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440 HIGHLAND AVE - BUILDING INSPECTION i CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBERLEY DRISCOl_L MAYOR 120 WASHINGTON S l'RrrT ♦SALEM,MASSACHUSETTS 01970 TEL: 978-745-9595 ♦ FAX: 978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �_ Please Print Ledbly Name (Business/Organization/Individual): P k M t�7le\pX0 k S\1t4t4r\JJ-1FCf/2-ACC) Address: \� _T;Fy fs+ 1—kZ� CZb City/State/Zip./1tJ'Ozur`c`'Z Wtla_ OKs10 Phone #: Are),on an employer?Check the appropriate box: Type of project(required): 1.Lef aim a employer with SO 4. ❑ 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. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. [1 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 12.0 R repairs � insurance required.] t employees. [No workers' 13. Other \7VES ✓'''\V—'�& comp. insurance required.] -Any applicant that checks box NI 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �W.VJ�IriQfkrc �- �( �l7StR�l � . �C�) . Policy#or Self-ins. Lic. #: Expiration Date: fXC Job Site Address: \-1\-l0 k QGktWiZ. City/State/Zip: 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 S 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 S250.00 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 certifyunder the pains'and penalties of perjury that the information provided aboveis true and correct. Siunatitre 1`( tlZSt�1 l `AZ1�� Date al—dt7lh� Phone#: `r) o1�rl 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 ajoint 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 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 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 Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia CITY OF SALEM n4ob � PUBLIC PROPRERTY DEPARTMENT nl\19.NI C1"�iN ail 1. VVAiI¢Vt:':Of:S:RflET 5:\u-%f, M.\u.u:ru x:rr\ CeI:978-745-')595 * r.%X:978-74G9846 Construction Debris Disposal affidavit (required fur all demolition and renovation work) in accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit >k _ _ 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 v1GL c 11 1, S 150A. The debris will be transported by: (name of hauler) fhe debris will be disposed of in (name of facilay) ladi:raa o(taei6�)� �� f Board of Building Regulations and Standards' Construction Supervisor License 's tp r r ' Licenso:•CS 78710 Blrthd�t;:b 1 011 9/1 9 62 CExpiration:,A10119/2008 Restriction -00 EDWARDL GORMAN '� S'" ,t 12 FOURTH, SCITUATE, MA 02066 ,y:' Commissioner A&IAA Roofing and Sheet Metal Co. Inc. February 6,2008 Route 107 Salem Associates Limited Partnership c/o S.R. Weiner&Associates,Inc. 1330 Boylston Street Chestnut Hill,MA 02467 Attn: Mr. George Terrien Re: Game Stop/Special Thoughts Highland Plaza Salem,MA Dear George: We have inspected the roofs at the above referenced project. We recommend new EPDM roofing systems on the various sections of the plaza in accordance with the following general specifications: Game Stop(approximately 2,400 square feet) 1. The existing membrane and built-up roofs would be stripped down to the existing metal deck and properly disposed of off site. 2. New pressure-treated wood blocking would be installed at the roof perimeter to accommodate the height of the new insulation. 3. A layer of 3.3"polyisocyanurate insulation having a LTTR-value of 20 would be mechanically fastened to the steel deck. 4. A layer of 60 mil unreinforced EPDM membrane would be fully adhered to the insulation in accordance with the roofing manufacturer's standard specifications. 5. The parapet walls would be properly flashed with EPDM membrane. 6. The parapet roof edges would be flashed with new gravel stop shop-fabricated from.040"bronze aluminum. 7. New gutters and downspouts would be installed at the rear shop-fabricated from.040" thick bronze aluminum. 8. The existing sleepers,duct penetration,vent pipes and pitch pocket would be properly flashed to the new roof system. 9. The completed EPDM roof system would be warranteed by the roofing manufacturer(Carlisle or Firestone)for a period of fifteen years covering labor and materials. Special Thoughts(approximately 11,400 square feet) 1. The existing stone ballast and EPDM would be removed and properly disposed of off site, leaving the existing EPS and perlite insulation. 2. New pressure-treated wood blocking would be installed at the roof perimeter to accommodate the height of the new insulation. 123 Tewksbury Street,Andover,Massachusetts 01810 Tel:(978)475-4500/Fax(978)475.8778 George Terrien S.R.Weiner&Associates,Inc. February 6,2008 Page Two 3. A layer of 1.5" polyisocyanurate insulation having a LTTR-value of 9 would be installed over the existing insulation and mechanically fastened to the steel deck. 4. A layer of 60 mil unreinforced EPDM membrane would be fully adhered to the insulation in accordance with the roofing manufacturer's standard specifications. 5. The parapet and abutting walls would be properly flashed with EPDM membrane. 6. The front parapet edge and rear roof edges would be flashed with new shop-fabricated .040"thick bronze aluminum gravel stop. 7. The existing roof-top units,pitch pockets and vents would be properly flashed to the new roof system. 8. Approximately 215'of EPDM walkway would be installed to match existing layout. 9. The existing roof drains would be replaced with new cast iron roof drains and be properly flashed to the new roof system. 10. The completed EPDM roof system would be warranteed by the roofing manufacturer(Carlisle or Firestone)for a period of fifteen years covering labor and materials. The price for the entire project would be Seventy-Four Thousand,Five Hundred dollars($74,500.00). The above pricing includes obtaining the local building permit. Our proposal excludes any gas pipe alterations or mechanical work. I We also offer the following unit prices: 1. For removal and replacement of deteriorated steel decking -$6.00/sf 2. For installation of 20 gage flat galvanized over steel decking- $3.00/sf 3. For installation of 30"x 30" walkway pads-$27.50/each Please contact our office if you have any questions or need additional information. This proposal may be withdrawn by us if not accepted within thirty(30)days. We appreciate the opportunity to quote you on this project and look forward to working with you again. cerely, �Cv� II James A.Loos President The above terms an a itions are accepted and you are authorized to proceed: By: Title: Date: A n rtbml provisions of this proposal cmrut ed electric on,,mmmuNembn fives:A&M shill not be Iwbk or h,M mspomkk for tie repair.replacement or for loses incurred he connection with electric wing or mmmuntcaCen cabgag eRxed to de mot strung temughde upper rib a the roofdeck,Inceed lessthan Y fromthebottom of the roofdeck or ofufmisefailing to complywiththe raze electrical code. Preexistine(.bMWere:Prior to mmnnounment of work.A&Mwillbe,provided renew en to any mofmg,plumbing of fIVA relsmJ leaks or othertypes of weer Infihmtonhavingamurmd on the property within 1 yews of commencement of roof work.A&M shall not be liable or heM responsible for the minor,rnplocemee or losses bcufred in meneeton with preexisting Owner's (eilurc ro discbe p,,,,,inq mmnfti0m wlll mwk be forfeiture of right to even my claim br damages against A&M. Roof Lmks between mmmentemeN and rompletion of Work:A cbim asserted for motkakdamage omurrbg aftcr mmmewement of mofmg work but prior tosubstantial completion of the work will be Bowmed by the ,Wwft procedure nee ,,,ens:1)the Owner will notify A&M imnnediatety by phone and in writing by fee,up my alleged damage.+)A&M will be Biven prompt access to the area where dare,.is aIkgnd prior to any rcmMiazion work for the purpose of performing a damage inspection.A&M shill not b,liable or heM responsgak for my remediation work,if timely access is dented or dremed'ution has cemme.d pror to inspection by A".3)Owing damage inspection A&M may phmtograph s oV r v eotape for the purpose of maunaining m amwaze retard of the tlamage.Likewbe eM as necessary this rigid of timely inspection shall olso be accorded A&M's insurer or public adjuster for the purpose of placing a oronetey value on the loss.4) During damage inspector,A&M will detesmie in its sink prokWeentljudgment whether i was respoemole Ibr rousing the alleged damages end will advise Owner of its firNings.5)In the event a claim for damages is assened,mid deither timely.,,is&nkd for whenever reason or if A&M is denied m opportunity to obtain an accurate recent ofth,damage:then in such on eventuality. Owner shell iMemmify.defend against and Imo A&M hemdess from my clebe asserted therefrom. BIBht of survivorship:Notwithstanding my commtt lenguage into maY be to tit motrwy,these additional pmvisime of this roofmg proposal shah survive the Pmjnd sM shall be valid aid enforceable by or agone the parks hereb aid tbei respective mccesson,subrogees aid-Wiles. ACORD DATE(MM/DD/YYYY) TM. CERTIFICATE OF LIABILITY INSURANCE 02/1 312 0 0 8 PRODUCER Phone: (781)933-3100 Fax: (781)933-9048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ,SALEM FIVE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BOYLE INSURANCE SERVICES,LLC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 445 MAIN ST BOX 606 ALTER THE COVERAGE AFFORDED F Pill lrlFq RF1111 WOBURN MA 01801 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: ACADIA INSURANCE COMPANY A&M ROOFING AND SHEET METAL CO INC INSURER B Firemans Insurance Co 123 TEWKSBURY ST INSURER C: ACADIA INSURANCE COMPANY ANDOVER MA 01810 INSURER D: Commerce and Industry Ins Co 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. P1SR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECW POLICY EXPIRATION LIMITS LTR INSR DATE MMIDOI DATE MMM2= GENERAL LIABILITY CPA011039913 05/01/07 05/01/08 EACH OCCURRENCE $ 11000,000 X1 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 250,000 PREMISES(En o¢urence) CLAIMS MADE OCCUR MED.EXP(Any one person) $ 5,000 AW_ PERSONAL B ADV INJURY $ 2,000,000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO. $ 2,000,000 PRO - POLICY LOG RO- AUTOMOBILE LIABILITY MAA011040013 05/01/07 05/01/08 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ B X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ Per accident GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS I UMBRELLA LIABILITY CUA011040113 05/01/07 05/01/08 EACH OCCURRENCE $ 10,000,000 X OCCUR CLAIMS MADE AGGREGATE $ 10,000,000 C $ DEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS COMPENSATION AND WC5312495 05/15/07 05/15/08 roav uM iS OT"ER EMPLOYERS'LIABILITY D ANY PROPRIETORIPARTNERIEXECUIIVE E.L.EACH ACCIDENT $ 1,DDD,DDD OFFICEWMEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYEE $ 1,000,000 Ryes.describe under SPECIAL PROnS10N9 below E.L.DISEASE-POLICY LIMIT $ 1,000,000 OTHER: DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS PROJECT: GAME STOP/SPECIAL THOUGHTS 4404"HIGHLAND AVE SALEM MA 01970 ADDITIONAL INSUREDS RE GENL LIAB:ROUTE 107 SALEM ASSOCIATES LP; SR WEINER&ASSOCIATES INC CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO ROUTE 107 SALEM ASSOCIATES.LP DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS C/O SR WEINER&ASSOCIATES INC AGENTS OR REPRESENTATIVES. 1330 BOYLSTON ST AUTHORIZED REPRESENTATIVE ��jj CHESTNUT HILL MA 02467 AI ] /Vf Attention: Gerard F Bo Jr ACORD 25(2001108) Certificate# 13602 ©ACORD CORPORATION 1988 ILI, The Commonwealth of Massachusetts Board of Building Regulations and Standards MUNICIP:MUNICIPALITYI OR �` ,n t Massachusetts State Building Code. 780 CMR. 7 edition USE Building Permit Application To Construct, a air. Renovate Or Demolish a Revised Junum i r 1, 'txi3 This Section For Official Use Only Building Permit Num r: Date Applied: fit Signature: 2 l Bui ng Commissioned Inspector of Buildings Date SECTION l: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map & Parcel Numbers k­ttio l tWa Nk3v'C 1.1a Is this an accepted street'?yes ✓ no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal.System: Zone: _ Outside Flood Zone? Municipal n-site disposal system ❑ Public Private❑ Check if ycso SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner[of Record: N>40-7 Q�r toZ Stii4.�f1s . t.P �3� T�V\` S� Cllttr94y?r\1\`\ t�+�A . Name(Print) Address for Service: Signature Telephone - SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work s "So SKI a Cti �t�sc7- t»w veav b� 37P te-o N-r-'a CsO w.v F_4- CzRo�. i- U-� Kl \1-�SCtaL\. 1J�Ttv.> > S� �`• SECTION 4: ESTIMATED CONSTRUCTION COSTS (J/� Item Estimated Costs: Ofticlal Use Only (Labor and Materials) 1. Building $ .-3 y Soo 1. Building Permit Fee:$ - Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6) x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount. Cash Amount: 6.Total Project Cost: $ ° ) 10p ❑Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) CS .—Ig-1\0 t0\q OK �9 �� CooQw r License Number Expiration ate Name of CSL- Holder 0a0Uo List CSL T \ \a. rvw,Q.t'� IlV� tt-v?�eE �Wl(� • Yf�(see t+elow) V Address T Description U Unrestricted(up to 35.000 Cu. Ft.) R Restricted 1&2 Family Dwelling Signature M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Inaallation V D Residential Demolition 1 I 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address iration Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.$ 25C(6)) Workers Compensation Insurance affidavit 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. Signed Affidavit Attached? Yes .......... No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 11 , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Dale SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1, \ wV✓.(U 1J as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. �v�hRzsa � o�.�•a.—� Prin Name >=. Signature of Owner or Authorized Agent . Date (Signed under the pains and penalties ofperjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. 'Total Project Square Footage"may be substituted for"Total Project Cost"