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600 LORING AVE - BUILDING INSPECTION CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KI ERLEY DRISCOLL MAYOR 120\wA$IIIN(iTON S772EET* SALEM,MASSA(:I'1USETTS 01970 Tm:978-745-9595♦FAX:978-740-9646 APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS IMPORTANT:Applicants must complete all items on this page - SITE INFORMA,T�ON _ Location Name V kkn,_ ,�OS Building T O 174x1\L Property Address C000 lorin A �� Located in: Conservatin Area Y/N Historic district APPLICATION DATE 5 f 5� oS T Use Groups (check one) Group Homes R3 R4_ Residential(3 or more Units) R2_ Type of improvement Residential(hotel/motel) R1 _ (check one) Assembly(Theaters) Al_ New Building_ Assembly(restaurants&clubs) A2r_A2ne_ Addition Assembly(churches) Al_ Alteration Business B Repair/Replacement Educational E_ Demolition_ Factory(moderate hazard) FI_ Move/Relocate Factory(low hazard) F2_ Foundation Only High Hazard H_ Accessory Building Institutional(residential care) Il_ Institutional(incapacitated) 12_ Institutional(restrained) I3_ Mercantile M_ Storage Sl_Moderate Hazard Storage S2_Low Hazard OWNERSHIP INFORMATION(Please type or Print Clearly) OWNER Name An i rc, ) Recce VAN." Shoos SLC Address oz M A Telephone (tip e 7 y V -'4140 Signature it n ek} loex\er A A DESCRIPTION OF WORK TO BE PERFORMED r lo�rlsl�, M•\12-w��'! ,fYl,(der Z.f Jwc,\\ c'.,hun�e.3 S�S. �10 jP(�nk\ar. ESTIMATED CONSTRUCTION COST .fia 5a , Sod' ao CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KINIMRLEY DRISC:OLL NIAYOR 120 WASI IINGPON STREET• SALEM,NLASSACIIUSEITS 01970 TEL:978-745-9595♦FAX:978-740-9846 CONTRACTOR INFORMATION Pe 5%17-0 5 Name �`S.nL Ser . i A C ry �lsnv Address lojl Nt. k-n rnA Telephone Construction Supervisor's Lic # C-S()Ia �a Home Improvement Contractor# ARCHITECT/ENGINEER INFORMATION Name (aSSor- s cS Address�a �2zs s� ,MA Telephone G\� sed- JaAs Mass. Registra ion # PERMIT FEE CALCULATION Estimated Cost x $11/$1,000 + $5.00=1 a 21 50 COMMENTS The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge under the penalties of perjury / Signed L- (owner) agen APPROVED BY: � DATE APPROVED: / y / © Bank America's Most Convenient Bank° VIA CERTIFIED MAIL April 15,2009 Village Shops, LLC c/o Centercorp Retail 600 Loring Avenue Salem, MA 01970 RE: TD Bank(Tenant)—Consent for Improvements for Premises at 600 Loring Ave, Salem, MA Dear Sir or Madam: Pursuant to the TD Bank lease for the above-referenced location, this letter serves as our request for Landlord's consent or acknowledgement to improvements TD Bank intends to make to their leased premises. Improvements shall consist of the items included on the attached list. All work shall be performed under the direction of the Tenant, shall be at the Tenant's cost, and shall be performed in a good workmanlike manner. Please indicate your approval and consent by signing below on both copies of this letter and returning one to my attention via fax at(207) 317-5109 at your earliest convenience, forwarding the original to me in the enclosed pre-addressed envelope. Please keep the other copy for your files. If you should have any questions about the specifics of the project, please contact me Emily Clark, Project Manager for TD Bank @(207) 317-5103 or via email at Emily.Clark@TDBanknorth.00m. Thank you for your prompt attention to this matter. Ve ruly ours, Emily Cla Project M ger TD Bank Enc. Seen and Agreed to this day of ,2009. LANDLOR — Village Shops LC By: I &W Its: AN o +3 (Guff Please print name: Village Shops, LLC April 27, 2009 Mr. Kenneth Wexler Elaine Construction 1037 Chestnut Street Newton Upper Falls, MA 02464 Project: TD Bank NE 38 Salem 600 Loring Ave, Salem, MA Dear Mr. Wexler: The undersigned is the owner of record for the building at 600 Loring Ave., Salem Massachusetts. The building is occupied by a branch of TD Bank. This letter authorizes Elaine Construction to proceed with application and filing for building permit in connection with planned renovation work located at this site. Approval has been granted to the tenant for this work by the Owner. Please let me know if you require additional information or assistance. Si rely, An rew B. Rose Village Shops, LLC Centercorp Retail Pr perties, Inc. Cc: L. Shanko, TD Bank E. Clark, TD Bank 600 Loring Avenue •Salem, MA 01970 • (978) 741-4740 Fax (978) 745-1223 •Email: andy@centercorpretail.com Architecture and Interiors Bergmeyer Associates,Inc. Phone 617 542 1025 Bergmeyer B Sleeper StorctA022 Fax .bergm17 542 1026 1 111 Boston,MA 02210-1205 www.bergmeyeccom Controlled Construction Affidavit City of Salem Project Name: TD Bank Location: 600 Loring Avenue, Salem, MA. Scope of Project: Renovation of existing bank tenant fit out In accordance with Section 116.0 of the Massachusetts State Building Code, I, Lewis Muhlfelder, Massachusetts Registration Number 5726, have prepared or directly supervised the preparation of architectural plans and specifications concerning the above-mentioned project. In my professional opinion, such plans and specifications meet the applicable provisions of the Massachusetts State Building Code and applicable architectural practices for the project, including Architectural Access Board Regulations. Per Section 116.2.2 of the Massachusetts State Building Code, our contract for professional services includes visits to the construction site, as appropriate, to determine that the work is proceeding in accordance with the documents approved for the building permit and progress reports will be submitted to the Town of Billerica. Services also include review, for conformance to the design concept only, of shop drawings,samples and other submittals,which are submitted by the contractor in accordance with the requirements of the construction documents. Our contract for professional services also includes the issuance of a Final Design Affidavit,which will be submitted upon substantial completion of the work. R.DAR, FG\ M HLF F 0 e�O F o No.57 3 BRIG A wMuhIfelderJJr., A1A, L�EFDAP Pt assachusetts Registration Number 5726 Fq�TH Of MASS ,FL On this�day of _, 2009 before me, the undersigned notary public, personally appeared (-�J` Pw1. , provided to me through satisfactory evidence of identification, which wererxry V-r , to be the person whose name is signed on the preceding document, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of his/her knowledge and belief. CHRISTOPHER BALERNA N ublic � Notary"Pubac3/ /2013 Commomveaflh Of Maiiwhiism My Commission expires my Ca Arissbn Expires Match 1,2013, 019A050609cb0_Controlled Construction Affidavicdoc f CITY OF S�U.Ei , �rLc1SSACHU5ETTS ElcumNG DEpkRTM&NT 130 WASHINGTON STREEr, Ve FLOOR TEL. (978)745-9595 FAX(978) 740-9846 lQJmat r~Y DRISCOLL THOMASST.PIERRS MAYOR DIRECTOR OF PtiBLIC pROPERTY/$t'IIaING COtLMISSIOtiER 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 111, S 150A. The debris will be transported by: ��Sk� So�vt,�nS (name of hauler) l The debris will be disposed of in : t- (name of facility) jc.�e.rv.}�2•.✓ �cMQS� te.. (address of facility) i signaiu f pe it ap icant -Auj g DI - -- date dcbrie ffdoc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lel?ib1V Name (Business/Organization/Individual): Elaine Construction Company,Inc. Address: 1037 Chestnut Street City/State/Zip: Newton Upper Falls, MA 02464 Phone #: (617)332-8400 Are you an employer? Check the appropriate box: Type of project(required): L❑ I am a employer with 4. N I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. N Remodeling ship and have no employees These sub-contractors have S. E] Demolition working for the 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 11.❑ Plumbing repairs or additi6ns myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t 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. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Massachusetts Employers Insurance Company Policy#or Self-ins. Lic. #: MCC2000172 Expiration Date: April 30,2009 TD Bank Job Site Address: 600 Loring Avenue 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 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 r the pains and penalties ofperjury that the information provided above is true and correct. Signature: �� Date' May 6,2009 Phone#: (617)332-8400 Official use only. Do not write in this area,to be completed by city or town 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire; .. express or implied,oral or written." An employer is defined as"an individual,partnership, association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials and printed legibly. The De Department has provided a space at the bottom Please be sure that the affidavit is completea pp p p of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. - The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia Client#: 156465 ELAINE CONS ACORDTN CERTIFICATE OF LIABILITY INSURANCE 5107/2009009 DATEYYYY) oos PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HUB International New England ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 600 LofLgwater Drive HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Norwell,MA 02061 781 792-3200 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Employers Fire Insurance Co Elaine Construction Co., Inc INSURER B: Firemans Fund Insurance Co 1037 Chestnut Street INSURER C: Massachusetts Employers Insuran Newton Upper Falls, MA 02464 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 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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATEVMM/DD/YY IEFFECTIVE PDATE MMIODTION LIMITS A GENERAL LIABILITY 7100194770001 04/30/09 04/30/10 EACH OCCURRENCE $1.000.000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $500,000 CLAIMS MADE F—XI OCCUR MED EXP(Any one person) $10,000 PERSONAL B ADV INJURY $1.000,000 GENERALAGGREGATE $2 OOO 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000 POLICY % jECT El LOC A AUTOMOBILE LIABILITY FB1E09167 04/30/09 04/30/10 COMBINED SINGLE LIMIT $1,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Perperson) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per aoddentI GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EA ACC $ AUTO ONLY: AGO $ A EXCESS/UMBRELLA LIABILITY 7100194770001 04/30/09 04/30/10 EACH OCCURRENCE $5 OOO OOO X OCCUR M CLAIMS MADE AGGREGATE $S OOO OOO DEDUCTIBLE $ X RETENTION $O I $ C WORKERS COMPENSATION AND MCC2000172012009 04/30/09 04/30/10 X w:STATu- OTIC_ EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $1 000 000 ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $11:000:000 It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 B OTHER Excess SHX00079556114 04/30/09 04/30/10 $5,000,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Where required by contract; additional insured,waiver of subrogation applicable (Auto, Liability and Excess Liability coverages). Job: Renovations to TD Bank 600 Loring Ave Salem MA CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TD Bank DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1_ DAYS WRITTEN 33 South Commercial Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Suite 308 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR Manchester, NH 03101 REPRESENTATIVES. AUTHORIZE RESENTATIVE_ ACORD 25(2001108)1 of 2 #S248999/M240226 W_RO01 0 ACORD CORPORATION 1988 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. ACORD 25S(2001108) 2 of 2 #S248999/M240226