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455 HIGHLAND AVE - BUILDING INSPECTION RECEIVED `I i NSPECTIONAL SERVICES 5I Zfte%�lrylppm I ealth of Massachusetts "•DeXrtnit;kWf Public Safety Massachusetts State Budding Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) 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) `4S5 I1 tc�kl A-A, SaL,, INo.and Street City/Town Zip Code Name of Building(if applicable) I`— SECTION 2:PROPOSED WORK. Edition of MA State Code used_ If New Construction check here❑or check a6 that apply in the two rows below Existing Building❑ 1 Repair — Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as Part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required?. Yes ❑ No ❑ Brief Description of Proposed Work: 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): 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 a plicable) - A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ R.—Factory F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ 1-2❑ 1-3❑ I-1❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ 116 ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CN1R 111.0 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑ Public❑ Check if outside Flood Zone Cl Indicate municipal❑ trench will not P required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: �I\t liyt-,ric.! m,nuslun it .���� I'n�_gss: Not Applicable❑ Is Structure within airport approach area? is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ 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: M P l t_. CO G -1 LtS—D 21 --TO L-1-tJ C( ma v) (�z305QDr—I tD7JtSloo OZ(8QD SECTION 9: PROPERTY OWN R AU_THORIZATION Name Address of Property Owner 1 �P�Z ,);,h1U1 i Name(Print)I No.and Street CI 11 �1 A Clity/pTbivn,y jy Zip Property Owner Contact Information: ram- 67L I a, 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 owner's behalf,in all matters relative to work authorized by this budding permit application. - SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix 2). - f buddingis less than 11 35,000 cu.ft.of encloseId space and/or not under Construction Control then check here❑and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control nor►.__ � $°3 -�i 5S� 1 ,�c,� 4 N. n Re ' trant) Telephone No. e-mail address Registration Number r^r� r SQJ tS � G1 u (: Street Addre s City/Town State Zip Discipline xptratmn Date 10.2 General Contractor Company Name l A ) c..l a C 000rOJIVO e S CS r a G'1 Name of Pdrson Responsible for Construction License No. and Type if Applicable W IVa 61 Street AddressCity/Town State Zip ­L )A CnnLlr✓cam A C-6'C_� a C<z- Tele hone No. business Telephone No. cell e-mail address SECTION 11:W0I2KEK5'CON1PENSA F10N INSURANCE APF'IDAV11' M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No O SECTION 12:.CONSTRUCTION COSTS AND PERMITFEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ d. Mechanical (f-fVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ 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 ap lic.Lion is tme and ac urate to the best yymy knowledge and understanding. - Please�priot an tgn name Title Telephone No. Date l'1 C p.�C.e� SO r rv�i YW a )gi d G Street KIdress City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date i Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-051097 I �c.r.ri.N °fti WAYNE A COCO 37 SPENCER AYVitg 7 f Saugus MA 01909 ' Expiration Commissioner 04/03/2017 1 J/ W�'��l/IJZd/iGM��O�UU/.G4'JQ.pGE(:mnw ! Office of Colus,umer Affairs&Business Regulation - ME IMPROVEMENT CONTRACTOR egistration: if"7g998 Type: piration: DBA T.I.A.CONSTRUCTION— WAYNE COCCRO'CH 37 SPENCER AVE. ? SAUGUS.'MA 01906 �`� r' e Undersecretary .4 4V CLEARCHANNEL OUTDOOR Date: January 25, 2016. Fax# 781-279-1493 To: Whom it may concern; 455 Highland Ave Salem, Me Clear Channel Outdoor will be subbing work out to TIA to Rebuild 2 of our billboards located on 455 Highland Ave MA. The total cost to rebuild these billboards will be $3,500.00 Sincerely: J n Cro y ista perations Manager 438-888u rd,781 379.1493 r,. Clcar Channel Outdoor 89 Maple Street^Stoneham,MA 02180^a .dcarehanncloutdoorxom V it, AV Z tGo Massachusetts / CLEARCHANNEL OUTDOOR RT 107/HIGHLAND AV ES 60OFT S/O CLARK RD SIF SALEM LOCATION # 008086 A �€+ 'e � i, t: ,x^ _ '.T" Syr✓ ''y s sx 14 IS Y I PM a' A `C rrr* p. 4 k -lu Cyr"^M zz m t ' i Y � I .rs.F+c'n r y CERTIFICATE OF LIABILITY INSURANCE FATE 1/25/a0115Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this Certificate does not Confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1-832-476-6000 CONTACT NAME: ACID Risk Services Southwest, Inc. PHONE FAX INC.No: E-MAIL 5555 San Felipe, Suite 1500 ADDRESS: INSURE S AFFORDING COVERAGE NAIC# Houston, TX 77056-3089 INSURER A: GREENWICH INS CO 22322 INSURED INSURERS: ACE PROP & CAB INS CO 20699 Clear Channel Outdoor, Inc. INSURER CXL INS AMERICA INC / XL SPECIALTY INS C c/o 200 East Basso Ed. INSURER D: INSURER E: San Antonio, TX 78209 INSURER F: COVERAGES CERTIFICATE NUMBER: 45309919 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL TYPE OF INSURANCE J=SUD POLIPOLICYNUMBER MMIDCYEFF MMND EXP LT LIMITS A X COMMERCIALGENERALLIABILITY RGD300052801 11/01/15 11/01/16 EACH OCCURRENCE $ 3,000,000 DAMA To RENTED CLAIMS-MADE X OCCUR PREMISES Eaocwrrence $ 1,000,000 MED EXP(My one person) $ Excluded PERSONAL&ADV INJURY $ 3,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 1PRODX POLICY JETPRO, LOC UCTS-COMP/OP AGG $ 3,000,000 OTHER: $ A AUTOMOBILE LIABILITY RAD943770901 11/01/15 11/01/16 COMBINED SINGLE LIMIT $ 2,000,000 COMBINED X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X H NON-OWNED PROPERTY DAMAGE $ X HIREDAUTOSAUTOS Peraccldenl S X UMBRELLA DAB X OCCUR XOO G2791701A 001 11/01/15 11/01/16 EACH OCCURRENCE $ 25,000,000 EXCESS LIAa CLAIMS-MAOE AGGREGATE $ 25,000,000 DED I X I RETEN[ION 25,000 1 $ L, WORKERSCOMPENSATION RMD300052901 / RNR300053 D1/O1/15 11/O1/16 X STATUTE EORH AND EMPLOYERS"LIABILITY Y I N ANY PROPRIETORIPARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ 1,000,000 OFFICERMIEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,descrbe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddHlonal Remarks Schedule,may be aneched H more space is required) EOP-South Station, L.L.C., a Delaware limited liability company (or its successors and assignees) Equity Office Management L.L.C., a Delaware limited liability company -eeadhouse Property and Electricity Manager, (or any successor) Blackhawk Parent LLC, and their respective agents, members, partners,employees, officers, directors, sbarebolders and lenders. Massachusetts Bay Transportation Authority is an additional insured on the liability policies, but only with respect to liability that arises out of the acts or omissions of the Named Insured; workers Compensation is evidenced for employees of the Mamed Insured Only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Blackhawk Parent LLC c/o Equity Office Properties THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ATTN. South Station 125 Summer Street, Suite 1707 AUTHORIZED REPRESENTATIVE Boston, MA 02110 /�� n USA Lien.a✓JR,bnuwh ion wA1;.4r+- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Dholden 45309919 The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriciaus/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'blv Name (Business/Organization/Individual): Address: City/State/Zip: In, Phone#: Are you an employer?Check the appropriate box: - ��� Type of project(required): I AJ r"rn a employer with 0 employees(full and/or pa:rke .- 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employeesng for me in g. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work m elf. 9. ❑Demolition ❑ g ys [No workers'cominsurance required]t 4.❑1 sal a homeowner and will be hiring contractors to conduct k on m ro 10❑Building addit on Y P Pe*tY. 1 willensure that all contractors either have workers'compensationce or me sole 1 I.❑Electrical repairs or additionsproprietors with no employees. - - 12.❑Plumbing repairs or additions5.❑I am a genera]commctor and I have hired the sub-contractor on the attached sheet.These sub-contractors have employees and have workers'coursnce.t _ 13.❑Roof repaiirrs6.❑We are a corporation and its officers have exercised their ri e 14.�thei r�-�Pt� gmption per MGL c. —�152,§1(4),and we have no employees.[No workers'comp.ice required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContracmrs that check this box must attached an additional sheet showing the name of the subcontmetors and state whether or not those entities have employees. If the sub-conlmctors have employees,they must provide their workers'comp.policy number. lam an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify \\under the pains and penalties ofperjury that the information provided above '' trueand correct. Signature: Date Phone#: F l use only. Do not write in this area,to be completed by city or town ofciat Town: Permit/License# Authority(circle one): d of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector rt Person: Phone#: ,r J Information and Instructions y Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the _ dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the cornmonwealth 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 cer ificate(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 perrnit/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 bur leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia