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280 JEFFERSON AVE - BUILDING INSPECTION RECEIVED (� The Commonwealth of Nmu use s Department u Public Safe $ A Massachusetts State Building Codel�CAPA Building Permit Application for any Building other than a One-or Two-Family Dwelling (This.Section For Official Use Only) , n Building Permit Number: Date.Applied: - Budding Official: SECTION 1: C TION(Please indicate Block if a Lot N for locations for which a street address is not available) � No.and Street City/Town Zip ode Name of Building(d applicable) - SECTION 2 PROPOSED WORK. Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out mid submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other CISpecify: 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: l p� Q(X 1 `KIJ C Vy,Or1 C'� 1 11 V,� C 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 applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: Hi h Hazud H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ L• Institutional 1-1❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑ S: Storase:ge S•1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special U SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ - 111E ❑ IV ❑ I VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) - Water Sup ply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: A trench will not be Licensed Disposal Site❑ Publiceck if outside Flood Zone❑ Indicate municipal.❑ required❑or trench or specify: Privateindentify Zone: or on site system❑ permit d enclosed❑Railf-way: Hazards to Air Navigation: MA I Isionc� ommksnn R ,i,,vNe❑ • Is Structure within airport approach area? Is their review completed? or Consenclosed❑ 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: Gfat1 � D Gat.)TfLp.c� �1EIS Cl-�Vu . tic, "TOM suc5cotls2_ q-0 P (V SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Addire�ss of Proper Owne - ) Name(Print) No.and Street f Ci /Town Zip 0 ,1 8-- 7( Pro AZ ontact_Information � 0 3��� llz.'� 7 W��h, �Tit e Telephone No.(business) TeNo. (cell) a-mail address pplicable,the roperty owe r hereby authorizes 521 s ' y ----A � Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to wo authorized bv this budding permit a plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,006 cu.ffi 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 Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 GensRI Contractor f -` -` wee o o Company Name csc. : o� y17 , , Name o on Respo si le f r Constrqction License No. and Type if Ap licable yv�c v�oftul " �- a PCO NOY Street r�s City/Town State Zip vie 3 J ' .I c�ar1W � Telephone No. business Telephone No. cell e-mail address SECTION II:W0kKF.RS'CObtl'hNSA'i'1<ANWSUIt:1NCEACF1UAVf1' M.G.L.c.152.§25C6 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 O No ❑ SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ 0 Building Permit Fee=Total Construction Cost x_(insert here 2.Electrical $ appropriate municipal factor)=$ 3. Plumbing $ d.Mechanical (HVAC) - Note:Minimum fee=$ (contact municipality) 5. Mechanical Other nclose check payable to 6.Total Cost $ —(-C'Ostact municipality)and write check number here - SECTION 13:SIGNATURE OF B ILDING PERMIT APPLICANT - By entering my name below,1 hereby aftest-under the.pLins_am penalties of perjury that all of the information contained in this application is true and accura the best f k—noo le ige.and understanding. o.` ® Bfivcc Mp, Wi0hg M���, C S L /_i cay t r S� un-�a� A Please pript a o3 sign f�me�� f / /Title ,A ,Telephonel� Date �[I-.v( dY y (�/avttsTt, /M�IYI� t Stree't Ad ressr City/Town State Zip / Municipal Inspector to fill out this section upon application approval: Name Date /�nc� Castle Hill Mini Mart Project: 1-Check adequacy of floor joist. DL Spaces between joists S= 16.00 in Wood framing 3.50 psf SPF :_> 4.67 Ib/ft Ceramic tiles 4.70 psf :_> 6.27lb/ft TOTAL 8.20 IDL 10.93lb LL FLOOR 100.00 psf Table (4-1)ASCE 10 L 133.33 lb ft Method LRFD 1.2DL+1.6LL 226.45 Ib/ft Span 15.00 ft Mmax(WLA2/8) 6369.00 Ib*f Vmax 1698.68 lb check design Joist size 2x12 SPRUCE PINE#2 (SPF) BENDING S x-x 31.64 in3. Fb Fb' 1738.00 psf S=M/fb' 43.97 in3. Not Good a bigger size of beam is needed TO SOLVE THIS PROBLEM WILL ADD SUPPORT TO THE MIDDLE OF THE SPAN. Mmax(WLA2/8) 1515.42 Ib*f Vmax 1051.25 lb check design Joist size 2x12 SPRUCE PINE#2(SPF) BENDING S x-x 31.64 in3. Fb' 1738.00 S need 10.46 OK DESING NEW SYSTEM GIRDER LOADS 1580.8 LB/FT Mmax 11367.62lb.ft VMAX IF EM FIR SELECT STRC b' 2901 IZE 410 S-X-X 49.91 S needed 47.02221 OK POSTS Pu 150001b L 7ft TABLE 4-6 AISC SELECT FY=35KSI USE: PIPE 3 STD fi*Pn= 19.8 FOUNDATIONS fc' 3000 psi fy 40000 psi Pu 15200lb qe 4 kip/ft2 assumed to confirm with geo report. A=Pu/q a 547.2in2 L=B 23.39231 in L=B 24 in Vmax 6.7 kip Mmax 33 Kip.ft d 5 in assumed h 6 Vc 13 kip ACI 11-3 Vc>Vn OK Rc minimum Use 3#6 each side -`� From; Deborah Feln-Brag deb@fein-designs.com f Subject: Details For Structural support system for Castlehill Minimart A Date: March 4,2015 at 1:28 PM To: danchau84@yahoo.com Cc: BOThach bo_thach@yahoo.com Hi, Herein are the details you requested.They may require a stamp since they weren't on the plans originally but ask Michael first. Deb Deborah S Fein-Brug AIA,NCARB Fein Designs www.fein-designs.com Off#508-497-9192 Cell#508-641-1771 "Think positive.Exercise daily. Eat healthy.Work hard.Stay Strong. Worry less.Dance more. Love often.Be Happy." CC) b:1 . D X A CD 1-9 X p � r p D . r7 d � F9 o -i c D_ Z t� (---j F- I, � r� O Z A U rrI tz W o N r- 1n ry w Ao , u 4 4 Q o ,o --- - 3 4 cow,ER I� I VCRETE BASE t2 I - I 'X24- II j LEXI LE HELMNG •� n >sr� #6 EACH SIDE, "`S""` I I PIPE 0 STD .z10 HEx rIR S CCT STRC , I i I i 1 `J 3 4 li r • ,T The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Workers' \'Porkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNDTTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Address: 0 City/State/Zip: J141 A Phone#: — OC7 Are you an employer?Check the appropriate box: Type of project(required): I.❑1 am a employer with employees(full and/or part-time).* 7. ,aF.,(New construction 2 1 am a sole proprietor or partnership and have no employees working for mein $, I/q� Remodeling Nary capacity.[No workers'comp.insurance required.] !f 3.❑1 am a homeowner doing all work myself.[No workers'camp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.= 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance 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. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. T Insurance Company Name p ma`s T�l,S�ywzi„u Q G(�,(,y L kC Policy#or Self-ins.Lie.#: p ,�6r�Q 6�� Expiration Date: Job Site Address;Ito 3:eXt eNfa1% kit City/State/Zip: C'1 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. Ida hereb under thepains an penalties ofperjury that the information provided above is true and correct. Sitmature: Date: —QJF-W m Phone#: 5'O — 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 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 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 burn 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 A� CERTIFICATE OF LIABILITY INSURANCE DATE(WIDDY"") 4/1/15 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(im)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 CONTACT NONE: Alice A LaRosee Daniels Insurance Agency Inc PHONE _ (SOH) 366-8736 �FAxN HSOB) 898-0403 Plt E test Main Street ADDRESS: alice@danielsinsurance.com stbOLOUgh, MA O154S INSURER(S)AFFORDING COVERAGE i NAIC0 INSURERA:Arbella Protection Insurance C ) INSURER B: Thomas Gaetani INSURERC: i Grafton Refrigeration INSURER D: I 12 Collette St INSURER E: i S Grafton, MA 01560 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. INSR. . - _ )AWL'SUBRI — — .._ _ r POLICY EFP `` POU CY M I. _ - LTR TYPE OFINSURANCE POUCYNUMBER , MWN t MdNprYYYy LIMNS A GENBMUABIUTY } i8500062695 1/22/1C 7/22/15' EACH OCCURRENCE I S 1,000,000 X C064JERCIAL GENE rTUV31UTY I f rEREEK$ESIFANT�E¢�ss1 s 100,000 uI ICIAINS41ADEL_JOCCUR I I INEDDP"..P..) $ 5,000 PERSONAL 6 ADV INJURY S 1,000,000 1 I GENERALAGGREGATE JOOO,000 GEN'L AGGREGATE UNIT APPLES PER PRODUCTS-CO NP AGG 1 S 2 POLICY PRO- ,QQQ_QOQ ECT ' LOC I S AUTOMOBILE UABIUTY a EINED IN L LI I S ANYAUTO , I I iBOpILY INJURY(Por parson) :S PLLOWNED SCHEDULED AUTOS AUTOS I I I ) BODILY INJURY(Per a.ic1m)is HIREDAUTOS NON-OWNED PROPERTY DAMAGE I S_AUTOS i ) (Perewkeml S UMBRELLALUIB OCCUR i� EXCESS UAB BEACH OCCURRENCE S CLAIMS,M W! I I AGGREGATE I E DED RETENTION i E WORKERS COMPENSATION j WC SrATU- 'OTH- ANDEMPLOYERBUASIUTY YINI I j I �. .TOBYLNUS� ER ANYPROPRIEIORIPARTNERIENECUTIVE 1 OFFKERMEMBER EXCLUDED? 7IN/A. � I I E.L.EALH ACOIEM IS IMYeNabry in NH) 1 E.L.DISEASE-EA E6PLOYEEIf DES(AIPTIO OF OPERATIONS below i I ( IEL.DISEASE-POUCYL"IS H I � I MSCRIPTONOFOPERATKINSILOCATIONSIVE CLES iAAaob ACOR01C1.AESIUonal Romre SDI Wo.IImoreslew Xnydn4) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CASTLE BILL MINI MART ACCORDANCE WITH THE POLICY PROVISIONS. 280 JEFFERSON AVE SALEM, ma AUTHORMED REPRESENTATIVE I Alice A Larosee ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: DANCHAU64@YAHOO.COM x S' yM� hli HUMMER 445-�4-2010 RK ad S05 µG j 0*462015 � V p55 c J CLASS 12 REST WSU M 16 tOr Sift *DM NONE i ied wyl� NIS 2g r A ..t? 4Q1 * H 54 ARUNGTON ST WORCESTER, MA 01604 OD 05-15-2010 Rev 01-15-2009 ,raa � QTY OF SALEM, MASSAQHUSE7'I'S BUILDING DEFARTMENr cla 120 WASHINGTONSIREET,YDFLooR ItL.(978)745-9595 KIMBERLEYDRISCX)LL FAX(978)740.9846 MAYOR THomm ST.FIERRE DIRECTOR OF FUBLiCFROPERTY/BUILDING OC)MffssIONER 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 c40, S 54; Building Permit of is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name f hauler) The debris will be disposed of in: (name of facility) (address o facility) Signature of ppli o � D to ! Massachta setts - Qeps%r-me.nt of Public Safety Board of Building Req ;alations and Stardaras Conftruction Supervisor A License: CS-071 477 mw BRUC'E A MA TUB,-ONIS 54 A RUNG ON ST � y Worcester m� ol'604 Expiration ComMis sroner 05/05/2015