90 LAFAYETTE ST - BUILDING INSPECTION (10) 41- —31to2
'K2
The Commonwealth of Massachusetts
Department of Public Safety S
Massachusetts State Budding Code(780 CMR)
ri
Building CT—
Pe Application for any Building other than a One-or Two-Family Dwwlling Z
1 (This Section For Official Use Only) lly
r—<
--9 Building Permit Number: Date Applied: Building Official: D rntl
ISECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not av ble)
No.and Street City/Town Zip Code Name of Bud(if applicable)
16-- SECTION2.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 ML Repair❑ 1 Alteration j8( Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 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 Engineerfn Peer Review required? Yes ❑ No ❑ 1
Brief Description of Propo ed 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 applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-L❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
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 ❑ ❑B ❑ IIIA ❑ IIIB ❑ 1 IV Cl I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Dis osal Site
Public U( Check if outside Flood Zone❑ Indicate municipal® A trench w81 not be P
required®or It
or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: CIA I h,u rµ.,Conumu�>n
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:
Dues the building contain an Sprinkler System?: Special Stipulations:
61Zk- ZS"7-- c7Y4 )
V 1 U -- F I�ANs (tJ 2r
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Maine(Print) No.aru1 Street City/Towne &wI 1
/6- A//g Zip
Property Oy?ner Contact Information: .1Al
Title= "" Telephone No. (business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
IJyvne Street Address City/Town State Zip
to act on the roper'Operty owner's behalf,in all matters relative to work authorized by this budding permit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix2)
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 Re g istered Professional Responsible for Construction Control - -
d2"f _ -7 .99Z9o ,
Name(Registrant) Telephone No. a-mall addresS'f Registration Number
/CL420—e-A/ <'K) S',a/
Street Address I City/Town State Zip Discipline Expiration Date
10.2 General Contractor - -
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town Skate Zip
TZS! 2�—eCez-lj4 -7 7Z9a9�
Telephone No. business Telephone No. cell a-mail address -
SECTION 11:4l'OI:KF.RS'COMPF.NSA1[ON INSURANCF:AF.FIUAVl'f M.G.L.c.152.9 25C6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and 'I
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 13
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE:
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
1. Building I $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ v appropriate municipal factor)_$
3. Plumbing $ D
4. Mechanical (HVAC) $ Note:Minhnum fee=$ (contact municipality)
5. Mechanical Other $ O Enclose check payable to
6.Total Cost $ (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 best of my knowledgeand understanding.
Please print an sii�H� _ Telephone Date
Street Addres 1-71
- /• ' •� City/Town State Zip
Municipal Inspector to fill out this section upon application approval: A \f
" •Ls-v d
Name D¢
The Commonwealth of Massachusetts
t Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,AM 02I14-2017
www massgov/dia
w1vorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERAffrnNG AUTHORITY.
Applicant Information TO
Print Lealbly
Name(Busiaws/OrgamTation/Individual):
Address: P
City/State/Zip: Phone —F7
Are you an employer?Check the appropriate box:
Type of project(require]additions
1.: am a employer withemployees(full and/or part-time).•
7. ❑New construction
2. 1 am a sole proprielor or partnership and have no employees working forme in
MY capacity.[No workers'comp.insurance required] 8. Remodeling3.Q Iam a homeowner doingll work myself.[Noworkers'comp.inmmnmrequired.]t 9. ❑Demolition
4.❑Iam a homeownaand will he hiring contractors to conduct all work on my property. I will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole11.❑Elechical repairs orproprietors with mo employees. 12.Q Plumbing repairs or
5.O I am a general contractor and I have hired the subccnbswma listed on the attached sheet
These sub-contnuors have employees and have workers'comp,mormamt 13.❑Roofrepairs
6.F�We are a corporation and its officers have exercised their right of exemption per MGL a 14.Q 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.
1 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 sheer showing the name of the mb-con acmrs and state whether or not those entities have
employees. If the sub=contractors have employees,they most provide their workers'comp.policy number.
I am 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.#: { (`�(/ �A` Expiration Date:(Z ZO/ / Z
Job Site Address: �� l Kpjts S j— Citylstate/Zi12�� o/S_7v
Attach a copy of the workers compensa on policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required trader 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.
FEM
I do harebloveMify under the pains and penalties ofperfury that the information provided above is true and correct
Si a e. n r — Date-
Phone M _7
Offcial 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 M
Information and Instructions
t
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(ILC)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 confirmationof 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
(M of SALEg WssACI3[kS m
BtnDn9GDar
' 120wn TS"=T,3IDFLOox
7kL(978)745.9395.
%IIr9BERLEYDRiSODLt PAX(978)74 OM
MAYOR T1ucSTP
Dnwcr BtcFpuuJCPROp y/Btm B#G cg�=
Construction Debris D1sposa/Aff1davit
(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 coo, S 54; Building Permit 8 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly lensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(na a of auler)
The debris will be disposed of in:
(name of facility)
(address of facility)
ignature of applicant
at
Client#:65359 MONACOJOHN
FE
,,dCORDn CERTIFICATE OF LIABILITY INSURANCE FAT
4/1212/OD/'/YY1
/12/2016
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:B the certificate holder is an ADDITIONAL INSURED,the policy()es)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 NAME:
HUB International New-England Pn"/C°NNo EX1:9786573100 1 FAX
No: 978-988-0038
299 Ballardvale St E-MAIL
ADDRESS:
Wilmington,MA 01887 INSURER(S)AFFORDING COVERAGE NAICd
978 657-5100 INSURER n:Travelers Indemnity Co of CT 25682
INSURED INSURER a:Travelers indemnity 25658
Monaco Johnson Group LLC
INSURERC:
C/O Christopher A.Monaco
INSURER D:
3 Elm Place NSURER E:
Marblehead,MA 01945
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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,
IT
AND CONDITIONS OF SUCH POLICIES. LIMIT$ SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
lip TYPE OFINSURANCE INSR µVD POLICY NUMBER �/NO YES MUM; LIMITS
A GENERAL LIABILITY 6803647NO841542 012016 04MO/2017 EACHOCCIATRENCE $1000000
DAMAGEE1O�ENTED
X COMMERCIALGENERALUABIL°Y PRREEMIS oocueence $3OO OOD
CLAIMS-MADE 4 OCCUR MED EXP(Any me person) $5 000
PERSONAL B ADV INJURY $1 00O 000
GENERAL AGGREGATE 52,000,000
GENL AGGREGATELIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000
POLICY X PEo- LOC $
B AUTOMOBILE LIABILITY BA3649N64415SEL 0/2016 04/10/201 Ewa aBcddeNINED SINGLE LIMIT
ANY AUTO
BODILY INJURY(Per person) $5009000
ALL OWNED X SCHEDULED BODILY INIURY(Per aaitlent) $500,000
AUTOS X HIRED AUTOSX NON-OWNED
AUTOS NED AUTOS T Ha rt DAMAGE $100,000
$
B UMBRELLAUN13 IV I OCCUR CUP3038T6601542 MOM01604/1=01 EACH OCCURRENCE s2000000
EXCESS UAS CLAIMS-MADE AGGREGATE s2,000,000
DED I X RETENTION$5000 1$
B WORKERS COMPENSATION IOUB3887N32115 O/2016 WGM017 X WCSTATU- oTT+
AND EMPLOYERS'LIABILITY
Y PROPRIETORIPARTNERIEXECUT YIN
AN E.L.E. EACH ACCIDENT $500000
OFFICERIMEMBER EXCLUDED? � NIA
(Mandatory in NH) EL DISEASE-EA EMPLOYEE s500 00O
It yes,describe wrier EL DISEASE-POLICY LIMIT $500 060
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(AH ACORD 101,AddKlorel Remarks Schedule,N moreepace is required)
"Workers Comp Information"
Proprietors/Partners/Executive Officers/Members Excluded:
Christopher Monaco,Member
Peter Johnson, Member
Blanket additional insured status applies to certificate only when required by written contract
RE:220 Highland Ave,Salem MA
CERTIFICATE HOLDER CANCELLATION
Tropical Products Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
P THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Berman Properties LLC ACCORDANCE WITH THE POLICY PROVISIONS.
220 Highland Avenue
Salem,MA 01970 AUTHORIZED REPRESENTATIVE
01988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S1588844/M1587432 CW001
Initial Construction ControlDocument
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8a'edition of the
Massachusetts State Building Code, 780 CMR, Section 107.6.2
Project Title: Restaurant Tenant Fit-UP
Property Address: 90 Lafayette Street Salem,Massachusetts
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: 1,220 SF Tenant Fit Up of Existing Business/Assembly Space to facilitate the occupancy by a
Restaurant per the submitted drawings and specifications.
(,Richard Griffin,MA Registration Number: 7814 Expiration date: August 31,2016, am a registered design professional,
and hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning:
Entire Project X Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that 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 I (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 withthe progress and
quality of the work and to determine if the work is being performed in a manner consistentwith theapproved
construction documents and this code.
When required by the building official, I shall submit field/progress reports(see item 3.)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'.
„t
Enter in the space to the right a"wet"or �yRD W
electronic signatureand seal: r a�
W /9t4
SAtEM,
Phone number: 978-740-9979 Email: richard@rgriffmarchitects.com
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If'other' is chosen,
provide a description.
f
J t