76 LAFAYETTE ST - BUILDING INSPECTION (3) , • ; . EI`I'�BF� --
��� ' PUBLIC PROPERTY
DEPr1R'I'�iF.,11T
��.M�.��.,uius,;�u,
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/f,� 130 Wwutactcw S`���y�u:�{M,�ss.�a�Lstl'ts 01970
�� lta:9'.6�1ii9593�F.�c:9767�0-9846
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION.
DEMOLITION. OR CAANGE OF USE OR OCCUPANCY. FOR ANY EXISTING
STRUCTURE OR BUILDING
. �.0 SITE INFORMATION � � �
Lacatlon Name: ?� L oe .e -� S-� Buildi�g:
— prp�ertyAddress:—•7-���oe��e�—�'z�— -- -------- ----- —
���
property fs bcated in a;ConaervaUon Area YM Hiatoric Distr(d Y/N I
2.0 OWNERSHIP INFORAAATION
2.1 Owne�ot Land 6
Name: LL�
Addresr. �o C� �U�—
� -? �✓'c�, lo o S� S-u�� /o�
' 1� 0 2-7 3
Teiephone: � i 7 (o�S 4'S �15
3.0 COMPLETE THIS SECTION FOR WORK IN EX�aT�N� BUILDINGS ONLY
Addition Existing 2,
Renovation Number of Stories Renovated
Changein Use New
DemoliGan �' Existing �' g!� p _
Approximate year of � Area per flaor (s� Renovated I
construction or renovation 1°��'v New '
of existing building
9aef Description of Proposed Work:
-�G,��� gs•' �x,��^� �r� �� �al'v`l �,p�
���-=. � 1.'��.�� � �.'�oti-��-� �+ ��c-T � Ce� l.� �,
�.o�� r a�� � ��o� �o✓� ;-✓n�� . �� 2,U'
�ri„ros-r,� T�-r.—n-e�'�--� �� �g ;-,,�)1 i'�-�, �
---
Mail Permit to: _ - - -- - --
What is the curtent use o(the Building7 � �
Material of Building? � Se''"! If dwelling, how many units?
Will the Building Conform to Law? — �sbegt°$? N��
qrchfted's Nama �� � -� �� �
AddressandPhons �? ��v ✓'?"� L'�� �S�'esvt( )b'L!1 d 617 �2� ?2O�
Mechank's Nams
Addresa and Phons
C��uc�on Supervisors License# G S v`s�I ��HIC Registratfon#
Estimated Cost of Project S r S,ovv Pertnit Fes CalcutaMon
Pertnit Fee i � � g, ° v Estimated Cost X S7/51000 Residential
EstlmatefiCost�S11/510006ommercial--- -
qn p,dditional$5.00 ia added aa an
Administrative charge.
Make sure that all flelds are properly and legibly written to avoid delays in prxessing.
The undersigned does hereby apply for a Buiiding Pertnk to build to the above stated
specificaUona. Signed under penalty oi perJury /� `����-���Z��
Date r �� a
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1�l1►7�bla�l�ts f7N�►1W
Consdntcd�o� Deb� Dtspaat AAtdsvtt
(nqNira�e�r ill e�oolidos�d e.eev�.brq
Ls�oead�eos wid���6cef�dtdos dt6�3t�Het{�e�Ccd�7f0 C!��eedc�l li.!
peb��d dr peovt�{ati of 3K8.s�4 S sM
B�y�N is hrs�w[1►�aoad�do�tdt Id d�Ma rew�lls��
cMr ara��II��d ot�s po��t Uae�i�r�dtqa�t Ad1f�a d�atl b�►!�3l.s
i t l.i tJOA. �
'I�debri��rill b�tr�n;o�ted b�R
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wn�.Imw�N
7'fi�doMs wiU b�dia�owd olin:
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� �ne/�.,�ca� � ��,(�►�
�Ide�of heilit�
LW�4ct af p+ �OYIkaa1
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� � CITY OF SALEM
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;; PUBLIC PROPRERTY
DEPARTMENT
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a!,►roe uo m�y�aesr.se�u.M�olq�o
'I�t:97Y7K9S9S �F�x:97t-7�09iK
Wor�en' Compensadon Insnrance A15davi� Bnildera/Contncton/Elccti{eiana/plymben
Aoolkant IniormaHon please Aiet •a+�ti•
Name l • . .aua��: l�'C6 �,.�(�L��g � Z—L C
Addresa• I 7 �✓'�n�o '4� �z�� )o�
City/SffiWZip:_S-�m-v� vi)Ze /7yq � `fl 03
Phone#:_ �/ ? �2 5 g �15
An yo�a�ampbyerT C�ee!tM approprtab yeu
1.0 I am a employar aith 4. Q I am a Ymaat eooteacwr md i ���1�(�qdre�:
O emrloy«�a(li�n,ua�or pr�e-ume>.• n.ve hina the�nau�s 6• ❑Nevv eao�trucdon
2. + I am a aole prop�cietor ar pumeo- Iisted on ths at4ched sheet= 7. ���1in�
ship and Lave no employw 'These wb-ron�acmn haw 8. Q"Demolitlaa
workia` for me in any cap�city. workas'ccmy,iy��,
�q�d°ias�aomR mweance 3 ❑ o���tiaa end ita 0.��m°i�ddidon
mca�ciaed meir ❑Eleeaicai eep�iis ar addttia�os
3.0 I am a homcownec doin�all woric right of mcemptiem par MdL 11.Q Plumbins rep�n a ad�d
myxlt.[No worlcros'eomp. a 132,�!(4�snd we have� 12. Root
tD�IItt 1O4�I f �P�oY�INo workrn' ❑ np�ss
comp,maaance requiiod.) 13.0 pther i�
f�r�PP�mr eeab boz rt maw ata eu out�ueel�4aow reoMo�thdr wak.� . . . . I
� Hom.o.on.�m�6eh w..flla.vlt md�e��bY w ddes a9.at md�ei.aWa. a�.na.��it�.ma.dt(adk+tles wid
=Coea�eeon tdt chaek thb bat mirt+thedd�e�ddfdood�6M tho�Nr ntmr of Ih��ob.eom�etas md�Adr walor�'aomR P�Y�aa � '����
I an�ow empfoya NYa;lt provldlnj worbn'eompenradow inr�raue�jor nry eurroloyres Below ts rhi pa/!ry anI fob sAfi II
lnjorwadow,- - _ —
insurance Compeny Name:__ Z ✓h� I
Policy k or Self.ins,Lia M: � ���D�• I
- Job Site Addrea�: 71� L-c1�wr' w-�P � Ciry/SbOdZip; }�.� '
Attae6�eopy ut tIw worten'compenutb�potley daluatlo�MN(�lowle�th�potley number and es '
Failure w seture coven ai P�s d�b}
ie ��ed uader Seetion 25A oPMGL c. !32 can lad te rhe impoypon ot����tia ofs
fine up to 51,500.00 aaya one.yar impriaonment,a�weU at civil penalaa in the form oPs STOP WORK ORDER and a fine
oP up w f250.00 a dsy agaiou da violuor. Be advixd tdat a copy of thii snrcmeat may be focwarded w[ha OfAce o[
Invescigadow oPthe DIA for insurance coverage verificaaod
!da hsrsby c�iriJj� dss th�poLu and dn oJP�i/�ry 1Aat rAv lnjansaatoe provfdsd i Is mrt anl comct
Sianaturo• i� ' D rw ! 7 J�� �
Phone te: L�) `7 10 2 g J ..� —��"�
0/jkld att onl�t Do not wrlf�4 thb aieq to b�eomOleqr br clry a foww ofy►c/aL
CIry or Tows: Perm(NLleenx N
Is�uin;Aut6ority(etrck ooe):
1. Board of Hea1tY 2.Buildlo`Department l.C(rylfows Clerk 4. EJectrkal Inspector S.PlumbinQ Impector
6.Other
Contaet Penoo• P6one k•
Information and �Instructions .
;�,�s�cyusem Genenl Laws o6apta l52 cequims all employees w�che savic�e o�f�unda any conaad���.
pursuant w d�is stuute.u►aMPfoY�s is defined as"...ev.aY P��
��press or impk�d.�or wciaeo.'
o ��fined as"an individual.Pacme�s6�P.as°°��°4�O6°�°�������or any two ot mae
An suipl Yp m a oimt eutaprisR va o[s deeeaaed emP�.or the
of ths foceicisi mi+i�� 1 aod inelumnt the kg�l�� � lo cas. However the
of an iadividual.P�emas�V.�a ahat le;at ena�Y.�P Y�i�P y �{the
�'���� ha�ta hsvinf aot mae thaa thxe�aad who taida thaein.a tbe ooc�p�
ownar of s dwellini � m do mainteoaoea.�°t�woik cn auch daetlinf h�
dwaU►nt h°ua°of aoothet �P�Y+�m shall mt bcauas of weh emPloy���tO be m empbyet.
or on th��a buildin4 BPW��°�
MGL chapca 151.42K(��°uata that"avary stW or beai tlee�si�f���Y shar wdth�old�W°�°��°�
te o s budnea or te eo�bofWlnP ia t�eomme�wealt�tor u7
re....d ur.ueee..or��b evWe�a or eompu..e.win chs�e.arana eovera�req°�''ed."
'pd�uc�oalty,biGl.ahaP�t s2.42�(�S�0°+"N°'�r tbe eommonwealth mc auy of its poGdcal subdivisious�
c[public walt undl aceepmbla evidmce ot eomPtis�with the innuance
• eater inco any conaad far the p� w dte conaacdni awho�i�Y••
��otthis�aP��ve beea�n�d
ppptlea�b
Plesse 81l out tlte wodcros' compensati°°a��vit comPutelY.t►Y��i ehe boxa that aPP�Y�'Y���O°a°d'd
neeesascY.wDP1Y�O�fO�a)namKs),ad�a)snd P��n�8��O°a with their�(�)�
(T,I,L7 or Limiad Lisbility Pacmush�p�(L�'�with no ecnploY�o���he
i�rance. Limioed Liability ComP!°�°�c�arockas'ac�mss�°°�°. If an LI.0 or LLP doa hsve
membees a��O not r��d tlut thi�a�davit m�y be�ubm[tted w the DapaRment of Ind�a»1
employees+�P��Y u� and dab the affidavM. '!'hs affidavit should
Accidenn fa coa&mauon of intunace covara�s. Abs M snn W s1� of
be mauaed to the city or wwa that the application fa the pamit a licenee is beini r�.�s wo�rke�s'
�Cial Aceideats. Should Y�b+°O��°�0�n��ths Lw or if yw aze required
cemPm�b°°Po�Y.P�O eali the Dep�mn��nuimbs lisoed below. Selt-inwied companus�d eatar d�eir
eelt innumce lice���°II d►e
Ctty or Tow�.Ot�dad
Please ba sure thst the afTidsvit is comp
le�aad pcinted legibly. The Departmeat hs+Provided s space at�ha bottom
of che affidavit for you W fill out in the event the OSica of tavestigatioes has w contact you regardiai the sPP��
Plesse ba sura to fill in the peimit/liceaae number whic6 will lx used as a mferea¢e number. In additio4 aa apP1�a�
that must submi�mulaPk P��CO°O°�
licanont in any Qiven year.need ody submit one affidavit indioatini cu�
policy informatiun(if naasrsY)s�d�°��7ob Sita Addcaas"the appiicant should wtite"aU locsaon�in__(�t�Y or
of ehe affidavit that has beaa otAciallY�or marked bY tke ciry a wwn msy be provided m the
town)•^A copy y on Hle for t�turo pa�mib or liawxt A naw afl,d�.vu mwt be 6lled cwt ach
aPpucaat as proof chat s valid affldsvit� s liceux a pamit not reisted w any busiaae ar eommaa�sl vanture
year.Where a home owm a ciazen is obniniut to eo lete this at8dsvie
(i.e. a do�licmae or Pe�to bum lava ex.)said petwn u NO'f required mP
nt would lilce w thaok you iu advaoee Pa your eoopaation and shauld You have aay 4���.
The OETice o4invesdi�ve us a cali.
please do oot haitate to gi
't'he�eParm�°���address,cel�Phona and fa�c numbac:
'CbiO�vl/�alt�Of IN�9S1Ch11SC1tS
�OP�tlSt[1v/�1dEIIb
�ml�0��Yd1��00i
600w��000 sa�e
s�,�►o�iii
TeL N 617-727-490�ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Revis�J 5-26-OS �yqryU,IpBgS.gOv/dli
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'^� ✓/� P��,�a,,�e�./rk y�✓G/�tr �
�� � f. .��. �: BOARD OF BUILDING R�GULATIONS � i
� `- Licease.,CONSTRUCTION SUPERVISOR k
� `r Number: CS 086143 �
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Birthdate: 1:1/0U1964 + '
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� � . Exp�res: 19/01/2007 Tr.no: `..86143 s��
3
� J R�kncted: 00 .., - , " ��
. ,MICHAELG BERNIER � - - �
���
- �,r',16 CHANDLER ST ' �_ ��-� i ;,�
� � � NEN!*fON MQ 02458 ��
� Admm�strator �'
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s. ti , .,,. . . :ry
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� � Client#: 35588 � RCGBU
ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DD/YVri)
o,nsim
PRODUGER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
INSURANCE MARKETING AGENCIES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
306 MAIN STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
WORCESTER,MA 01606
508 753-7233 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: C�Ufil$FOfSt@I 42471
RCG Builders LLC iNsuaea e: Associated Employers Insurance Co. 11104
CIO RCG-LLC INSURER C'
17 Ivaloo Street, Suite 700 �
INSURER D:
Somerville, MA 02143
INSURER E:
COVERAGES
THE POLICIES OF INSl1F2ANCE LISTE�BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR
MAV PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SIJBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLIGY E%PIRATION LIMITS
LTR NSR DATE MM1llDD/VV UATE MM/�O/YY
/\ GENERALLIABILITY GL0097705 03/37I06 03/31/07 encHoccuaaENce s1000000
X COMMERCIAL GENEft4L LIABILITY �AEMGE TO RE�ccu Dn $$O OOO
CLAIMS MAOE �OCCUR MEO E%P(Any one person) $
X BI/PD Ded:15000 PERSONALBADV INJURY $'I OOO OOO
GENERAL AGGREGATE $2 OOO OOO
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMPIOPAGG $'I OOOOOO
POLIGV PRO-
JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANVAUTO (EaacddenQ $
ALL OWNED HUTOS BODILY INJURV
SCHEOULE�AUTOS (Perpersan) $
HIRED AUTOS BODILV INJURY
NON-OWNE�AUTOS (Peracadenl) $
PROPERTV DAMAGE S
(Peraccitlanl)
GARAGELIABILITY AUTOONLV-EAACCIOENT E
ANVAUTO OTHERTHAN �ACC $
AUTOONLV: qGG $
E%CESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCGUR �CLAIMS MADE AGGREGATE E
$
�E�UCTIBLE $
RETENTION S E
B WORKERSCOMPENSATIONAND WCC5005531012006 OSI�O/OB OSI'IO/O� X WCSTATU- OTH-
EMPLOYERS'LIABILITY
ANVPROPRIETORIPARTNEWEXECUTIVE E.LEACHACCI�ENT $SOO�OOO
OFFIGERIMEMBEREXGW�ED9 ELDISEASE-EAEMPLOVEE $SOO�OOO
If yes,tlascnbe under
SPECIALPROVISIONSbelaw E.LOISEASE-POLICVLIMIT $rJ�0�00�
OTHER
OESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS AOOEU BY ENUORSEMENT/SPECIAL PROVISIONS
Re:76 Lafayette St.,Salem, MA
CERTIFICATE HOLDER CANCELLATION
SHOUL�ANV OF THEA90VE OESGRIBED POLICIES BE CANCELLEU BEFORE THE EXPIRATION
Dodge Area LLC OATE THEREOF,THE ISSUING INSURER WILL ENOEAVOR TO MAIL �_ DAYS WRITfEN
c/o RCG-LLC NOTICE TO THE CERTIFICATE HOLDER NAMEO TO THE LEFf,BUT FAILURE TO UO 50 SXALL
17 Ivaloo Street� SIl1YB'I OO IMPOSE NO OBLIGATION OR LLIBILITY OF ANY KIND UPON THE INSURER,RS AGENTS OR
Somerville, MA 02743 REPRESENTATIVES.
AUTHORI2ED REPRESENTATIVE �
ACORD 25(2001I08)� of 2 #137597 GCE O ACORD CORPORATION 1968
� • ' �
. 76 LAFAYETTE
ST, SALEM
�� µ�9 RETAIN WATER SUPPLY,VENT AND
p������ I WASTEFORNEWSINK TEN UNITS
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SEEPLANFORNEW I �'—,F—�P==�-- MA01910 rxaea
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SEEPLANFORNEW Toll-Iree:B88848-LOFT
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GENERAL DEMOLITION NOTE: GENERAL DEMOLITION NOTES:
, THESE OR4WING5 SHOW COMP�ETE ARCHRECNRAI ldL RSBUILT oRAWINGS PROVIOEU FOR DEMOLITION PRICING.VERIFY EXAGT IOCATI0N50F
SGOPE Of OEMOLITION ANO REMOVAL.CONTPACTOR IS FIXTIlRES,APPIIFNCES ANO WP1LS IN FIELD
RESPONSIBLE FOR iIMING AN�SEpUENCING OF OEMO TO
LIMITE%POSUREOFTHEBUILDINGTOWFATHFR,RETAIN WALLSTOBEREMOVEDSHOWNAS�NSHEO
' . . � CLEPRAGCESSANOEGRESS�UWNGCONSTRUCTION,LIMIT
� PUBLILNGCESSTOWNSTRUCTIONSRE.ANDDISRUPT PLLTEMPORARYENCLOSUREWALLSSHONMASHATCHE� n�
BL�G OCCUPMlTS AS LITRE AS POSSIBLE.NO�EMOLITION
ORREMOVALOFANYBEARINGORNONBEARINGWALLSON PLLEXISTINGMASONRYTOREMAIN 10�EC06 PERMRSET
PARTITIONS IS PERMIITED UNTIL COMPREHENSIVE
MSPECTWNBYSTRUCTtIRPLENGINEER.CONiRACTORTO REMOVEALLCEILINGFINISHESFRqME5PN01NSlILATION
ftEMOVE ALL PVSTER ON WALLS AN�CEIlINGS PRIOR TO
INSPECTIDNBYSTROCNRALENGINEER. ftEMOVEALLCARPETAN�FLWftFINISHES
IFCONTRFCTORENCOUNTERSMATERIALSiHATMAY CONiRACTORRESPON5IBLEFORTREATMENTOFE%ISTNGPIPES,RA�IATOR&FlXNRESAND
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NOTIFY TIE OWNER PN�HAVE MATEPIALS TESTED. -
' BEMOVE ANO PROPERLY pI5PO5E OFALL DEMOLITION WASTE,INCLU�ING RPPLIANCES AN�FIXTURES �
. OWNERS�ESIGNBUILDSUBCONTRACTORSPAE �^�'T'0� °60�
RESPONSIBLEFOR.BUTNOTIIMITE�TOTHEFOLLOWING: �EMOSUBGONTMCTORiOPERFORMAWALKRIROUGNOFPRQIECTBEFOREPROVIpMGFINNL
�ETERMININGNLLM,E,P,FPREMOVAL,CAPPINGAN�MAKE PRICMG
suE. . DEMOLITION
PERIMETER WALLS AND FINISHES TO REM1W N
THIRD FLOOR
p �I DEMO�LA�TAON -THIRDFL030R-0
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76LAFAYETTE
RETNNWATERSUPPLY,VENTAND ST, SALEM
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