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0092-0096 LAFAYETTE STREET - BPA-16-676 Lk t ` tso ClC -Z-0 z M' KfGEdVEt3 . . ,, ,z� , The Commonwealth of A�s;Fc usetts Department of Public Safetx �)2 O P 2; 00 1� Massachusetts State BuildingCode A ` Building Permit Application for any Building other than a One-or Two-Family Dwelling 9 (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: n - SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 92-96 Lafayette St. Salem No.and Street City/Town Zip Code Name of Building(if applicable) - _ SECTION 2:PROPOSED WORK I Edition of MA State Code used St_h If New Construction check here❑or check all that apply in the two rows below 1 Existing Building 4 1 Repair❑ Alteration 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 a Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Descri tion of Proposed Work: Interior rehab of the 2nd floor and lofts of an existing 2 story building including electriral machanirA and plumbing upgrarias 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.) 3 352 B 3 Total Area(sq.ft.)and Total Height(ft.) NAM l SECTION 5:USE GROUP(Check as applicable) A. Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Businesses E: Educational ❑ R Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H„3 ❑ H-4 Cl H-5❑ I: Institutional I-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ 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 ❑ HA ❑ IIB ❑ IIIA ❑ IIIB 6 IV ❑ 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 0 Check if outside Flood Zone4p Indicate municipal■ A trench will not be Incensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑ or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ orNoS 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?:�e S Special Stipulations: rv% ISA t (� K- ^GXAt•t Gt o P C.pnt 1— st;�i. �.z✓r-1pPavt� <-raa ' SECTION 9: PROPERTY OWNER AUTHORIZATION - Name and Address of Property Owner RCG Klondike Club 17 Ivaloo St Somerville 02143 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Jim Gagnon 617-625-8315 617 512 P9RR jgagnon@rcg-Ilc.com Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Scott Allison 58 Glad Valley Dr Billerica MA 01821 Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 ca.ft.of enclosed space and/or not under Construction Control then check here 0 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 General Contractor Supreme Builders Company Name Scott Allison CS 069628 Unrestricted Name of Person Responsible for Construction License No. and Type if Applicable 58 Glad Valley Dr Billerica 01821 Street Address City/Town State Zip 781-953BO36 scottCa supremebuilder.net Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 Cl 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 $ 5 400 appropriate municipal factor)=$ 3.Plumbing $ 0—b 4.Mechanical (HVAC) $ fj Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ foot 600 (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 oo the bept of knowledge and understanding. Scott Allison affCon-6mcic o r' 781-953-6036 Please print and si name Title Telephone No. Date 58 Glad Valrey Dr Billerica 01821 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: v 'L` 2/d Name Date SUPRE-1 OP ID: JM ACQRO" CERTIFICATE OF LIABILITY INSURANCE DATE(MMI°D WYY) `— 06/08/2016 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: 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 CONTACT Foster Sullivan InsuranceJ-1 NAME: Ryan Arsenault 163 Main SLLL A/CNNo E.1:978-686-2266 AIC N„ 978-686-6410 North Andover,MA 01845-1-1 E-MAIL Foster Sullivan Insurance LLC ADDRESS:certificates@fostersullivangroup.com INSURERS)AFFORDING COVERAGE NAICN INSURERA:TRAVELERS CASUALTY INS 19046 INSURED Supreme Builders&Design Inc-n INSURER B:Merchants Mutual Ins. Co. 23329 58 Glad Valley Drivel J Billerica, MA 01821 INSURER C:TRAVELERS INSURANCE CO 19046 Bi INSURER D INSURER E 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 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 TYPE OF DL R POLICY EFF POLICY EXP LTR INSD WVD POLICYNUMBER MMMD MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE lxl REMISES Ee OCCUR X 6803D251673 07/09/2015 07/09/2016 P ooccat rents $ 300,00 MED EXP(Any one person) $ 5,00 PERSONAL A ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑ JET LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COM BINED SINGLE LIMIT $ 1,000,00 Ea a ddard B ANY AUTO MCA1001684 07/09/2015 07/09/2016 BODILY INJURY Per person) S ALL OWNED X SCHEDULED BODILY INJURY(PeraccidmA) $ AUTOS AUTOS X X NON-OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIETOR,PARTNERIEXECUTIVE YIN 7PJUB-4768P16-5-14 07/21/2015 07/21/2016 E.L.EACH ACCIDENT $ 1,000,00 OFFICERa11EMBER EXCLUDED? F-1N/A (Mandatoryin NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 Ir yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached IT mom space is required) RCG Klondike Club &RCG-LLC are listed as additional insureds on R F the General Liability policy as required by written contract. L_ UU ❑❑ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. RCG-LLC u Li 17 Ivaloo Street[]❑ AUTHORIZED REPRESENTATIVE Somerville, MA 02143 / / `�©19888--2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations I Congress Street, Suite 100 r` Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Supreme Builders & Design,lnc Address: 58 Glad Valley Dr City/State/Zip: Billerica, MA 01821 Phone #: 781-953-6036 Are you an employer? Check the appropriate box: Type of project (required): 1.M I am a employer with 3 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑■ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' insurance.# 9. ❑ Building addition comp.[No workers' comp. insurance p• required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. (No workers' 13.❑ Other 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 time of the sub-contractors 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:Travelers Policy#or Self-ins. Lie. #: 7PJUB-4768P16-5-13 Expiration Date: 7/21/16 Job Site Address: 92-96 Lafayette St City/State/Zip: Salem Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 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 S1,500.00 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceMjy under the pains and penalties ofperjury that the information provided above is true and correct Signature: Date: 6/20/16 Phone#: 781 -9536036 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 #: PITMAN & WARDLEY ARCHITECTS LLC CONSTRUCTION CONTROL AFFIDAVIT June 16,2016 RCG 92 Lafayette St (Second Floor and Mezzanine) Salem, MA 01970 I, Peter F. Pitman, affiliated with Pitman & Wardley, Architects LLC submit that 1, or a designated representative,will perform the following professional services, as specified in the 2009 International Building Code(including all Massachusetts Amendments) Section 107.3.4: 1. Review for conformance to the design concept, shop drawings, samples, and other submittals, which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approve the quality control procedures for all code-required controlled materials. 3. To be present at intervals appropriate to the stage of construction, and complexity of the project,to become generally familiar with the progress and quality of the work, and determine to the extent practical and possible the work is being performed in a manner consistent with the construction documents. Our observation during site visits will not relieve the Contractor or its Subcontractors of their responsibilities and obligations for quality control of the work, for any design work which is included in their scope of services (i.e. design delegation), and for full compliance with the requirements of the Construction Documents, applicable rules, regulations and building codes. Furthermore, the detection of, or the failure to detect deficiencies or defects in the work during our site visits does not relieve the Contractor or their Subcontractors of their responsibility to correct all deficiencies or defects,whether detected or undetected, in all pars of the work, and to otherwise comply with all requirements of the Construction Documents. Peter . Pitman, Architect Massachusetts Registration No. 8749 32 CHURCH ST SALE M MASSACHUSETTS 0 1 9 7 0 9 7 8-7 4 4 - 8982 (�.a74� FAX 978-744-0400 - 7 (A Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC T 17 7 Electrical p 8 Plumbing include local connections 9 Gas(Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 1.6 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Com ensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other S ecg 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information �eltr �t 6w.e ✓� o - I _ 8qe _ 87 Name(Registrant) Telephone No. e-mail address Registration Number _L2 Chure $� - /e71 ^ oi em Ych. Street Address City/Town Discipline Expiration Date State Zip Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Discipline Expiration Date Street Address City/Town State Zip 1 massachusptta Oep, Board of Buii_ding RM License:CS-06962A' Construction suo r SCOTT B ALLISON 58 GLAD VALLEY DR BILL.ERICA MA 0182 b i i � 0 612 212 017 . �"` .� 4$pn11117551OP i