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135 LAFAYETTE ST - BUILDING INSPECTION (5) loll . C l` Zq, 3 Co nn m ot�Ns The Commonwealth of 1Gf�s`�a�hi�9 tt-RVICES r_ �� . Department of Public Safety ssachusetts State Building Co 8 ur rng error pp nation for any Building other t an a ne-or wo- a y Dwelling (This Section For Official Use Only) Nr�JI Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) t 135 Lafayette Street Salem. MA 01970 n No.and Street City/Town Zip Code Name of Building(if 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 9 1 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 M No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No R Brief Description of Proposed work: HVAC, Electrical, Framing/Drywall Plumbing Minor FA & FS Finishes. 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) 0 Existing Use Group(s): Business Proposed Use Group(s): Business -- SECTION 4:BUILDING HEIGHT AND AREA ' Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 1 1536 1 1536 Total Area(sq.ft.)and Total Height(ft.) 1536 14'-0" 1536 14'-0" SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business 1A E. Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ 1-2❑ 1-3 ❑ 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 O IB O IIA O 11B 10 IIIA O IIIB O 1 IV O 1 VA O VB O 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 IN Check if outside Flood Zone IX Indicate municipal A trench will not be Licensed Disposal Site M 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 1A Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ . Yes❑ or No M Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code:2009 Use Group(s): B Type of Construction: 1IB Occupant Load per Floor: 44 Does the building contain an Sprinkler System?: YeS Special Stipulations: TO DA TIME AM PM p FROM 4 PHO ELI- ) a`•v w CELL p a O OF N E m s 1 Ui lb 2 5�S E' a I M E O E-MAILADDRESS SIGNED " PHONED AOK RETURNED❑ MNTVO O— AGAIN ALL yygS IN URGENT❑ 02012 ®BluelirWREDIFORM. i i • - LaCroix g U I Monoger A Las Vegas NATIONAL RETAIL TENERAL EONTRACTOR ii I . I I i I t SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 135 Lafayette LLC Care of POUA 84 State Street Suite 600 Boston, MA 02109 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 617- 350- 8885 -_- whyCa)ooua.org Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes 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) f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 101 10.1 Registered Professional Responsible for Construction Control Patrick G Blees (012). 547-1300. MObbink@cmarch.com 30871 Name (Registrant) Telephone No. e-mail address Registration Number 800 Washington Ave N. suite 208 Minneapolis MN 55401 Architecture 8/31/15 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Falcon Construction LLC Company Name Rob Mercurio 092125 Name of Person Responsible for Construction License No. and Type if Applicable 2001 Marina Drive#704 Quincy MA_ 02171 Street Address City/Town State Zip 617 38o 7800 617- 717-9298 rmercurio0falconconstruction.net 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? Yes IA No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 147,026.00 1.Building $ 46 965.00 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ 40,665.00 appropriate municipal factor)=$ 3.Plumbing $ 39,800.00 4.Mechanical (HVAC) $ 19,596.00 Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to City Of Salem 6.Total Cost $ 1 (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 knowledge and understanding. Rob Mercurio President 617- 717. 9298 7/20/15 Please print and sign name Title Telephone No. Date 11 Bay Street Dorchester Ma 02125 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. checklist below is a compilation of the documents that may be required for this. The applic, shall fill out the checklist and provide the contact information of the registered professions 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 X 2 Foundation 3 Structural X 4 Fire Suppression X 5 Fire Alarm(may require repeaters) 6 HVAC X 7 Electrical X 8 Plumbing include local connections X 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications X 12 Structural Peer Review 13 Structural Tests&inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance X 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application subnuttal must be identified her so identified must not be commenced until this application has been amended and the proposed construction document am, has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the origin, fee. Registered Professional Contact Information Patrick G Blees _(612) 547-1300 MOhhinkarmarrh-enm 30871 Name(Registrant) Telephone No. e-mail address Registration Number 800 Washington Ave N. suite 208 Minneapolis MN 55401 Arrhltarhne 8/31. Street Address City/Town State zip Discipline Expiration L Name(Registrant) Telephone No. e-mail address Registration Number Street Address - Ci /Town State Zi Discipline Expiration L Name (Registrant) Telephone No. - e-mail address Registration Number Discipline Expiration L Street Address Ci /Town State Z{ 1he Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 UIF www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Falcon Construction, LLC Address: 11 Bay Street City/State/Zip: Dorchester, MA 02125 Phone #: 617.380.7800 Are you an employer? Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 7 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' [No workers' comp. insurance comp. insurance.'* 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box 41 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Braley & Wellington Insurance Agency Policy#or Self-ins, Lie. #: CA000019458-02 Expiration Date: 5/27/16 Job Site Address: 135 Lafayette Street City/State/Zip: Salem, MA 01970 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 $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. 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 ce!r:ti2 under the airs and enalties o er'ur that the in ormation provided above is true and correct Signature: - Phone#: 617.380.7800 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#: t_ t Massachusetts-Department of Public Safety �f Board of Building Regulations and Standards Construction Supenisnr License: CS-092125 ROBERT J MERCt M.0 } rmamma 2001 MARINA DR#709 _ Quincy MA 112171 Expiration Commissioner 1112812016 I A� CERTIFICATE OF LIABILITY INSURANCE 6/4/20 sue' 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 endorsements . PRODUCER CONTACT Heather Belton NAME: Braley & Wellington Insurance Agency PHONE (508)754-7255 FAX (508)797-3507 44 Park Avenue EMAIL P.O. BOX 15127 INSURERS AFFORDING COVERAGE NAIC If Worcester MA 01615-0127 INSURERA:Admiral Insurance Company INSURED INSURER B:Arbella Mutual Insurance Co. 17000 Robert Mercurio, DBA: Falcon Construction, LLC INSURER C:Markel Insurance Co. 11 Bay Street INSURERD:AtlantlC Charter Ins.Grou 2nd Floor INSURER E: Boston MA 02125 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1552904108 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 INSURANCE AD POLICY EFF POLICY EXP LTR POLICY NUMBER (MMIDDIYYYY) IMWDDNYYYI LIMITS GENERALUABILITY EACH OCCURRENCE $ 1,000, 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Eao rr n S 50,000 A CLAIMS-MADE OOCCUR 000019458-02 /27/2015 /27/2016 MED EXP(Ary one person) $ 5,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea c Ident 1, 000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED 1020038632 /7/2015 /7/2016 AUTOS X AUTOS BODILY INJURY(Per accident) S X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Pe,.cci ant Uninsured motorist BI split limit $ 100,000 C X UMBRELLA LIAB X OCCUR ON3600614 5/27/2015 5/27/2016 EACH OCCURRENCE S 2,000, 000 EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS S D WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000, 000 M FICERIMEMBER EXCLUDED? NIA CV01166701 6/4/2015 6/4/2016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEEI $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addltlonal Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington Street Salem, MA 01970 AUTHORIZED REPRESENTATIVE Heather Belton/AMY ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. -1 Armen