12 PALMER ST - BUILDING INSPECTION �ggOro
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The Commonwealth of MassachuAVFT
Department of Public Safety P 35
YU Massachusetts State Build ing Code(780 CbIR) 1114 DEC �2
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for which a skeet address is not available)
X 12- Pn\ r ST Sal¢� O l q -7 O
No.and Street City/Town Zip Code Name of Building(if applicable)
e` SECTION 2:PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair&I 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 Cl
B ief Description}If Proposed Work:
i o O rx Q v' D
t-�e oftI aa wtk I.QQ•/Q l $ID-M
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): I Proposed Use Grou p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational Cl
F: Facto F-I ❑ F2❑ It: High Hazud H-1 ❑ H-2❑ H-3 ❑ FI-d❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ 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:CONSTRUCITON'tYPE(Check as a licable)
[A0 Ill CI IIA ❑ IIB ❑ IIIA0 IIIB ❑ I IV ❑ 1 VAC3 VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 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❑
required ❑or trench or specify:
Private❑ Or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %I h I I. t..rg_i mn i.,�.I'. . I roy.�•,c
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 conlain,m Sprinkler System?: __ Special Slipulations:
gk-0 7S / `b :5yML4 tNG RSP p.
t`/ toe 0 CNA.c.� jVtIlll ED '11U CD0CAiIq-�Ajp— CPT 1,24S
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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'Lcz\d oe�•,r,o�;�.:..5��c 21S Wc 02116
Name(Print) a No.and Street City/Town Zip
'Piopirty Own rCon frct Information:
17a 30� �..�\V� -�ws 4aa 7sit »;k ;l.��
'line Telephone No. (business) Telephone No. (cell) a-nmil address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the ro er 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 built ng is less than 35,000 cu.ft.of enclosed s ace and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
owe Go\\m���goGSb`L 4f �a11ae1,.rP�se„I1�4
Name(Registrant) Telephone Nu. a-run ldrusr Registry ton N1umber
-7 Si-_ /H�4LQ v RnC�o v. AA p1 Z,- CrC1..;i-e cX'
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Co/n'tractor., _
C-Je`&V kck\
Company Name
i >'w A01-7 3 7 Cs l —
Name of Person Responsible for Construction License No and Type if Applicable
Street Address City/Town State - Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:W_0RKVR.S'C0611'LUSAI IOiv INtiUILI N(.'1S:V'FilmVfF M.G.L.c.152.§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
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 0
1. Building $ o oo Building Permit Fee-Total Construction Cost x 11 (Insert here
rtmeand
ctrical S appropriate municipal factor)=$$ .
mbing $
chanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
hanical Other $ Enclose check payable to �"•.\� o� �l2.vn
W Ya
\ al Cost $ O Q O (contact municipality)and write check nu rber here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
tering my name below, 1 hereby attest under the pains and penalties of perjury that all of tile informationcontained in this
ation Is true and accurate to the best of my knowledge and understanding.
e, Q o� w. Ila- -7S1 12 1 1 print and sign name Title Telephone No. Date
.�<sE Ca� 4 �Ao2tAddress City/,rown State Zipipal Inspector to fill out this section upon application approval: t'f
Name Date
CITY OF SALEK MASSACHUSEM
a
BUILDING DEPARTMENT120WASHINGTONSTREET,311DFLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978) 740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 111.5 Debris,
and the provisions of MGL c40, 5 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
Sa ,Jy
(name of hauler) J
The debris will be disposed of in:
S
�o
(name of facility)
V2 S `� � PSCo � �d AAA
(address of facility)
Signature of applicant
'Date
t° Ciz'Y OF S:U EM. NLUSACHUSETTS
BL'ILDIING DEPARTNLE-NT
120 \' ASHIINGTON STREET, 3'a FLOOR
ka.n TEL (978) 745-9595
F.♦.x(978) 740-9846
KI\1BERLF-YDR1SC01_L THoii sST.PiFRRn
t-kAYOR
DIRECTOR OF PUBLIC PROPERTY/BCB.D(\G COJL\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informatinn Please Print Leeibly
Name(OminessDrganiratiam'Individuat: C- "1i-car Ca J `qL",01 T a
Address:
City/State/Zip: MA O.Z-k Phone n:
Arc no can employer"Check the appropriate box: Type of project(required):
I.(1I am a employer with 4- 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full antYor part-lime)." have hired the subeontractora
2. 1 am a sole proprietor or pwtner• listed on the attached sheet. i 7. Remodeling
ship and have no employees These sub-contractors have 8. []Demolition
working fix me in any capacity. workers'comp. insurance. 9. 0 Building addition
INo workers'comp. insurance 5. 0 We are a corporation and iu 10.❑Electrical repairs or additions
reytdreJJ officers have exercised their
3.0 I am a homeowner doing all work right of exemption per M IL 11.0 Plumbing repairs or additions
myself. (No workers'comp. c..152, §1(4),and we have no 12.❑Roof repairs
insurance required.) t employees. (No workers'
comp. insurancereyuircd.) 13.❑Other
•Any applicnnl that checks bus*1 must also rill uat the suction belswallowing their voikrn,compemadon puliey inrormmlon.
'11,unuowrent who submit We atnrhrvil indicating they are doing all work and than him ouisidocontncron mrel submit a new amdayil indicating such
:c.,.nrwrors thin check this box must atachol an addidural ahul showing Its-name of the"It4oraOcton and their workm'romp.policy hnfirnnation.
1 unt un eitiployer ilia!is pruvldliig worker✓'comprusatlon lasura»ce for my employees: Holow/s the policy mad Job sire
iufaroration. 1 L
Insurance Company Name:_r Cam"--••`� �'� `^S U
Policy if or Sclf-ins. Lie N: W:r 0-7 7 6 S 7 Expiration Dale: 2 1 ( AAA-Job Site Address: Z P a``�-i r S� Cily/State/Zip: C LLIL — ✓" `r ` C)Lp`
Attach a copy of the workers'compensalloo pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of,%IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 und/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a line
of up to 525o.00 a day against rile violator. Be advised that a copy of this sratement may be rurw hded to the Off iec of
Investigations ol'ihe OIA for insurance coverage verification.
/du hereby c•errify wider the palsy and penaldex of ver%ury that the infurataliarr provided above is true and correct.
Si'millarc I �+ AQ Q Data:
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P 1: '7O 3 ( 8O —? U .
A
Of/iriu!use anly. Du not tvriu in this area, to 6e cunrylerad by city at,mrvn s/Jiriu[
I
City nr Torra: _ _ Permlt/l.Iecnse g__.....__. ..__-..
Issuing Aut hurity (circle one):
I. Board or Ilealth 2. Building Deparlmcut I.caylruwu Clerk 4. Electrical Iuspcctor 5. Plumbing Irripeetor I
6, Otter
Confect l'c fit,n: ___... Phone .T:
T UP IU:GH
,4 INSURANCE BINDER ;;;,�74Y'
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM.
AGENCY COMPANY BINDERa 25913
edger Insurance Agency, Inc. Llo drs
0 West Cummings Park EXPIRATION
Suite 6725 DATE EFFECTIVE TIME DATE TIMM
obum,MA 01801 AM 1201 AM
PHONE 11/13/14 PM 12/13/14 NOON
( a Ea:781-933-2626 A�,,781-932.6341
THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY
CODE: SUa CCDE: PER EXPIRING POLICY aTO BE ISSUED
cu •OCELO-1 DESCRIPTION OF OPERATIONSAIMUCLESIPROPERfY(NMutflM L*cW=)
INsuRED Ocelot Operations LLC APARTMENT BUILD84G:located at 12 Palmer
c/o Dan Botwinik Street,Salem,MA 01970
PO Box 55071##49220
Boston MA 022055071
COVERAGES LIMRg
TYPE OF INSURANCE COVERAGISPORMS DEDUCTIBLE COINS% AMWINT
PROP' CAUSES OF LOSS SLDG/REPLAC COST/BLDRS RISK 2500 Boo
BASIC BROAD a SPEC ENHANCEMENTS INCLUDE
ORD OR LAW:COV A 8000
COV B&C(EACH) 80
GENERAL LIs�Y EACHOCCURRENCE f 10000od
X COMMERCIAL GENERAL LIABILITY
R S 50091
lu
CLAWS MADE OCCUR MED EXP(Any one permn) S 50
PERSONAL&ADV INJURY $ 10000
GENERAL AGGREGATE S 200000
REMO DATE FOR CLAIMS WIDE: PRODUCTS-COMPIOP AGG f Included
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E
ANY AUTO BODILY INJURY(Par Panora) b
ALL OWNED AUTOS .BODILY INJURY Per=kImt S
SCHEDULED AUTOS PROPERTY DAMAGE f
HIRED AUTOS MEDICAL PAYMENTS $
NON-OVLNEDAUTOS PERSONAL INJURY PROT b
UNINSURED MOTORIST f
8
AUTO PHYSICAL DAMAGE DEDUCTIBLE ALL VEHICLES SCHEDULED VEHICLES ACTUALCASHVALUE
COLLISION: STATED AMOUNT b
OTHER THAN COL: OTHER
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT S
AGGREGATE b
EXCESS LIABILITY
EACH OCCURRENCE- S
UMBRELLA FORM AGGREGATE b
OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELFdNSURED RETENTION f
WC STATUTORY LIMITS
WORILER'S COMPENSATION E.L.EACH ACCIDENT b
AND
EMPLOYER'S LIABILITY E.L.DISEASE-EA EMPLOYEE S
EL.DISEASE-POLICY LIMIT S
TWIE LICY IS IN EFF IT FROM 1 14-11J13/15.
TOTAL ANNUAL PREMIUM:$4104AO FEES S
OTHERC ERA0E8 TAXES f
ESTIMATED TOTAL PREMIUM IS
NAME&ADDRESS
X MORTGAGEE ADDITIONAL INSURED
EASBOB4
X LOSS PAYEE
LOAN
East Boston Savings Bank
ISAOA/ATIMA c/o MGA Hazard
Tracking,lnc. PO Box 8455 AUTHORIZED REPRESENTATIVE
Reston VA 20195
ACORD 75(2004109) NOTE:IMPORTANT STATE INFORMATION ON REVERSE SIDE ®ACORD CORPORATION 1993.2004
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