Other,
comp.insurance required.]
•Any apphram that chicks hoc 91 must abw fill Out the section belowAowing theirworken'wmpensarion policy infutmation.
*I Inmeownen who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a txw affidavit indicating such.
=Commaon that duck this boa must attached an additional sheet showing the�of the subcontractors and their workers'comp,policy infamutim.
I am an employer that Ls providing)vorkers'compensation insurance for my employees. Below is the policy and Jab site
information.
Insurance Company Name:
` r
Policy#or Self-ins. Lic.#:yr�,�C,(l'� ic,1f3�(�j Expiration Date;-3
Job Site Address:2.�— /' �l �Y I�t�C—'\I ilio City/State/Zip: ,Yt jl1 Yh . �rn
Attach a copy of the workers'comperlaRtion 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 51,500.00 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations or the DIA for insurance coverage verification.
I do herr cert46 r older the pains and penalties )per try that rhe information provided above is true an correct
Sign gnat tr 'L. -D
L1
Ojrcial use only. Do not write in this urea,to be completed by city or town oJrciaL
City or Town: Permit/I.Icense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityffown Clerk 4,Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _.__ Phone#:
i CITY OF SSU Em. XLkSSACHUSETTS
BI:MDLNG DEP,,RTMEINT
o� 130 WASHNGTON STREET, r FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
ICI\tBERLEY DRISCOLL
MAYOR T Hoatrc ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMSSIONER
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
I 11, S 150A.
The debris will be transported by:
name o hauler���
The debris will be disposed of in
Nku d Ili s6aD
(name of facility
G- -k-D-� , M A--
(address of facile y)
Osignatur'epmit applicant
7 /a
date
a�n��,v�rax
FROM (VRI>000 17 2010 10: 16/ST. 10: 16/M-0303464306 V 3
MASSACHUSETTS ASSIGNED RISK POOL
REQUEST FOR CERTIFICATE OF INSURANCE
Use this form to request a Certificate of Insurance from an Assigned Risk Pool Carrier.
Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the
Certificate of Insurance should be issued. If this form is fully and accurately completed,the Certificate of Insurance will be
issued and distributed by facsimile to each tax number provided below,within two(2)business days of the carrier's receipt
This Form may be mailed or taxed to the Assigned Risk Pool Cartier. To obtain each carrier's contact information refer to the
Certificates of Insurance section located in the Producer Community section of the Bureau's website,(www.wcribma.ora).
1. Name, address, telephone number and facsimile number of the INSURED:
Name: Redco Construction Inc.
Mailing Address: 8 Pheasant Run Dr. NewburvoortMA 01950
Physical Address: SAME
Phone: 978-270-8740 Fax: 978-255-2489
2. Name,address, telephone number and facsimile number of the CERTIFICATE HOLDER:
Name: 25-27 Briggs St. LLC
Mailing Address: 25-27 Briaas St Salem. MA 01970
Physical Address: Same
Phone: Fax: 978-744-0868
3. Name,address, contact person, telephone number and facsimile number of the PRODUCER:
Name: Arthur S. Pace Insurance
Mailing Address: P.O. Box 391 Newburvoort. MA 01950
Contact Person: Kate E. Quill
Phone: 978-465-5301 Fax: 978-462-0890
4. Policy Number, Policy Effective Date and Policy Expiration Date
If a Certificate of Insurance is needed for more than one policy term, provide the Policy Number,
Effective Date and Expiration Date for each policy term.
If the policy has not yet been issued, you must attach a copy of the Notice of Assignment.
Policy Number. WC002011897
Effective Date: 03/05/2010 Expiration Date: 03/05/2011
5. List any special requests for optional coverages/endorsements(see Page 2 for listing of coverages available
in the pool and the conditions of availability)or additional information(including changes in exposure notyet
reported to the carder)that will assist the carrier in the Issuance of the Certificate of Insurance.
NOTE: An additional Insured(s) shall not be listed on any Certificate of Insurance unless such additional
Insured(s)is a named insured on the policy.
l
FROM (VRI)OEC 17 2010 10: 16/ST. 10: 15/Mo.S30348930e P 2
ACO/2p' OP ID:Ka
CERTIFICATE OF LIABILITY INSURANCE °"'12M/ 0
12/17/10
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 policypea) must be endorsed. R SUBROGATION IS WANED,subject to
the terms and conditions oftheponcy,.urta'"policies may require an endorsement A statement on this certificate do"not confer rights to the
certificate holder in lieu of such endorseme s.
PRODUCER 978465.5301
MAYS T
Arthur S Page Insurance Agency 978462-0880 W he
57 State St. Ne-
Newburyport, MA01950
None P REDCO 1
IMBYR B AFFORWMCCOWRAOE NAICR
INSURED Redco Construction,Inc. INSURER A;Scottsdale Iris Co
Erica Reddy WauReLs:
8 Pheasant Run Drive
Newburyport,MA 01950 1INSURERC:
NSIINER e:
WauNOLe:
MBURE F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THEINSUREDNAMED 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.
INTRR TYPE OF WBYRANCE 3= POLICY POl1CY NlMBFN Lep E MLeT9
DEMFML WRUtt EACH OCCURRENCE { 1,000,00
A X COMMERCIAL GENERAL LIABILITY CPS1186773 08108/10 99/09111 pp SES Eaoeoarane f 50,
CLAIMS-MADE X❑OCCUR LIEDEXP(Mrone Penw,) { 5,
PERSONALaADVWJURY i 1,000,00
GENERALA°OREGATE { 2,099,00
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COWIOPAGG S 1,000,
POLICY PRO- Loc S
AUTOMOBILE W RRItt COMBINED SWGLE LMIT
ANYAl1T0 (En eodeMO {
ALL OWNED AUTOS
BODILY INM
SCHEDULEOAUTOSBOON INSPROPERTHIRED AUTOS (Awbodd
NON-OWNEDAUTOS S
t
LAURE"LMEOCCUR EACH OCCURRENCE S
EXCESS LAS CLMM&MADE AGGREGATE f
DEDUCTIBLE
i
—EIRETENTION 3
WORKERSCOMPENSATION C STATLL -
S
ANOEMPLOYfiRS'LIWLItt YIN TWOR
%TH
ANY PROPRIETORPARTNEIVEXECUTIVE
OFFICERME MSEREXCLUDEOI NIA E.L.EACH ACCIDENT a
IMaMMOry In NN) ELL.DISEASE EA EMPLOYE S
tl res,aaaviba ander
OE SLRIPTIOH OF OPERATIONS below E.L.DISEASE-POLICY UNIT I S
DESCRIPTIONOFOPEMTN)NSJWMTIONOIVEMClas (ANUII ACORD tpl,Adeabna RNMnu 6dladyb,Nmen tpLsalayubM)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN
25.37 Briggs St LLC ACCORDANCE WITH THE POLICY PROVISIONS.
25-27 Briggs St
Salem,MA 01970 AUTHORRED REPRESENT
None
IED 1 SM-2009 ACORD CORPORATION. 71117MRghtit reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
qk
p F- I y� �ee 'Pocrv»xo�cu�e¢l� n�./�'neaar,�cudelld
c
m Office of Consumer Affairs&Business Regulation License or registration valid for individul use o
•= o ,a HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
rN w Registration 164675 Office of Consumer Affairs and Business Regal
n Expiration 10127/2011 Tr# 290056 10 Park Plaza-Suite 5170
—x _ w rn Type.7 PrNate Coryoration Boston,MA 02116
r rA
Q REDCO CONSTRUCTION INC, ,'
ti Z � Vy, PATRICK RED
{ W w O � F- �\ _ 8 PHEASANT RUN DRIVE' t
s o c u g W -- 0 - NEWBURYPORT, MA 01950 ~� � �.—__�
d' = Undersecretary
�� N Ot Z �, _ Nat vali2t�hoAk gnature
o u j
R
f a Z
� y
' � � a:
0<
of