323 HIGHLAND AVE - BUILDING INSPECTION 31q
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Ulf Building Permit Application for any Building other than a One-or Two-Family Dwelling
f110 (This Section For Official Use Only)
I Building Permit Number: Date Applied: Building Official
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
-- 323 Highland Avenue Salem, MA 01970 Irving Oil Store#73806/Circle K Store#7502
1 No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
�J
Edition of MA State Code used$((_edition If New Construction check here❑or check a6 that apply in the two rows below
Existing Building Repair❑ Alteration �. Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of
8 Occupancy g ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes X No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
commercial interior remodel of existing Circle K convenience store and Irving Oil gas station.
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): M/S-1 Proposed Use Group(s): MIS-1
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 1 3,535 s.f. 1 3,535 s.f.
Total Area(sq.ft.)and Total Height(ft.) ETR ETR ETR ETR
SECTION 5:USE GROUP(Check as applicable)
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 ❑ H4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 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 Check if outside Flood Zone❑ Indicate municipal X A trench ill not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ require or trench or specify:
permit is enclosed❑ W O—V WASTE
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable P' Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No X Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
T1�U f= � L7>Pl'fir
CEjFEDERAL
CONSTRUCTION CORP
50 Salem St., Bldg A
Emilio Licclardi Lynnfield, MA 01940
President phone 781.246.1700
fox 781.209.5978
ceu 508.951.8983
web www.federalconstructiancorp.com
email emilio@federalconstructioncorp.com
General Contracting I Construction Management I Design-Build
LnJI
t
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
The Richmond Highland Salem,LLC 23 Concord Street Wilmington,MA 01887
Aftn William P Cronin
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Director of Finance 978 988 3900
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owners behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control TBD
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor TBD
Company Name
Name / C]
L/-rlLra `ICL M2�7/ �S — �E7 C�.( 92
Name of Person Responsible for Construction License No. and Type if Applicable
576 SA l.CM Cctr, -y0,j i=, Zr� � 0 1940
Street Address City/Town State Zip
-211b- (700 $983 FMwoe Fc—oeru�wNs�n yen Iw�P.c�rt
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT F E
Item Estimated Costs:(Labor 475,000
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 320,00.00 $111$1,oQo
Building Permit Fee=Total Construction Cost x (insert here
2.Electrical $ 90,000.00 appropriate municipal factor)=$ 5,225.
3.Plumbing $ 40 000.00
' 4.Mechanical (HVAC) $ 25,000.00 Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ — Enclose check payable to City of Salem
6.Total Cost $ 475,000 (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
application is true and accurate to the b st of my knowledge and understanding.
Kendra Sorensen Project Manager 21 ra 749- 7800 8/18/16
Please print and sign name Title Telephone No. Date
3723 Pearl Road Cleveland,Ohio Ohio 44109
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: *'t /
Name Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Locatio (Please indicate Block # and Lot#for locations for which a street address is not
available) 11
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107.The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural X
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas(Natural,Propane,Medical or other
10 Surveyed Site Plan(Utilities,Welland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investi ation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Bruce Taylor 216749 7800 bruce@arkinetics.com 31362
Name(Registrant) Telephone No. e-mail address Registration Number
3723 Pearl Road Cleveland Ohio 44109 Architect 8/31
Street Address City/Town State Zip Discipline Expiration Date
Kelley F. Moran 440.953.8760 kmoran@tecincl.com 39933
Name(Registrant) Telephone No. e-mail address Registration Number
Electrical 6/30/18
Street Address City/Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State 1p
Discipline Expiration Date
CITY OF SMYM, &LkssikCHLsms
BUILDING DEPARTMENT
4� 120 WASHINGTON STREET, r FLOOR
TEL (978)745-9595
FAA(978)740-98"
tUttBERI.EY DRI$COII.
MAYOR THOMAS ST.PiERRRE
DIRECTOR OF PUBLIC PROPERTY/BUELDIING COM-asSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le¢ibly
Name tBusinessorganizationfmdividuap: Federal Construction Corp
Address: 50 Salem Street
City/State/Zip: Lynnfieid, MA 01940 Phone 1#: 781-246-1700
Are you an employer?Check the appropriate box-
1. (required).
1.® [am a employer with 6 4. El am a general contractor and 1 Project
Type of ect
employees(full and/or part-time).* have hired the subcontractors 6. ❑New construction
2_❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7• Remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity• workers'comp.insurance.
No workcts'coon q• ❑Building addition
l p.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workers'comp, c. 152,§1(4),and we have no ME]Roof repairs
insurance required.]t employees.itx'o workers'
comp.insurance required.] 13.❑Other
Any applicant that checks bolt ill must also Fill out the section below showing their workers'compensation policy information.
I ktmeowttm who submit this affidavit indicating they ate doing all work and then hire outside eontracron must submi=i-wnranon Ihot cheek this box mtest anxhd an vlditionol ahmi showing the name of the au b-eontractotg and their wot a new amdavil indicting such
rkem•comp,policy infomtation.
lam as emphryer that is prat iding;porkers'compensation Insurance for my employees. Below is the po!!cy and Jab site
information.
Insurance Company Name: CNA
Policy#or Self-ins.Lis#: 6S59UB5B987445 Expiration Date: 5/15/17
Job Site Address: 323 Highland Ave City/State/Zip... Salem, MA 01970
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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. De advised that a copy of this statement may be forwarded to the Office a
Investigations of the DIA for insurance coverage verification.
/falterebyaaw
certify ua t leper nd nalfles of per ar that the injormatlon provldeJ above is true and correct
Date• / /
lure-
Phone � (. 7-416•t7oo sv'3-e, sr S 983
OJJleW use only. no not write in this area,to be courplefed by c4 or town aJfcia[
City or'fuwn' Pcrmit/Liccnse#
Issuing Authority(circle one): _-
1. Board of Ilealth 2.Building Department 3.Cityf Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other,
Contact Person: ___ _ Phone#
i CITY OF Si-1 xmg NI��SS.ICHL'SETTS
13UILDLNG DEPARTMENT
130 WASHINGTON STREET, 3'0 FLOOR
TEL (978) 745-9595
Fex(978) 740-9846
KIJfBERI.EY DRISCOLL
MAYOR THor-w ST.PmRRE
DTRECTOR OF PUBLIC PROPERTY/BUILDING CON5USSIONER
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
1 11, S 150A.
The debris will be transported by:
EZ Disposal - Revere MA
(name of hauler)
The debris will be disposed of in
Wood Waste
(name of facility)
85 Boston St, Everett, MA
(address of facility)
signature of permit applicant
date
dchr(salT.dce
Massachusetts Department of Public Safety Commonwealth of Massachusetts
q) Board of Building Regulations and Standards Department of Public Safety
License: CS-068192 11ni4tinn Frpi'Mr
"
Construction Supervisor License: HE-081423
<e:n s p•h r
EMILIO LICCIARDI EMILIO IACCL,AAD`p��L.
24 GARDEN LN ',�1� 24 GARDEN LNEj�i}
WAKEFIELD MA 01980 r wakefield MA
{ V
Expiration:
Expiration: Commissioner 04/29/2017
Commissioner 04/29t2015
OSHA 001073429
Office of Consumer Affairs&Business Regulation er
@OME IMPROVEMENT CONTRACTOR
�- egistration: 162769 Type: U.S.Delmnment of Labor
Expiration: 4/6#017 Private Corporatio, Oooupatonel Safety and Health Adminisoahon
FEDERAL CONSTRUCTION CORP Emilio Li COardi
has suceesafully Completed a 1041"Occupational Safety and Health
EMILIO LICCIARDI Trainng Course in
50 SALEM ST ,\•r,.t i `V.•._4 �} _ Construction Saiery 8 Health
LYNNFIELD,MA01940 Undersecretary JZEeY E d dD 6/24/06
Rrsiner) (Date)
Emilio Licciardi
Scaffolder Competent Person
The employee named above has completed training and Training Program
has demonstrated understanding and proficiency in the
following:
Forklifts m1lio Licciard-i _
Safety tnstruetar-Bob Jerszyk 08/22/03 W21199 232969
Date ID.No. Authorized
r
SI .�I ., r tl 93055770,7
V h(M1 J OIYvv
..a..�..�...�..�.a,. 3.31.,7
0o arkinetics
❑0 architects+urbanists
TRANSMITTAL SHEET
Arkinetics, Inc. Project#: 16008.11 Date: 11/18/16
To: City of Salem Building Department Re: Irving Oil/Circle K 7502
120 Washington Street 323 Highland Avenue
Salem, Mass 01970 Salem, Mass 01970
Phone: 978.619.5648
Attn: Michael Lutrzykowski
Please find: 0 Enclosed ❑Under separate cove the following:
Description: Copies:
Architectural Initial Control Construction Form 1
MEP Initial Control Construction Form Ij
These have been sent via: FedEx
If enclosures are not as listed, please notify us immediately.
Comments:
Please feel free to call with any questions or if you require any additional information or if any of the
above listed items are missing from the package.
From:
Arkinetics, Inc.
By: Kendra Sorensen Project Manager
Printed Name: Title:
Copy:
File
Cleveland 13723 Pearl Road, Cleveland, Ohio 44109 1216.749.7800 1 arkinetics.com
Z :Initial Construction Control Document
nl S f n 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: Irving Oil/Circle K 7502 Date: 11/17/16
Property Address: 323 Highland Avenue Salem, MA 01970
project: Check one or both as applicable: New construction \/Existing Construction
Project description: commercial interior remodel of existing Circle K convenience store and Irving Oil gas station.
I Bruce Taylor MA Registration Number: 31362 Expiration date: 8/31/17 am a
registered design professional, and 1 have prepared or directly supervised the preparation of all design plans, '.
computations and specifications contenting:
[�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 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 J.)together with pertinent
continents, in a form acceptable to the building official.
pED qq
Upon completion of the work, I shall submit to the buildi 1t; truction Control Document'.
�t�d00
Enter in the space to the right a"wet"or NO. 31362
electronic signature and seal:
C' CLEVELAND
OHIO ot�y
Phone number: 216.749.7800 � AEli Bp'S ce arkinetics.com
Building Official Use Only
Building Official Naine: Permit No.: Date:
Version 06 11 2013
0
i
i
Initial Construction Control Document
I tr, To be submitted with the building permit application by a
F' •4
Registered Design Professional
for work per the 81h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Irving Oil/Circle K 7502 Date: 11/17/16
Property Address: 323 Highland Avenue Salem, MA 01970
Project: Check one or both as applicable: New construction \/Existing Construction
Project description: commercial interior remodel of existing Circle K convenience store and Irving Oil qas station.
I Kelley F. Moran MA Registration Number: 39933 Expiration date: 6/30/18 am a
regisrered design professional, and I have prepared of-directly supervised the preparation of all design plans,
computations and specifications concerning:
[ ] Architectural [ ] Structural [ Mechanical
[ ] Fire Protection [vr 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 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.
I 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 J.)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: KW.
gEMMMM l
xo.euosa
Phone number: 440.953.8760 Email: kmoran@tecincl.com
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 112013