35 PALMER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts f
Department of Public Safety
;i• iy� [[7 klasachu Set ls til,uc Nuild ing C III,•(7811 CNIK)
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Building 1 omit Application for any Building other than aOne-or Two-Family Dwelling
(I his Section For Official Use Onto)
Building Permit Number: Date Applied: Building Official:
SEcTIONA: LOCATION(Please indicate Block p and Lot N for locations for which a street address is not available)
--- ----
C� No.,Ind Strad Coy/Barn Zip Code Name of Building(if applicable)
srcriON 2:PROPOSED WORK
,dilion of NIA Stale C,de used If New Construction check hen•❑err check all that apply in the two rotes below
Existing Building 12apair Alteration ❑ Addilion❑ Denutliliun ❑ (Please fill out and submit Appendix 1) t
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or conslnlcliun d0<umentS being supplied as part of this permit appliauion? Yes ❑ No Er
Is an Independent Structural Engineering Peer Review rei ufred? Yes ❑ No GT
Brief Description of Proposed Work: G�-- - 7,
e 0 - C' o.+ r ..oat r < Ovs - r1 a ! a . e.
r az
1
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 CAiR 3.4) ❑
Existing Use Group(s); Proposed Use Grou p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq. ft.)and Total Height(ft.) I
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑- A4❑ A-5❑ 1 B: Business ❑ E: [educational ❑
F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ 11-1 ❑ H-4❑ H-i❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ 1 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 ❑ HA ❑ IIB ❑ ILIA 0 IIIB ❑ I IV ❑ 1 VA ❑ 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 Reams it:
Public , Flood nf• hulicala numici tat ❑
A trench will not be Licensed Disposal Silo❑
I uL he ❑ Clack It r utsida I h t d 7_t t ❑ 1
Private❑ or indentify Zone:___ or on site Sy stem❑ required ❑or tench or specih':_
penned is enclosed ❑ � _ _
• Railroad right-of-way: Hazards to Air Navigation: �i u��i.�„ ..n �, r . _;
Not Applicable❑ ;Is S1ntRure within airport approach aea? Is tlu•ir rav iaw iomplcleJ? x
Or Gno+anl to Build enclosed❑ lcs❑ (Ir:Na❑ ),.S❑ No ❑
SECTION B:CONTENT OF CERTIFICATE OF OCCUPANCY
Edilion of Coda: Use Grou p(s): l\'pe of Construction: -. ____ Ocrtgtant Load per Flour: --__ ._-
Docs Ilia building coolain an Sprinkler Svstt m). ._.-- __Special Stipulations:
SFC'170N 9: I'ROI'Eli'1"V U1VN Eti AUPIIORIZA'I70N
Name anal Address of Pro ,rrh Owm
Name(Print) - - No.and Street — — �'/Town ------ ------- -- Zip--- Z�Cl
Property Owner Contact Information: �� .L•703 No -7S t8 �� J . ` • c 61
Title -- - Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town Stale Zip
load on the property of+'oar'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 slum 15,000 cu,fl.of enclosvd.space and or not under Construction Control then check here O and skip Seliun Ill.l
10.1 Re istered Professional Responsible for Construction Control
N1 Nano(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Dale •'
10.2 General Contractorpot—
s
�l
Dw/1'
Company Name -
Name of Person Responsible for onstruction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No, cell a-mail address
SECTION 11:m wKl":I.': ((.)\11,1_`5:vu\x_I�c:+U_r.:\.��r.'I�nr1111AVI t 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 pernpit.
Is a signed Affidavit submitted with this application? Yes O No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE -
I[em Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item b)_$
I. Building $ iD O 0 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=S
.1. Plumbing $
a. Mechanical (HVAC) S Note: Minimum fee=$ (contact flit]nicipality)
i. \otA cost
Other S Enclose check payable to _
h.Total Cost $ t O 6 O (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By cnlrrint; my nan L.below, I hereby attest i,ilder the pains and penalties of perjury that all of the information contained in This
applic��ation is true and accurate to the best of my knowledge and understanding
¢¢ .
Please print and sit{n nant,cJ� � Titlefcic---tc o. Itc
Street Address -" -- Cih'/town Stale ip-_ -
Municipal Inspector to fill out this section upon application approval: _ - __ -
Name - -- D.n�-
w
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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►►urken' Cumpenaation Insu li,l. o l°1x
runca � '1111vit: liuilders/Cuntractors/Elr lriclynyPlumbars
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Cily,Stare,Zip. (,/,
.\ry) its an v lnployer?Chvuk the;wpruprluto boa: Phone il:
II.❑ 1 :un a employer wish 0, 0 I,un a junural conlraelor and i f yPe a/proJvef(rulluireJ):
MIycu r(full imYur p4rt•time).• huvv hiruJ she.+uh•cunrraulun h ❑Now cusixtructiun
111.01 tole prnPrit:One or partner• listed on the anached.rheot f
.ship and have no um lu evs Theme 7. ❑Remodeling
I' "(riling rilr Inv in any apauily, ,orken'mnp�mursnce e
nyuircJ.J
S. Cl f7emolirion
I Na wnrkurs'camp. insurance J. Wen a colpontinn and its a 9, ❑Oulwing idditial
)Irce
I.0 1 unl a hoinvuwnvr doing all work r'.'Uhl rs �m cthrn ircyl their 10.0 Electrical repairs or additions
inyself INo lvnrken'comp• C. hl O¢I(J),mJ wrur l a no
GL I I.0 Plumbing repairs or adJilimy
insurance rcyuired.) r mpluyeun. (No workers' 12.0 Ruul'rcpairs
ctnnp. imuranivteyuircd.J 13•DUt1rn
\'O •dplw'oe tlid chucks k,N rl may:dw fill uW ate Woo"I-% - awnm r
I lUmmrW nrrr,.M"Janut this anlesNr inaluJline nyr�n Jwn a Nw xwkvi cwilarnualuw
f,wnriafiYr ihr.Mse fAs kon molt Jnikrd,in aaJliiursJ'kant oil work still
l Ilim him vursynnurerasrorn Imaaiuy inriuinni{yra
e nN aInr iu►eem n h si.vnil s films,alrlJnrit irwiaarirq uk•
/fun MAPvrrrpleyer thuJ If providing lvorkrra'eurnpenrnr/on lnrnnnree/or rxy rrn aM rkw wuAne'roiip.ryrliny,nlbrxinnua
/o/yrns"timiL pl rra Br/mr/a/M pu/ley anal/e1 Yih
Invurunuo Company,Vmne:�__
Policy V,r Sulr•ine. Lie.n:
Expiration 0:110:�_
Jab 5iW �\ddrexr: --��
\mach a a, C ity'slateizip:yy o/fho workers'cumponrailua pulley Juelrrallun puye(showing the Polley number and vrplrarlue duly.
Pallure w vccura w,f eruje as required w1Jur Secliun'JA ut'.%IGL e. 132 eau lead to rho imposition oferiminal yenolfiea of a
ine up nl iL1n0.IM JnJ/urmre•ynr mipri.m.mincnr, .r.r well Jt civil punalhw in ihu 1'unn ol'a s'I' W
0/14l rn i25010,4 Jay ,juinst the v611anv. Ile aJn.ti•d fAul a aipy of ihis viufcmcnt smug bo STOP
wR the WDeR jnJ j
In1'Ce11 jJlp inf ul ,IW UI,\ ;9r ni.urn',:e He J lmilif.Jlirin, a tint
/du hcrrAy r orti�y rurrrr drr prrinr,aril prnu/iirr v/yrr/ary shot rhr in unnvr/on
rorirrd u0eve it true n rr eoneet
If 1//Irir/,r,r vn/y. /)r rtn/uritr inldri.r urea, ru Ar runry/rrrr sy city ur lawn a//IciaL
l (try,rr town: _
1lvainy .\ulhuriiy (circlo nnc ; Pcnnif/L4vnra s
I. ILr.u'd r I(IleJlih !. Ihuldfli� Ihp.lru❑eel 1. t:ilp'fo�1n C'Ierk J. L•'Icctrir.11 Iu+IvrWr i,
j G. t)Iher 1 Phuobinlyln,pettor
Anne 17
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information and instructions
w Is dctitl ui as.. every pel.+on ,n the service of anulher un,ler eny tunlntt of hire.
\L1)),IKIIUSCIIs licneral Laws chapter I72 ,cywres all anpluycn to provide workers compensuuun ty their chop hires.
1111r,ua111 to tills Slalult, do t"'01Ill
;.pica or ,,nplfcd, oral of svrmcn." oration ur other Icgal entity,or any Iwo or inure
to elnpfuy'er 14 dclincd U"an individual, p
urtnanhip..lasdtlanua.Corp gu s,r or the
joint enlerpns°. and including tht legal represemucros Of to ?n evmployees. However the
t the toteguulg engage) m a I lanoe or other legal cooly. P Y g t of'
ecewcr or trustee of.In iudivldu:d, partnership,assoe
vin not Inora thso three apartmanu and who resides therein,or thean Iwh occu �•.
owner of a dwelling{house ha r to c persons to d l Inat bcmtnteo f s`h emPloymcnt be deemuct'On or epour worked to be+ntelnpl ysai.
,hvCUmg huuia of another who a one mt thereto shall not Ixeaus+
r,,It Ih r grounds or building{ app shall withhold the Issuance or
-,tGL chaplet 152, 423C(6) aisa states that"every slate or lees) truceHCOOS u agaeey
for say
table svldeaee of cumpUasco wlt\the Insurance covers$°required:
renewal of a Ilcaso u►parlult to uyorate•buslasss or to eoUlruet buildings U the u political sulbJivisiuns+hall
applicant who has not produced�SCtPI ilaies"Neither the commonwealth not any
kdJilionally,%IGL 010161 1 S_ i ublie work until 3ceeinable evidence ol'curtPliattcewith the insurance
enter into any cumracr for the parfomwnc+Ot'P
re ttf int enls of this chupl+r haw been presantaJ ro the contacting authority."
�yyUcuus checking{the boxes'hot apply to yuur situation and.if r
Itsation affidavit compand p�y.bdd nulttber(s)lion$with then certiflcan(s)of
Ploa ut rill twt the *Of We' cumgx addreaNas)and P LLP)with no employuar other Than the
necessary,supply sub-eontruCorclor s) tles(Lb have
insurmlee.,Limited Liability Companies(LLC1 or Limited Liability
��W(If so LLC or LLP Joan
netnb+rs Of paMars, are not required to tarry worker►' con,gs+naa of Industrial
employees.a Policy is requited Be advised that this Ala beill sur truly In be and date he of idav16nt71"A n�anshould
lieaoon for the p moil or license is being requested.to obtain a workers'
1s ciJtnle for confirmation
ale ci n o'°awnithut�caPP o cv�roge the low or if you are req
ha $calmed w dw City nu haw any gaestiooa regarding companies should enter their
I nduitrial Ateid+nte. Should y ant at the number listed below. Self-insuraJ comp
compensation policy. please call tM Depamlist line.
Nel6insurance licanse nwnbor on the a ro
City or'rown Officials
nt has
"spud at
ttom
You tf fill out in the avant the OINco of investigations has to contact you regarding the applicant.
PICa.c he sure that the affidavit is cmpeveits" tali Prwhieh wilbllb+usedy. The a,enfeerence i umbtralln addition,an JPPl cant
of lilt Itriduvis far y
lll.,a u b+ sure to till in Iht permit/license
nw' ions in any given year,need only submit unt,t1Tldevit indicating current
that must iubmit mulliPle Ponnivl talltsa+�erv'lob Site Address"the upplitmll shnuld write"all luwtiuns in l' Y
policy iufermanun lip necessary)
�d or marked by the city or town troy be provided to ilia
wwnl•" COPY of the affidavit That has ban officially sump' business ur commtroial venture
applicant as proof that a valid atfiJuvit is on rile for Mauro Petmits or licema, A new a1TlJuvit must be Illled nut eat
y err. �0'here a home owner ur citizen is obtaining a litmse or pannU not relate)to any
1 i.e, ,1 dug litenwo or permit 10 burn leaves etc.)said persmt is NOT reuurreo t erau n al Jhlwuldy outha%a •ICY 011111ons.
�gca,elJu not hesi troy o grve`us mall e w Jtwtk you in adv;ume 1'ur y P
0111
fhc Ucp•Irunenl's addters, telcphune and fax number.The Cotnrncnwealth of Massaehusetta
D,,,,Mcnt otlndtuttial Accidents
01flee of lovad4adons
600 Washington Sueet
Boston, MA 02111
'fel. 41617.727- 617.
0072 o77d977.WSSAFE
wvnv.M=s.dov/dis
CITY OF S.ULE.NI, ,�L�SS.�CHL'SETTS
13L DLNG DEP.IRTNONT
120 W.tsHLYGTON STnu. 3'O Roo&
I12L (978) 745-9595
NX(978) 740.9846
KI.%®EALBY DRISCOLL
NfAYOA T1io.+w ST.PIEm
DIRECTOR OF PLBLIC PROPERTY/9L DLYG CO%MISSIONER
Construction Debris Disposal Aftzdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit p 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
l 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposedof in
- �(name of facility) ,.
(address of facility)
77�:),
signature of permit applicant
dace
�i till vlt,bK
25 This Spectrum Policy consists of the Declarations, Coverage Forms, Common Policy Conditions and any
94 other Forms and Endorsements issued to be a part of the Policy.This insurance is provided by the stock
y ZQ insurance company of The Hartford Insurance Group shown below.
SBA
INSURER: SENTINEL INSURANCE COMPANY, LIMITED
HARTFORD PLAZA, HARTFORD, CT 06115
COMPANY CODE: A
HE
Ilf
Policy Number: 08 SBA ZQ9425 SB T
HARTFORD
SPECTRUM POLICY DECLARATIONS ORIGINAL
N
m Named Insured and Mailing Address: COUGAR CAPITAL II, LLC
r (No., Street, Town, State, Zip Code)
0
20 WASHINGTON AVE #1
0
WALTHAM MA 02453
Policy Period: From 09/03/10 To 09/03/11 1 YEAR
12:01 a.m., Standard time at your mailing address shown above. Exception: 12 noon in New Hampshire.
m U
a '
m Name of Agent/Broker: H & K INSURANCE AGENCY INC
Code: 088286
o
0
m Previous Policy Number: NEW
Named Insured is: LIMITED LIAB CORP
Audit Period: ANNUAL
Type of Property Coverage: SPECIAL
Insurance Provided: In return for the payment of the premium and subject to all of the terms of this policy, we
agree with you to provide insurance as stated in this policy.
TOTAL ANNUAL PREMIUM IS: $1,222
Countersigned by
Authorized Representative Date
Form SS 00 02 12 06 Page 001 (CONTINUED ON NEXT PAGE)
Process Date: 09/08/10 Policy Expiration Date: 09/03/11