207 HIGHLAND AVE - BUILDING INSPECTION (6) 19
^n The Commonwealth of Massachusetts
\Y I Department of Public Safety
Massachusetts State Building Code(780 CMR)
07- W Building Permit Application for any Building other than a One-or Two-Fainily Dwelling
('Phis Section For Official Use Only) -
Building Permit Number: Date Applied: I Building Official: c
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not ilabAj;,
-70
No.and Street City/Town Zip Code Name of Building(if appt**le) D '
SECTION 2:PROPOSED WORK Go r`t
Edition of MA State Code used If New Construction check here❑or check all that apply in the two r ws beMv
Existing Building Repair❑ 1 Alteration Addition❑ 1 Demolition 0 (Please fill out and submit Apjrndix
Change of Use Change of Occupancy ❑ 1 Other ❑ Specify: 30 - c"
Are building plans and/or construction documents being supplied as part of this permit application? Yes ET No ❑
Is an Independent Structural Engineerin Peer Review required? Yes No
Brief Description of Proposed Work: &M%10-� 'tiI 5� ,k4 ,
J<. D kQ ass -wa! v 4 u�
A,. ry _ 0.
o,I cud `�"t�.+-� ✓i 1 JGf c..�l CAr o.,
SECTION 3:COMPLETE THIS SECTION IF FJQST NG BUILDING UNDERGOIN RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O
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.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as app licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B. Business E: Educational ❑
F: Facto F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 O H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use 0 and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB O IIA 0 IIB IIIA O IIIB O TV O 1 VA O VB O
SECTION 7:SITE INFORMATION(refer to 780 CMR111.0 for details on each item) -
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Publio!f Check if outside Flood Zone❑ Indicate municipal° A trench will not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required 0 or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is thew review completed?
or Consent to Build enclosed❑ Yes 0 or No❑ Yes❑ No ❑
SECTION8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: 60 Use Group(s): BVS,' 3-1S Type of Construction: d Ti Occupant Load per Floor:
Does the building contain an Sprinkler System?: ' ' Special Stipulations:
.7 ` 7 14 r_ 2. 03 - 8 `fV3 (VJWh
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
�1C� kAyc� ACN 4' St>Mx3x� y L
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
(J,Jutt— -_- 0-571- FSSb Ja.rrl�P0S Jrt(ru . NY�
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
res�t Nwssa 3�� iLer SJ . kdL—1 POA 6)-Js5
Name Street Address City/Town State Zip
to act on the p property owners behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 30.1
10.1 Registered Professional Responsible for Construction Control
j�aNNe (YCON..I<.1� rosd�y01_� 90;L .Ib&AWC0 0. 1. CAM
N (Registrant) elephone No. e-mail adds Registration N mber
t-t_I i .istrant) address
A',%k Q 91 �s t0rz lid<c .31. 16
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Keuj A (alp 6, trS - Q j S`l I
Name of Person Responsible for Construction License No. and Type if Applicable
30o pit- z S4• CAN-Torl V1 _ dv-0�21
Street Address City/Town State Zip
339� Cbpo 7 l- 3 - Wy3 -n� Cc-sJtiC4-J.
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 theAance of the building permit.
Is a signed Affidavit submitted with this application? Yeslff No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)
1.Building $ f LA5D, p Dp
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ X5' 006> appropriate municipal factor)_$.
3.Plumbing $ ) 00 b Note:Minimum fee=$ (contact municipality)
4.Mechanical (HVAC) $ 000 -
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ f i-60 O�v (wntad 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.
77y
Please print and sign n e Title Tele hone No. Date
36v pj - 5 , MA �00;-- 1
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name - Date
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8d' edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
including new parking,walls,finishes, pumbing, lighting, HVAC and modifeations to structural system.
1,Joanne O'Connell-Foster MA Registration Number: 7913 Expiration date: Aug. 31,2016 ,am a registered
design professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
X Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, information,and belief 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 the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept, shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this bode.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a`Final Construction Control Document'.
a
Enter in the space to the right a"wet"orelectronic.signature and seal:
Phone number: 401.436.3532 Email: joanneo@nemd.comew
OF
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
Initial Construction Control Document
To be submitted with the building permit application by a
Ufj Registered Design Professional
for work per the 8a'edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x) one or both as applicable: New construction X Existing Construction
Project description: Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
including new parking, walls, finishes, purrbing, lighting, HVAC and modifcations to structural system.
I, Stephen J. Goan MA Registration Number: 46226 Expiration date: June 30,2016 , am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans, computations and
specifications concerning':
Architectural X Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, information,and belief 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 the construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports (see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the build' 'Final Construction Control Document'.
OF
Enter in the space to the right a"wet"or STGO J. �Gm os SrEPHEra !.c5
electronic signature and seal: o STRUCTURAL y 4 ( '0�" n
V � ' STRUC TURRL
No.46226
F
Phone number: 603.232.6142 E d. omcast.n -
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06_11_2013
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
Project Title: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
Including new parking, walls, finishes, plumbing, lighting, HVAC and modifications to structural system.
I,William T. Mayer III MA Registration Number: 46021 Expiration date: June 30, 2016 ,am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
Architectural Structural X Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge,information,and belief 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 the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'.
Enter in the space to the right a"wet"or F7' "OF
electronic signature and seal:
Phone number: 401.765.7659 Email: wmayer@edesignservice.com
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8d'edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Tide: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description:Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
including new parking,walls,finishes, plumbing, lighting, HVAC and modifcations to structural system.
I, Raymond W. Dusseault III MA Registration Number: 40709 Expiration date:June 30, 2016 ,am a registered
design professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
Architectural Structural Mechanical
Fire Protection X Electrical Other:
for the above named project and that to the best of my knowledge,information,and belief 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. 1 understand and agree that 1(or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a 'Final Construction Control Document'.
Enter in the space to the right a"wet"or '-
electronic signature and sea]:
AL a
. =
3
alp, , 0 t
Phone number: 401.765.7659 Email: rdusseault@edesignserviee.eom 'sy •;otsyE :
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8d` edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
including new parking,walls,finishes, pumbing, lighting, HVAC and modifications to structural system.
I,Glen G. Markey MA Registration Number: 41542 Expiration date:June 30, 2016 ,am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
Architectural Structural Mechanical
Fire Protection Electrical X Other: Plumbing
for the above named project and that to the best of my knowledge,information,and belief 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 the construction site on a regular and periodic basis to:
I. Review, for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'.
a 4
H OF M
Enter in the space to the right a "wet"or
electronic signature and seal: N G. s
E
ME A C
Phone number: 401.765.7659 Email: gmarkey@edesignservice.com STE
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 80' edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20,2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
including utility plan.
1, Paul D. Carlson, PE, MA Registration Number:40995 Expiration date: June 30,2016 ,am a
registered/professional civil engineer and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning':
Architectural Structural Mechanical
Fire Protection Electrical X Other: Civil
for the above named project and that to the best of my knowledge, information,and belief 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 the construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'r,,,,nlr1
Enter in the space to the right a"wet"or / `— ;
Pit/t
electronic signature and seal: `� l o _
NO.ti0395
Phone number: 508-336-4500 Email: PCarlson@InSiteEngineers.com < >`
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1. Indicate with an's'project design plans.computations and specifications that you prepared or directly supervised. If`other'is chosen,
provide a description.
Version 06 11 2013
Initial Construction Control Document
.UT* To be submitted with the building permit application by a
Registered Design Professional
for work per the 80' edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
including new parking, walls, finishes, pumbing, lighting, HVAC and modifcations to structural system.
I,Joanne O'Connell-Foster MA Registration Number: 7913 Expiration date: Aug. 31,2016 ,am a registered
design professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
X Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, information,and belief 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 the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept, shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work,I shall submit to the building official a 'Final Construction Control Document'.
Enter in the space to the right a"wet"or _
electronic signature and seal:
7Yt3�
Vlt
Phone number: 401.435.3632 Email: joanneo@nemd.com �
;k ac
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
1
Initial Construction Control Document
To be submitted with the building permit application by a
> Registered Design Professional
for work per the 81' edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
Including new parking,walls,finishes, plumbing, lighting, HVAC and modifcations to structural system.
1,William T. Mayer III MA Registration Number:46021 Expiration date: June 30, 2016 ,am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
Architectural Structural X Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge,information,and belief 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 the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, 1 shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work,I shall submit to the building official a `Final Construction Control Document'.
OF
Enter in the space to the right a "wet"or
electronic signature and seal:
Phone number: 401.765.7659 Email: wmayer@edesignservice.com
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 I1 2013
k lk Initial Construction Control Document
UlfTo be submitted with the building permit application by a
Registered Design Professional
for work per the 8`h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
including new parking, walls, finishes, pumbing, lighting, HVAC and modifcations to structural system.
I, Stephen J. Goan MA Registration Number: 46226 Expiration date: June 30,2016 , am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans, computations and
specifications concerning):
Architectural X Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, information, and belief 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 the construction site on a regular and periodic basis to:
I. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107,
When required by the building official, I shall submit field/progress reports (see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, 1 shall submit to the building off al Construction Control Document'.
ki OF M9191, �k0 k OF M4S
Enter in the space to the right a"wet"or STEPHEN J. U) o 5�
GOAN STEPHEN
electronic signature and seal: o STauCTUwAL GOAN
> y �� STRUC.TURAI
No.46226 q 9 No.462 2
°�F9�cGi Got isT
A
Phone number: 603.232.6142 Email: st.n
Building Official Use Only
Building Official Name: Permit No.: Date;
Version 06 11 2013
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8u' edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Tide: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description:Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
including new parking,walls,finishes, pumbing, lighting, HVAC and modifcations to structural system.
1, Raymond W. Dusseault III MA Registration Number: 40709 Expiration date: June 30, 2016 ,am a registered
design professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning:
Architectural Structural Mechanical
Fire Protection X Electrical Other:
for the above named project and that to the best of my knowledge,information,and belief 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 the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'.
```"pppnruutrr
Enter in the space to the right a "wet'or ���```���y1 �0 •
electronic signature and seal: • -
•
r •9No.� !1r
Phone number: 401.765.7659 Email: rdusseault@edesignservice.com •�eISTE�`.'h�Q
rye's„FSSIOHFSE�.���
Building Official Use Only
Building Official Name: Pennit No.: Date:
Version 06 11 2013
. Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8ih edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November 20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Conversion of existing vacant space into dialysis clinic-with all necessary upgrades
including new parking, walls,finishes, pumbing,lighting, HVAC and modifcations to structural system.
1,Glen G. Markey MA Registration Number: 41542 Expiration date:June 30, 2016 ,am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning':
Architectural Structural Mechanical
Fire Protection Electrical X Other: Plumbing
for the above named project and that to the best of my knowledge,information,and belief 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 the construction site on a regular and periodic basis to:
I. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'.
a d
OfIIA
Enter in the space to the right a "wet"or
electronic signature and seal: N G. ✓
! E
ME A C
Phone number: 401.765.7659 Email: gmarkey@edesignservice.com oTE
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
Initial Construction Control Document
.UT To be submitted with the building permit application by a
Registered Design Professional
for work per the 8`h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: DaVita Healthcare Dialysis Salem Northeast 03313 Date: November.20, 2015
Property Address: 207 Highland Avenue, Salem, MA
Project: Check(x) one or both as applicable: New construction X Existing Construction
Project description: Conversion of existing vacant space into dialysis clinic—with all necessary upgrades
including utility plan.
1, Paul D. Carlson, PE, MA Registration Number:40995 Expiration date:June 30,2016 , am a
registered/professional civil engineer and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning!:
Architectural Structural Mechanical
Fire Protection Electrical X Other: Civil
for the above named project and that to the best of my knowledge, information,and belief 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 the construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept,shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
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 progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, 1 shall submit to the building official a `Final Construction Control Document'
rltll,l!r
Enter in the space to the right a"wet"or �
electronic signature and seal: Cil4
't 1 09 NO995 1
Phone number: 508-336.4500 Email: PCarlson@InSiteEngineers.com
Building Official Use Only
Building Official Name: Permit No.: Date:
Note I.Indicate with an `x'project design plans:computations and specifications that you prepared or directly supervised. If`other' is chosen.
provide a description.
Version 06 11 2013