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175 LAFAYETTE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts T WIV, Department of Public Safety Massachusetts State Building Code(780 CibIR) Building Permit Application,for any Building other than a One-or Two-Family Dwelling (Phis Section For Offici:d Use Only) Building Permit Number: ' Date Applied: Buihlhig Official: _ SECTION 1: LOCATION(Please indicate Block#.,nd Lot#for locations for which a street address is not available) 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 ❑ Addition❑ Demolition 117 (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 Engineering Peer Review required? Yes ❑ No ❑ Brief Descr lio�n o�f�`P�ro`posed Wor c nA �r >s�1 r� 1IO�L� EA ta>�f� KlAl e SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE SIN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s)i IProposed,Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/Stories(include basennent 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 ❑ A-4❑ A-3❑ B: Business E: Educational ❑ F: Facto F-1 ❑ F2❑ If: High Hazard H-1 Cl H-2❑ H-3 ❑ H-4❑ H-5❑ , 1: Institutional I-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ . R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use Eland please describe below: Special Use SECTION 6:CONSTRUCTION TYPE(Check as a plicable) IAO - Ill ILA ❑ 11B13 IIIA ❑ IIIB ❑ 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: LLicensedl)i ris Removal: Public y3' Check if outside Flood Zune❑ Indicate municipal A trench will not be sisalSite requiredB rtrench y: VC Priv[te❑i or indcn[ify Zone or on site system permit is enclosed❑ Railroad right-of-way: ILizards to Air Navigation: .\L\I I I r 2„,i,�,„� v n l ;cu f r o•,..: Not Applicable� is Structure within airport approach,ire 1 Is their review_ completed? J or Consent to Build enclosed❑ Yes❑ or No®" Yes� No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code- Use Gruup(s): Type of Construction: Ottupant Lund per Floor: Does the building con Liin.ni Sprinkler Systeni?: Special Stipulations:_ SEC•rION 9: I'ROI'EIL"FY OWNER AU'r11ORIZA'riON Name and Address of Property Owner - -�._--i �avSeVo�_ S 35� Cazc�c��Cc .e =u _ Zip Name(Print) No.and Street City/Town roperty Ow``ncr Cuntac[hthumntion: f_�♦dC1\� 1`�.-�'_.�e 0�6\ �1--��Slav' .fin ��_ �c>\J\SS Title Telephone NO. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes ^` n �O�CSS�\ \ 1 � ,fc`S` Name Street Address City/Town State Zip to act on the ru er owner's behalf, in all matters relative to work authorized b this buildin' errnit a lication. r-i SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (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 Registered Professional Res onsible for Construction Control Nome(Registrant) Telephone No. e-nail address Registration Number Street Address City/Town State Zip Discipline Expiration Dale • 10.2 General Contractor Company Natitc � / 1 \1cS�cs_CrtiC .. . f• Name of Person Responsible for Construction License'No. and Type if Applicable Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:1\'QRRBRS'(lJnu'HNS,\raAV insuen��ca::u�I LIAVi'i M.C.L.c.152.5 25C6 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 ❑ SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor �P1�(1 O �� Item �+ and Materials) TO Cie ISR Lion ost tom Iten 6 =5 1. Building 5 Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical 5 appropriate municipal factor) -$ 3. Plumbing 'S Note: Minimum fee=S (contact municipality) -1. mechanical (HVAC) 5 5. \Iechanical Other 'S Enclose check payable to 6.Total Cost S (contact u1 polity)and write cheek number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICAt By entering my name below,I hereby attest under the pains and penalties of perjury that all of tl -information contained in this application is-true-and accurate to the nesra,iyknowledge-and understanding. l Title n Telephoe No. Date Plntsc print.rod sign name City/Town t; e -Zip Street Address /f Municipal Inspector to fill nut this section upon application approv 1: + Name Date Front Amber Nelson FaxID: Date: 4/10/2013 12 : 02 PM Page: 2 of 2 ./� OF ID:AN a�o�ro CERTIFICATE OF LIABILITY INSURANCE DA 04110N3 ) 4N O 3 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 pollcy(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 781-642-9000 CONTACT NAME. Eastern States Insurance 781-6q7-3670 PHONE FAx Agency, Inc. ac No Ext: FAX NO_ 50 Prospect Street E-MAIL Waltham,MA 02453 ADD PRODUCER RESS: CUSTOMER ID r:ALPRI-1 INSURER(S)AFFORDING COVERAGE NAICI INSURED A.L. Prime Energy Consultant INSURERA:Utica Mutual Insurance Co. 25976 Inc. INSURER e:Hartford Underwriters IS Lark Avenue INSURERC:Torus Speciality Insurance Co Saugus,MA 01906 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. NOTMITHSTANDING 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. TRW ADUL LICYEXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYW CYEFF MM0DfY1'YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 UP A X COMMERCIAL GENERAL LIABILITY 4604211 12/01/12 12/01/13 PREMISES EHEN Erence $ 100,000 CLAIMS-MADE lxl OCCUR MED EPP(Any one person) $ 5,000 Contractual PERSONAL&ACV INJURY $ 1,000,000 Liability Include c GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $ 2,000,000 P $ POLICY .IROi T LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 A ANY AurD 4604210 12101112 12/01/13 BODILY INJURY(Par person) $ ALL OWNED AUTOS BODILY INJURY(Per acoiden) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (PeI.11denp $ X NON OWNEDAUTOS $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,00 EXCESS LIAB CLAIMS-MADE AGGREGATE $ C 76859C7 20AL I 12/01/12 12/01113 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X TORV LIMITS OT AND EMPLOYERS'LIABILITY FIR B ANY PROPRIETORIPARTNERIEXECUTIVE YIN 6560UB4973P27-7-12 72/01/12 t2/01l13 EL.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) EL.DISEASE EAEMPLOYEE $ 1,000,00 Eyes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE POLICYLIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: 327 Market Street, Rockland, MA. CERTIFICATE HOLDER CANCELLATION ROCKLAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Rockland ACCORDANCE WITH THE POLICY PROVISIONS. Rockland,MA AUTHORIZED REPRESENTATIVE —r- ©1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: A L Pik IM 6 Z—W c G Y Address: I F LAP-)< ' Ue5 City/State/Zip: S /� U G U S )� .019�6 Phone #: 0 Zo I x z oz Are you an employer? Check the appropriate box: Busines Type (re,quired): 5, Retail 1.d I am a employer with 1 50 employees (full and/ [�] 6. ❑ Restaurant/Bar/Eating Establishment orpart•time).* 2.❑ I am a sole proprietor or partnership and have no q, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. g, ❑ Non-profit [No workers' comp. insurance required]3.❑ We arc a corporation and its officers have exercised 9 Entertainment❑ their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11,[] Health Care 4,❑ We are a non-profit organization, staffed by volunteers, with no employees, [No workers' compse . insurance req.] 12,❑ Other 'Any applicant that checks box#I must also fill out the ction below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1, ' I ant an employer that is providing workers'cwupensation insurance for my employees. Below is the polic}l inforncaelon, Insurance Company Name:�j A& T _ n t y -1 126 (� W A l T C-A S Insurer's Address: (2-Cl_ City/State/Zip: (A ) At'TLIAM Mn rJ z `/ S'3 Policy# or Self-ins, Lic.#6S 6 U U 13 — �l � T 3 ?Z -- - 'I ' ] Expiration Date: 1 2-/of 12,e 13 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 MOL 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 co verification. I do hereby certify, under the pains did penalt as o rjury that the information provided above is true and correct. Signature: Date: _� Z u Phone# � � �� Zc/6 oZa1 A 2oL 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 Cleric 4.Licensing Board S. Selectmen's Office G, Other Contact Person: Phone #: www.mess.gov/die L �vr CITY OF S U ENt, NL-1SSACHUSETTS Buim IN,GDEPART-%tENT e 120 %V.ASHINGTON STREET, 3w FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KI\tBERIEY DRISCOII. INLAYOR I1-tO.%w ST.PtERRg DIRECTOR OF PUBLIC PROPERTY/BUILDING CO.%L%IISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section l l 1.5 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 be 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 : fall (name of facility) � - address of facility) si p,, It applicant date ICI)1'IiJ li•I•R N+�o1T��a CITY OF SAL.EM, MASSACHUSETVS �j5 3b PUBLIC PROPERTY DEPARTMENT u .120 WASHINGTON STREET, 3RD FLOOR SALEM. MASSACHUSETTS O 1970 A, TELEPHONE: 978-745-9595 �. FAX: 9 78-740-9846 KIMBERLEY DRISCOLL - MAYOR Section 116.0 DEMOLITION OF STRUCTURES Structures over fifty (50) years old must have approval of the Salem Historic Society UTILITY DISCONNECTIONS REQUIRED onzed Agent Date of Disconnection Water ' (see attached requirements) Electrical vL Firer Health Sewer 7 Salem Historic Commission Dig Safe Number Pest Control: ***DOCUMENTATION OF ALL THE ABOVE MUST BE ATTACHED BEFORE PERMIT CAN BE ISSUED*** Fee for Demolition $5.00 application fee plus $2.00 per 100 square ft gross area, Minimum $25.00 Demo a_�1S .s��a