90 LAFAYETTE ST - BUILDING INSPECTION (4) t The Commonwealth of Massachusetts
�• I Department of Public Safety
\tassadnuells Slate Building Code(780 C:VIR)Seventh Edition
1 City of Salem
1 Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Onlv) -
\rt Building Permit Number: Date Applied: Building Inspector.
"VUU7 SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
'
No.and Street Citv /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here ❑or check all that apply in the two rows below
Existing Building,, Repair❑ Alteration ❑ Addition ❑ 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%;L
Is an Independent Structural Engineering Peer Review required? Yes ❑ No I$
Brief Descri ti in o Pro used Work:
-jv h e v cozy r
1 i n ,-2,
v
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use Group(s): M K > Proposed Use Group(s): S
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) I •Z„ I 7d-0-D
Total Area (sq. ft.)and Total Height(ft.) I / ?Yja
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Businesses E: Educational
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2 ❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 14❑ 1 M: Mercantile(a R: Residential R-113 R-2❑ R-3Ilk R-4 ❑
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 ❑ 1160 IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) -
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public'm Check if outside Flood Zone ❑ Indicate municipal$. A trench will not be Licensed Dis�u. i Sits
required ❑or trench- or.pecily: -
I'ricah•❑ or indcntily Zone:_ or on site sestem ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I,\ I li,t,n,( ... Itoc ir:. Pw,r��:
'wt :\p pl ic,i blew I.tilrueturu icithin airport approach area' I, (heir review completed.'
n;Cunsent In Ru dd cnc o.ed ❑` It vs or No-R Yes❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I dilion of Code, C,e Group(,), rvpe of C on'tnlClion: Occupant Load per Flour.
I)110, the bUdding Contlon.tn Sprinkler Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Prop•r y Owner
RCS 'ro �cn� e LLC 17 TVa1� aS�1 Sol e 117D SayYRnyiYL MA UZI
Name(Print) Nu.and Street Cih'/Town Zip
Property the ner Contact Information::� c
A" �� 1,i 1� , r'6-2i�?- OOOZo -- -A— Ic1-
.N1;P R VC'4 -IIC -
Title Telephone No. (business) Telephone No. (cell) a-mail address
If applicable, the �ruperty owner hereby author zes 1
4A etiuz ,l l6!r �Pnr' f? L✓1-t7-1 '4 ' U;V4 e /n� SyXnW Nl 4 O zl
Name Street Address Citv/Town State Zip
to act on the ro perty owner's behalf, in all matters relative to work authorized by this buildin • permit a >plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is less than 35,tA10 cu. ft.of enclosed s acc and/or nut under Construction Control then check here O and skip Section I0.0
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 General Contractor hCC=1 ) J. �ti St/!i5, ZZ L.
Cumg�iny Name:
V°(�e n .(_ ✓,boo C S cab 11i�
Name of Person Respunsibe fur Cur+tructiun y,l icense No. and Type if Applicable?
2 LCs ! 7 �a/a an O
Street Address City/Town State �itP
6j0 2 ZS 7 7 45 6�-S 2 z
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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? Ye No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor ,,�g}
and Materials) Total Construction Cost(from Item 6)=$ 'py 025
1. Building $ 00-1b Building Permit Fee=Total Construction Cost x 17 (Insert here
2. Electrical $ appropriate municipal factor)
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality))37
5. Mechanical (Other) $
Enclose check payable to
6. Total Cost $ za-- (contact municipality)and write check umber here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury thatall of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
T ,_kec_j 6)7 .sS3 28b rl c�
flea+e print and ign nam • Tyylr Telephone \ Date
027�3
}tree[ :\ddress Cih'/Town
.M f Municipal Inspector[o fill out this section upon application approval: a`�j}��
ame D�ate
t 1
� iNfassachusetts - Department of Public Safety
Board of Building, Re-ulations anti SCmdards
3J Construction Supervisor License
License: CS 86143
Restricted to: 00
MICHAEL G BERNIER
65 WABAN PARK
NEWTON, MA 02458
Expiration: 11/12011
l l,nnni"io..... Tr#: 8918
i
CITY OF SALEM
~ �`\ PUBLIC PROPRERTY
QT-ANWI DEPARTMENT
.0-. ,Ic 120
Fri V8.1434595 • 1::\s:979-)4049846
Construction Debris Disposal Affidavit
(required fior 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 c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(name of hauler)
The debris
will be disposed of in
Q
(name,u face ny)
An
(address ut tacduy)
ignature of permit applicant
late
dclu i.aa dac
v .
� Y
CITY OF S.U-F-,Ni, NAkSSACHCSETTS
BL'DDLNG DEPARTSMNT
ti• 120 WASHINGTON STREET, 3no FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
�.,(BEALEY DRISCOLL THobNS ST.PrEIRR
MAYOR DIRECTOR OF PLBLIC PROPERTY/BU ILDLNG CO%MUSSIONiER
Workers' Compensation Insurance Afi)davit: Builders/Contractors/Electricians/Plumbers
knnllcant Information 7 / Please Print Legibly
Name (ausiocv Orsa iiranon lndavideal): RLCT 1�� �ll) ( Q/!� a—c—
Address: S
City/Statc/Zip: -ry; I-C—> fi/;A Phone Al: 6 ;-71,- 7-7 �
Are you to employer?Check the appropriate boas Type of project(required):
1.❑ I am a employer with 4.4Ehl am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-caruractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet : 7. ❑ Remodeling
ihip and have no employees Theme sub-contractors have g. ❑ Demolition
workingfor me in an capacity. workers'comp.insunto e
Y P tY• 9. ❑Building addition
I No workers'comp. insurance S. ❑ 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.[Na workers'comp. C. 132,41(4),and we have no 12.0 Roof repair
insurance required.) t employees.[No workers' 13. Otha
comp. insurance required.]
.Any applicant chat duxln boa Of must alma fin Uld the MitM below.elowieg their worker'Wmpenaatiwt policy info mtaJim
'I hvneownem who submit this aflldsvh indicting their am doing all work and than him outside cone iciom.ma suhtnh a raw affldevil indicting suds
:C,mua.•bn that cheek Ohio boa mast attached an additimal ahem showing the nuar of+a mb coetnnsm and tick wwkm-comp.puficy infamouoa.
I unit as employer that Os providlnir workers'compenradon Insureace for my eaep/ayeer, Below/s the pollcy and/ob r1ta,
injormurfon. —���,,
Inwrance Company Name: MM
Policy 4 or Self-ins. Lic.N: Expiration Date: ,� /�
Job Site Address: �a Z o 6w�--z--�g� City/State/Zip: 2n" /!/!IV
,►"me h a copy of the workers'compensafl4 policy declaration page(showing the policy number and expiration data). -
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 51,500.00 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. Ile adviw:d that a copy of this statement maybe forwarded to the OIYiCe of
Invcaugatiuna ol•the DIA for insurance coverage verification.
I da hereby cord#m%unndi,,{{{rho pains and pen of perjury that the informarlon provided ubov is t a and earreea
G / `7
Pion 4: 2— z
((7 S 3
e
iOfcial use only. Do nor write in this area,to be umpleted by city or town q lciol
city or town: Ycrmit/LlccnseM ___
hsuing.►ulhority (circle une): - --
I. Iloard of Ilralth 2. Building Department 3. City/rown Clerk J. Electrical lnspector 5. Plumbing Inspector
6. Other
t..,nttacl Person: _ -- --- Phone g•
Client#: 35588 RCGBU
ACORDT. CERTIFICATE OF LIABILITY INSURANCE ivoa/zoos
✓'YRbD CER 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 01608
508 753-7233 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: Arbella Protection 41360
RCG Builders LLC INSURERB. Associated Employers Insurance 11104
c/o RCG-LLC INSURER C.
17 Ivaloo Street,Suite 100 INSURER D:
Somerville,MA 02143
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.
TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY E%PIRATION LIMITS
LTR NSR DATE Mil DATE MMIOD/W
A GENERAL LIABILITY 3600042885 03/30/09 03/30N0 EACH OCCURRENCE $1000000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $1 OO OOO
CLAIMS MAOE 7 OCCUR MED EXP(Any one person) $5 000
PREMISES fE,,ccurwrce�
PERSONAL S ADV INJURY $1 00Q 000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2000000
POLICY PRO LOG
JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (En accident)
$
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Peraocitlent) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
1
AUTO ONLY: AGO $
EXCESSUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION AND WCC5005531012009 05/10/09 05/10/10 X TCRYWO STATU- OFIR
TH-
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $500,000
ANY PROPRIETOR/PARTNERIEXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT I$500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
RE:90 Lafayette Street,Salem, MA
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Salem DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 9n DAYS WRITTEN
120 Washington Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Fourth Floor IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Salem,MA 01970 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001108)1 of 2 #S176669IM161634 GCE o ACORD CORPORATION 1988