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56 MARGIN ST - BUILDING INSPECTION (2) 1J The Commonwealth of Massachusett ) / ` ® Department of Public Safety Massachusetts State Buildin e(780 g Cod I Building Permit Application for any Building other than a 7e,-or Two= 16ay Dwelling 1`�e) (rlds Section For Official Use Only) J Building Permit Number: Date Applied: Building 'cial: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for s!,�ic s a s is not available) s(o M6rsj dj . s4lem M l 01970 No.and Street City/Town Zip Code t,,Xanie 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 ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 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 Description of Proposed Work: Re jno v t_ y S Tt^., EP rim Csac�-� 'l" /�014 iso 4 w.r�-C hs",.lr..hb. �o r%sh+�, vo4e� 1- insia-mac I- A R%((j 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) O 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.@.) .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 1❑ A-5❑ B: Business ❑ E Educational ❑ F' Farto F-1❑ F2❑ H: Hf Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ - 1: Institutional I-1❑ I-2❑ I-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 O IIA ❑ It ❑ HIA ❑ IIIB ❑ TV O VA O 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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed 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❑ 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: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9 PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 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) 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 Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 102 General Contractor Ptco,� Cvk4Mn.yM i Cd•P Company Name Name of Person Responsible for Construction License No. and Type if Applicable f3 5- e vu & LoweAt M+ D 183 / Street Address City/Town State Zip aro gy- 9 (oI3S� aN -m-17sy Dicwc_CartP— OMoIC�ffnt_r Telephone No. iness 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 th,eJh'y5uance of the building permit. Is a signed Affidavit submitted with Otis application? Yes Itl No ❑ SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building Building Permit Fee=Total Construction Cost x (Insert here Z Electric $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose payable to 6.Total Cost $ Q'� (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. aFPlease rint and sign name Title Telephone No. Date Pe.vo.r., L ac� M* 018 4 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval• Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location(Please indicate Block #and Lot#for locations for which a street address is not available) No.and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other(if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other(if applicable) 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 NotRequired 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 _nMTbmg 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&Ins ions program 14 Fire Protection Narrative Report 15 Existing Building Stuv /Invests ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mfti ation Documentation 20 Other S 21 Other S 22 Other S *Areas of Design or Construction for which plans we not complete at the time of application submittal most 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 Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci /Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town/Town State Zi Discipline Expiration Date s The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information t Please Print Legibly Name(Businesss/Orgmimtion/Individml): ccs.,14 co/l&ryk'')U-i / roe Address: 17 S P L7 <Syr � City/State/Zip: Lot_vUk m, 0/?5 / Phone#: 9 78 ' S F 613 s Are you an employer?Check the appropriate bow Type of project(required): 1. ❑ I am an employer with 4. a general contractor and I 6. 0 New construction employees(full and/or part time).' have hived the sub-contractors � ❑ Remodel n 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. S" , g ship and have no employees These sub-contractors have `/' 8. ❑Demolition working for me in any capacity. employees and have workers' 6.1 [No workers' comp. insurance comp. insurance.) 9. 0 Building addition required] 5.11 We are a corporation and its 10. 0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. 0 P1 mJ�ing repairs or additions myself [No workers' comp. right of exemption perm MGL @ R/ insurance required]t c. 152,§ 1(4),and we have no 12. oof repairs employees. [no workers' 13. 0 Other comp. insurance required.] +Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing as work and then hire outside contractors must submit anew affidavit indicating such. :Contactors that check this box must attach 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: Policy#or Self-ins.Lic.#: -r tn1 Ci 3 Expiration Date: 811 j L Job Site Address: .ham b M�lti cgra City/State/Zip: 919k 41 M17' 0 /9 7 0 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration (date). Failure to secure coverage as required trader Section 25a of MGL 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: ,t,.. -,�.� /�fWt- Date: 2q—1y" � , 10 PrinfName: ail' rLts Vlwt4 Phone A.- /78 /S/ 6,135� Official use only Do not write in this area to be completed by city or town official City or Town: Permittlicense#: Issuing Authority(circle one): 1.11oard of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: 3 ol)ca6hei D n'v-�- N o 3 o 6 Z OP ID: LH AFRO" CERTIFICATE OF LIABILITY INSURANCE DAT2113 02/13/12 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 REPRESENTA71VE 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 978433-2728 CONTACT Brown&Brown(Pepperell)P.O.Box 1497 978433-8658 INC.PHON o Est INC No Pepperell,MA 01463 E-MAIL House ADDRESS: CUSTOSTOMER to .PICAR-1 INSURE S AFFORDING COVERAGE N=# INSURED Picard Construction Corp. INSURER A:N m Insurance Company 14788 86 Pevey Street INSURER s:Commerce Insurance Company Lowell,MA 01851 INSURERC:N m Insurance Company14T68 INSURER D:TechnologyInsurance Co Inc 42376 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. IN q TYPE OF INSURANCEJbISIL ADDL B POLICY NUMBER MMIDDYEFF POLICY UP OMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY MST42800 OSH 1111 05111112 PREMISES Ea owurrencel $ 60,00 CLAIMS-MADE �OCCUR MED UP(Any one person $ 10,00 PERSONAL S ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 WN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,00 POLICY X PRO- LOC $ AUTOMOBILE LIASUM COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00 B ANY Auro E72860 05/07111 05I07112 ALL OWNED AUTOS --- BODILY INJURY(Far Parson) $ — - BODILYINJURY(Peraccident) $ X SCHEDULED AU OS PROPERTY DAMAGE $ X HIRED AUTOS (Parauitleni) X NON-OWNEDAUTOS $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS LUIB CLAIMS-MADE AGGREGATE $ 1,000,00 C CUT42800 05111/11 05/11112 DEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILm' D ANY EMBERIPARTNDED? CUTNE YIN TWC3289791 08/17111 08/17112 E.L.EACH ACCIDENT $ 1,000,00 (Mandatory In ER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEES 1,000,00 Dyes,daecdbe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remuka Sehedule,It more space Is mqulred) CERTIFICATE HOLDER CANCELLATION CISALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI Of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington St,3rd Floor Salem,MA 01970 AUTHORIZED REPRESENTATIVE C9Aw- ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD PICARD CONSTRUCTION CORP. 85 Pevey Street•Lowell,MA 01851 Contractors • Developers Tel:978-459-6135•Fax:978459-7078 Residential • Commercial • Industrial www,picardeonstructioncorp.com February 13,2012 The Salem Mission Inc. Dba Lifebridge 56 Margin Street Salem, MA 01970 Attention: Mark Cote Dear Mark, I hereby propose to supply all labor and material necessary to complete the following scope of work. Scope of Work 1. Remove existing EPDM Roofing on 2 separate roofs. The highest of the 2 is approximately 30' x 18' =540 square feet and the front lower roof is approximately 30' x 12' =360 square feet. 2. Mechanically fasten 2"Polyisocyanurate insulation to the existing deck. 3. Fully adhere 060"EPDM to the new insulation. 4. Run EPDM up the parapet walls and terminate per manufacturers' details. 5. Flash all inside and outside corners per manufacturers' details. 6. Flash roof hatch per manufacturers' details. 7. Install new roof drains at the existing location and flash per manufacturers details 8. Dispose of all trash. Exclusions—Permits Note: Any work needed other than what is specified in the scope of work above will be based on a$50.00 per man hour plus the cost of material. All work will be performed in a workmanlike manner for the sum of$6,800.00(six thousand eight hundred dollars). !� / Sincerely, ro ✓,� f>�(-tom Christopher Clarke President Picard Construction Corporation e •'- Massachusetts- Department of Public Safe y Board of BuildingRegulations and Standard's Construction Supervisor License License: CS 6bMi CHRISTOPHER L CLARKE „. 3 NEWFIELD ST N CHELMSFORD,MA 01863 o - - Expiration: 7J31/2013 (Lmm ssiuner. Tr#: 9022 _