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268 HIGHLAND AVE - BUILDING INSPECTION CrrrciFaA1X,,v - ` PUBLIC PROPERTY © DEPARTMENT 496-CC1 w \NCM 4V R\RI'IV 1 / 130wASWN WW SrUff 05y4% A0ACM%-M01M Mm-974745.OSI S 1 FAm r&7J04" APPLICATION FOR THE REPAIR. RENOYAT[ N CONSTRUCTION _DEMOLITION. OR CHANGE OF USR OR OCCUPANCY., XI FOR ANY ESTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION . Lomdon Name - s�S ,ES Building: -— -- Property Address f�i�r✓ U - - - - /` _ Property is located In s:Conservalion Aron YM Historic Dhtriet Y/N__e 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN " JITING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New 9oef Description of Proposed Work: Mail Permit to: -� What is the current use of the Building? Material of Building? ifdweltirg.how many units? Wig the Building Conform to Law? Asbestos? Architect's NarM Address and Phone Mechanic's Name Address and Plane Consbuatim Supetviscm License# COS 6 51la1- HIC Registration 0 Estimated Cost of Projeet ice— Permit Fse Calculation Permit Fee i�9 Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$100ACornmercia4----__. _._. . An Additional$5.00 is added as an Administrable charge. Make sure that ail fields are property and legibly written to avoid delays In processing. The undersigned does hereby apply for a Building Permit to build /to tthhe�e above stated specifications. Signed under penalty of perjury Date 9'o7-a7 of i Q§LN!� � � N -- v".- - - 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." iati corporation or other legal entity,or any two or more m o per is defined as"an individual,partnership,association. rpu `f e 1 including the le representatives of a deceased employer,or the 'f of the foregoing engaged in a joint enterprise,and itwl g gal ep receiver or trustee of an individual,patntership,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 appurtenant thereto shall not because of such employment be deemed to be an employer." or on the grounds or building btGL 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 beat not produced acceptable evidence of compliance with the Insurance coverage required." Additionally,ivIGL 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 orcompliance 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLQ 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 cntployees,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 u 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 Offlcials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom. 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 permidlicense number which will be used as a reference number. In addition,an applicant k that must submit multiple permitilicense 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 tilled 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 burn leaves etc.)said person is VOT required to complete this affidavit. l'hc Oftiec of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do nut hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts I Department of Industrial Accidents O®tee of Inveestiglidoes 600 Washington Street Boston,MA 02111 Tel. N 617-727-4900 ext 406 or 1-977-MASSAFE Fax #617-727-7749 Revised 5-26-05 www.mass.gov/dia l CITY OF SALEM " PUBLIC PROPRERTY r DEPARTMENT M%131 RUN DRtWOLL MAYtat IX wA\HLINGTkcSTREET 1 SAIEM.MASSAC1ll.l'f•:1"tsol973 Tt1:970-743-9593 *FAX:9M740.9946 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anolicant Information Please Print Leeibly Name lllucim%vorganintiordlndividwtl):_y4—, GJ 46W1 illd/ Address: / ?5? 15 City/Stare/Zip: /eidrx- z . 2W Phone #: ,%rc you an employer?Check the appropriate box: 'type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6, ❑ New construction employees(full and/or pan-tine).• have hired the sub-contractors 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 are a corporation and its required] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑ 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.❑Other comp. insurance required.] -Any appliuua that chucks box cal mast also fill ask,the section bvluw slowing their wotkus'cumpansaaion policy infurnratiun. '1 was+toners who submit this affidavit indicating they are Joins un work and then hilt outside contrantxs must tubmil a new affidavit inJialina such. �C.,, turs thu check thus box must altaehad an additional Asaet stowing the namo of tho als-contractors and their worker'comp.policy information. fain an employer shot is providing)vrkers'compensation Insurance for my employees. Below is the policy and job site information. l Insurance Company Name: Policy 4 or Self-ins. Lis #: &,IC/ 7 %//-/3S7,T/6Q_ p/ 7__. Expiration Date: 7 Q/-Q® Job Site Address: d k I�iZQC�.rc� /`✓U.� City/StatdZip: fY,V /w I4 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 ofcriminal penaltiesofa fine up to S1.500.00 and/or one-year:mprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against,the violator. lie advised that a copy of this statement may be forwarded to the Office of Invcau.-atiuns ol'Ihc DIA far'insurarce coverage veriticilion. l do hereby certify under Ilse pains mrd penallies ofperjary1that the information provided above is true and correct Sienantre' a e-1•-rso�• Date• 9-Q�ei=o7 Phone da9 9B9 as ��/ l)Jf1cial use only. no not Ipriie in Ihlr area,to be compleled by city or town oJ11rial. City or Town: _-, Permit/License# Issuing Aulhurily (circle one): I. Iloird of Ileallh 2. Building Department 3.City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: --- Phone At: Thi certificate is executed by Lihn Mutual Insurance Group as res,tecla such insurance as is affraded by those companies. BM0068 Certificate of Insurance This certificate is issued as a matter of information only and confers no rights upon you the certificate holder. This certificate is not an insurance policy and does not amend extend,or alter the coverage afforded by the pal' I'[edb 1 This is to certify that(Name and address of Insured) II New England Retail Construction Corp and named insured listing on file Liv� 139 S.Main St l� Fall River,MA 02771-3701 10�mutt m. ji fP is,at the issue dace of this certificate,insured by the Company under the policy(ies)listed below. The insurance afforded by the listed policy(ies)is subject to all their terms,exclusions and conditions and is not altered by any recarvement,term or condition ofsa contract or other tatwithrearecleo.1nob this certificate ma be issued Ez iration Type Eff./Es .Dates Policy Numbers Limits of Liability Continuous* 07/01/2007/07/01/2008 WC2-I11-257569-017 Coverage afforded under WC law of Employers Liability Extended the following states: Bodily Injury By Accident dx Policy Term CT,MA,NY,RI,SC $500,000 Each Accident Bodily Injury By Disease $500,000 Policy Limit Workers Compensation Bodily Injury By Disease $500,000 Each Person 07/01/2007/07/01/2008 TB2-111-257569-137 General Aggregate-Other than Prod/Completed Operations General Liability $2,000,000 Products/Completed Operations Aggregate Claims Made $2,000,000 f X Occurrence Bodily Injury and Property Damage Liability Per G $1,000,000 Occurrence I ,, Retro Date Personal and Advertising injury Per Person/ $1,000,000 Organization Other Liability Other Liability $100,000 Fire legal $5,000 Medica]Limit " 07/01/2007/07/01/2008 AS6-111-257569-037 Each Accident-Single Limit-B.I.and P.D.Combined Automobile Liability $1,000,000 Each Person NX Owned Non-Owned Each Accident or Occurrence Hired Each Accident or Occurrence UMBRELLA EXCESS 07/01/2007/07/01/2008 TH2-611-257569-067 $10,000,000 General Aggregate $10,000,000 Each Occurrence $10 000 000 Products,Completed Opt.Agg. Job Number:Evidence of Coverage C O M M E N T S Notice ofcaneellation:(not applicable unless aoumberofdays is entered below). Before the stated expiration date the company will not cancel or reduce the insurance afforded under the above policies until aslrazt Ja days notice o(such cancellation M1as been mailed lo: /�{7 /'�/ /J� Office: WESTON,MA-SOUTH Phone: 781-891-8900 Certificate Holder: CLARE HALLAHAN New England Retail Construction Corp. Authorized Representative 139 South Main Street Fall River, MA 02720 Date Issued: 07/03/2007 Prepared By: KS CITY OF SALEM PUBLIC PROPRERTY DEPARTv1ENT \1.�7vM 12C W. SI"'::ONS.REET•UU U.\tA&Witt a:1h i:9/C TF.r:97L74f•)M •F%x:9M74G9946 Construction Debris Disposal Affidavit (required for all demolition atul renovation work) In accordance w ith the sixth edition of the State Building Code. 780 CNIR section 111.5 Debris,and the provisions of M. GL c 40. S 54; Building Permit A - . _ 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 I11. S 1.50A. The debris will be transported by: tname of haulac) f E Tic debris will be disposed of in Inane of facility) Lot loo . D CITY OF SALEM goy. ROUTING SLIP �. NEW CONSTRUCTION X I CERTIFICATE OF OCCUPANCY Z� LOCATION: PS ICE/P p DATE APPLICANT: Pw_T ASSESSORS DATE:d / �a FRANK KULIK (93 Washington Street) CITY CLERK CHERYLLAPOZ4g:�� DATE: (93 Washington Strut) BLICESERVIo.. DATE..CES I� / 01 6 K..owlf - ( �,(,(/`�� �.1 �✓ —� _ (l..o Washington Street)4°Floor " WATER � — DOTTIETHIBODEAU ATE: (120 Washington Strut)0 Floor CROSS CONNECT sIJPER BRIAN THIBODEAU (5 Jefferson Avenue) PLANNING V, _-- l iU�'�U \1 (� DATE: (12tr Washington Strut)Yd Floor / CONSERVATION COMMISSION ` v 42 DATE: 5 (lit f�uZv0-(120 Washington Strut)3n/Floor ELECTRICAL JOHN GIARDI ,J'of��✓ G, v� DATE: -& (48 Lafayette Strut) FIRE PREVENTION rY ERIN GRIFFIN DATE:A4_ wJ (29 Fort Avenue) � HEALTH y JOANNE SCOTT DATE:�7 (120 Washington Stree Floor / UI BLDING THOMAS ST. PIERRE DATE: (120 Washington Street3° r ED WILLIAM STARCK ARCHITECTS, INC. 114 Durfee Street• Fall River, MA 02720 • tel. (508) 679-5733 •fax (508) 672-8556 CONSTRUCTION CONTROL AFFIDAVIT PROJECT NUMBER: N/A PROJECT TITLE: Tri-City Plaza - new 12,900 s.f. CVS/pharmacy Building & new 10,400 s f Tri-City Sales Building PROJECT LOCATION: Corner of Highland Ave& Marlborough St. NAME OF BUILDING: Tri-City Plaza SCOPE OF PROJECT: Construct two new stand-alone buildings In accordance with Section 116.0 of the Massachusetts State Building Code, 1, William C. Starck, Mass. Registration No. 3643 being a registered professional Architect, hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project _ Architectural X Structural _ Mechanical _ Fire Protection_ Electrical_ Other (specify) For the above named Project and that, to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws and ordinances for the proposed use and occupancy. I further certify that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in Section 116.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for building permit, and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code required controlled materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standards listed in Appendix B. I shall submit periodically a progress report together with pertinent comments to the i ding Inspector for the Town of Salem. Upon completion of the work, I shall submit a final re atisfactory completion and readiness of the Project for occupancy. `V 1 n No.3W Commonwealth of Massachusetts �r County of Bristol , On this 1116T day of 2007, before me, the undersigned notary public, pertonally appeared proved to me through satisfactory evidence of ide ity, which was/were r to be the persons wh ame(s) s/we signed on th preceding ttached docu nt in my presence. Sign d N'RE I / Not Public My commission expires: assachusetts My commi;slon Expires Nov,15.2013 Z,d 9992ZL9909 Pel!yoay Wae3S welll!M dZt £0 LO 6l deS -0262 HIGHLAND AVENUE 290-08 GIs #. 43 COMMONWEALTH OF MASSACHUSETTS Mp:ap: 08 Ma CITY OF SALEM Lot: 0104 Category: (2)Business Permit# 290-08 BUILDING PERMIT Project# JS-2008 000569 Est. Cost: $825,000.00 Fee Charged: $9,080.00 eEs.- Balance Due: $.00 PERMISSION IS HEREBY GRANTED TO:Const. Class: Contractor: License: Use Group: Groom Construction Lot Size(sq. ft.): 71516.808 Owner: TRI CITY SALES INC Zoning: B2 Units Gained. Applicant: TRI CITY SALES INC Units Lost: AT. 0262 HIGHLAND AVENUE Dig Safe#: ISSUED ON. 12-Sep-2007 AMENDED ON: EXPIRES ON. 12-Mar-2007 TO PERFORM THE FOLLOWING WORK.- CONSTRUCT NEW RETAIL STORE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: Underground: Underground: Excavation: Service: Meter: Footings: Rough: Rough: Rough: Foundation: Final: Final: Final: Rough Franca: Fireplace/Chimney: D.P.W. Fire Health Insulation: Meter: Oil; Final: House# Smoke: Assessor Treasury: Water: Alarm: i Sewer: Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: BUILDING REC-2008-000668 12-Sep-07 7312 $9,080.00 GcoTMS®2008 Des Lauriers Municipal Solutions,Inc.