6 WARD ST - BUILDING INSPECTION (5) t
�a-
;► The Commonwealth of Massachusetts
I j Department of Public Safety
\las.tchueett.Stale Bwlding C odr(780 C:.IR)Seventh Editun
/ City of Salem
Building Permit Application for any Building other than a 1- or Z-Famil w Ilin
(rhis Beckon Fur Official U.se Only)
Budding Permd Number: Datr Applied: (G Bwlding Inspectur:
SECTION 1: LOCATION IPlease indicate Block a and Lot a for locations for which a street address is a ilable)
6 wPr-c! Sk Sales-- MA p19-7 o
Nu. and Street City /Town _ Lip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Comtructtun check here❑or check ail that apply in the two rows below
Eniming Building I Repair Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
ChangeofUse ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur cuastructiun documents being supplied as part of this permit application? Yes ❑ No
Is an Inde�wndenl Structural Engineering Peer Review required? Yes ❑ No f�
Brief Description of Pruposeci Work: r•.er ..� IS
r (au 3ro( a b• —r :ar S
er 0, la l b .•••-
.,ems
y
oreptasa O t : f. .n ants r Six t-
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O
Existing Use Gruup(s): Proposed Use Group(s)-
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.) 3
Total Area (.sq. ft.)and Total Height(ft.) 13,p p(D
SECTION Sr USE GROUP(Check as applicable)
A.- Assembly A-I ❑ A-2r ❑ , A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E. Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H- ❑ H-5❑
1: Institutional 1-1 ❑ 1.2 ❑ 1-3❑ 14❑ M= Mercantile❑ R: Residential R-1 3 R-2 R-3❑ R-4 ❑
5: Storage 5.1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special U.se:
SECTION 6:CONSTRUCTION TYPE(Check as ap 11 Ill I
IA ❑ ISO IIA ❑ Ilea IIIA ❑ IIIBO IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water So Flood Zone Information: J/ Sewage Disposal: / Trench Permit Debris Removal•
Pubbo Chack tt uutstalr Fh,,,a Lone liE -Indicate municipal fJ A trench w nut br Ltcenwd Diavt..d Site
ac
I'naate❑ or malanuf� Lunn or an air�c.trm ❑ doortrench ,r.pccit%
required
permit t.encio. d ❑ a�2G $'ei..a�••- S{'
Railroad right-of-way: --Hazards to Air.Navigation: ,•,...„ I'n•.,�•: '
\nt \p)ditably a, I'�truc(un•trnhin.nrpurt ay mach area.' I. (heir recivac onnplcted"
.a l m�cnt t, lAid.l encli,val ❑ l e,❑ nr No,f'J )c ❑ \o O
SECriON 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I ,litnat,q l •,dc. __-- L,e(;r mupt.t. rt pv,,, lkatpant I-,ad per I-I,,,,r
I>„a•, dw bodatu,t;c,mimn.,n Sprinkler st.tcm•� Ne �Ivaal?tiptdauan.. -
SECTION 9: PROPERTY OWNER AUTHORIZATION -
.Vamr anaf Aaldrr>..01 Pnrperly Owner
z0 wosG;-e P-0'4 wa MA 4ExpirationDate3
Name(Print) No.and Strcwl Cilv/Town 1'ropurty 0%%ner Contact Intormalnm:Title relephoneNo. (business) TelephoneNo. (cell) e•m.ulaaiIfapplicable, the property•owner hrrrbyauthorizes
Name Slmvt Address Cilv/Town State Zitoact on the +ro +rrh owner',behalf, toall mallers relative to workauthorized by this buddin +ermna , ,licaliSECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(if buddin is Irs than 3S,uWcu.It.of emloscJ> acv and/ur nut under Comeniction onttvt then check here Oand,ki10.1 Re istered Professional Res onsible for Construction ControlName(Registrant) Telephone No. e-mailaddress Registration NumbStreet Address Cily/Town State Zip Discipline
10.2 Central Contractor /
Company Nam
i7 0.. F3 a C_S C_ # 1 O 1 7 3 -7
Name of Person Respmslble 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:WORKER9 COMPENSATION INSURANCE AFFIDAV (M.G.1-e. 1S2 28C(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 O No O -
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)-f -3�lt O O -
1. Building - f Building Permit Fee-Total Construction Cost x (Insert here
2. Electrical f appropriate municipal factor)-5 'q
3. Plumbingf
i. Mechanical (HVAC) f Note: Minimum fee-f (contact municipality)
5. Mechanical (Other) f Enefose, check payable to X
6. Total Cost f '37S- d OO (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Itv entering my name below, I hrrrby a11"t undw the pains and penalties of perjury that all of the information cnnlatned in this
applicalnm is true and accurate to the best of my know) git and understanding.
I'Iva.e print and ,ign name rule rvlcp me 'u. Date
�hYa•I .\J,Irc.. Cats-i Tow'n
Municipal Inspector to fill out this section upon application approval: / ' a
!Alame I me
��o a
38 `'
I
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
t:C K'.tawv...w)rr.ct •!W I N. it J 1..:I•r':
\I ...•w trl: 'Ia-:J4.1M9 �I'\:J:%7tv S•
Construction Debris Disposal A111davit
(rcyuired lur all demolition:ued renovation work)
In accunlattce with the sixth edition of the State Building Code. 730 CMIt section 111.3
d the provisions of MGL a 30. 54:
Debris. an
Duild�ing Prmtil iss issued with the condition that the debris resulting fl"otn
this work shall he disposed of in a properly licenacd wrote disposal facility as defined by MGL e
I11. tJOA.
The debris will be lransportcd by:
Inane ul hauler) I
The d bris will be disposed or in : 1 S i 0Q'I r t t
(n:unt ul aer ity
I:�trwand'1'ardity)
. p�atute nl IwrmiJ apylicaM
.late
CITY OF S.UX.M, NYL%sS. aiUsETIS
3L DLVG DEf.MIBTILNT
120 W.t3HG4GTON STRaiT. Yo FLOOR
TIL (978) 74S.9595
P.ut(97� 7�496N
KINIOEA"Y ORMOLL Tf10btASST.Pl7laas
"AYO>< OlaWMa of n euc pWPVATV/KMVLNG Co-%04S3XX%EA
Warkers' Campenasllos Insurance Alfldsvif: Builders/Contrac9or/6leetrlelsnaiPfwmbers
+onllcant Infnrmallow Pleer Print LUM
Vatnd Ieruna+�Oryeusrter►h.br,`aell:
AJJrcae: — —
n/1 A ('bone N: �'O `7
City/StitdZip: I /� l
•%ro you as emydeyor!CbscY lbo epprgrlab bra Type of proied(rsqukco
I.❑ 1 am a,y"~with a• Q 1 am a pnaal con"w rl"a 1 f< ❑Now cenaensaoe
.mployew(fad and/or pufaar).• have hlrud rig arYteraacaore
7.LYO i no a sole proprietor nr prenaa6
IiYedm theanached"sect= 7. Q Ramablins
+hip and have to eerpbye� Theca eu�sareeaseera have x Q Demolition
workers'C iaaars anti
.orYlna forms in ny capacity. 9. ❑OaiWlttg addition
N��ers'coa+p.inwrance 7. Q Wa ero a capwalen and it/ 10.Q ENcaiwl repairs or o"dosee
to View haw aawtiasd rMr
7.❑ 1 am a haneownw doing ad wort riwo ofaa�ioo Pw 1NOL 1 LQ PherttNng repaint or addtlaan
mysel[(Yn workers'comp. c- I n/1(4),asd we haw not 12.Q Roof rspeire
inaaraltre ngairedi t "evil"),eL(Ne watnre I l.Q 016ee
Comp6 ineuwnw�1
,AMI ,r,ravr nr arc.e.sl nwr gas M ar u..wot.arlwwtl as u�Most atria' a .�.rlEnt mJr.Y ir.Ms:m w
tarmw.rra.Ir mikete etk rNM"I.aleYq hay daft oll
Y'.wr otte,aa uawa,He beg.wee arAra an shelved ohs.Awly er sae d ti eA..erUMM rd,h*me,bae'Illp tr+v ieeaeatiM
/ern ew Mlyy w rAr byewv!//wg rrerasra'eawperadru/aeaewaav/ir q saYlq ea Sihete b riboa/fej ad/Ia1 alit
;w/wnrrrw
In%urance Company Name:
Policy Al or Self-ins,Lis.M Expiration Dag
Job Siu Addecee Cityi3eaWtip:
Attack a copy of sire woman'compeaotloo policy dockntim pop(ab owleg!b pdkey nuaMe sad espystitNn dW)6
Failure to acvuea coveap u regain"undw lcelim 2SA of MOL a 152 w lead to she imposition of eriminel ponalaa of a
line up to S I.J00.00 and/oe ono-yew imprisonmem,a8 wet"civil peaches in Use farm of a STOP WORK ORDER art/a Am
Of up to 3210.00 a day ty0irtn the violator. Ile advsavl thus Cully of this rawnwm may be funvarded to the Otl1co of
Inv.,uyariurre ul'the MA for insararnce covcraya v%;ndcalica --
/dr her.61 rcrr! uwlM rMO+iM reI yNwr/rhl r//n/r7 rArr rAi in/wMdM Preri/.rU clew is rrw rw1••wrrd
old I o
P�va a: 03 ( O y 7 S l b
OflF4:ie1 rrr,u,/y6 Oe not w 4v is this d"t%ri ba•rmv/ire"by rily w,.wve..//1rirL
City or fuun: errmit/l.leemol__
Ivme f.whonly !circle une►: -
I Ituard u/Ilwllb 1. Ruddley 1l.•p srrmvne I. Cil!/fame Clerk !. flrclrical hnpector S. Plumbing In.peclor
a. Usher _
L.,ur ad I enon: _ _ .. Phone I:
U RZA N C E P IN P 17 R
Ili(,,U!Id II5U1�1!1' 1, i' '1 1 11
"1111)nm J ILUl I U'VI P. NY
A.T I Bust 101iJIL A i (IX)
-%Ssigned Policy if: NIC910696 2U09 to Uo�,(ii Njlu
I I Is it I ed: Cougar Capital 11, LLC Biudcr N111111wr
Nlailing Address: 20 Wushim_,ion A\r :"I
Waltham, MA 0245 ,
This Binder shall be effective from 12:01 A.-M., 09/03/2009 standaid time at the address of the 111SUIC(I as stated above, and Shall b�
Subject to all the terms and conditions of the policy
Y in current use by the Company. Unless cancelled in accordance \�ith the provision
set Faith below, this Binder shall remain effective lot 90 days or until replaced by issuance ofthe Cornpany's policy, whichever first
occur S.
CO-NIJIMERCIAL GENERAL LIABILITY COVERAGE
L1T\41TS OF LIABILITY
Product I
General Completed Personal Each Fire Medical
Aggregate Operations Advertising Occurrence Damage Expenses
OPTION Limit Aqqreqate Injury Limit Limit Limit
1 $2,000,000 INCLUDED $1,000,000 $1,000,000 S50,000 $5,000
DEDUCTIBLE(S)
Bodily Injury Property Damage
OPTION Per Claim) Per Claim)
1 $1,000 $1,000
Forms and Conditions:
IL0003 Calculation of Premium
IL0017 Corrunon Policy Conditions
IL0021 Nuclear Energy Liability Exclusion Endorsement
S013 Miruirturn Earned Prenuiurn: 25%
E906 Service of Suit
CG2173 Exclusion of Certified Acts of Terrorism
CG0001 Contruercial General Liability Coverage
CGO067 Excl - Violation of Statutes That Govern Ernails, Fax, Phone Calls or Other Methods
CG2136 New Entities Exclusion
CG2147 Employment Related Practices Exclusion
CG2196 Silica or Silica-Related Dust Exclusion
L213 Exclusion- Certain Computer Related Losses
L217 Exclusion- Punitive/Exemplary Damages
L223 Exclusion-Total Pollution s, Bioaerosols or Organic Contaminants
L241 Exclusion - Microorganisms, Biological Organism
L601 Amendment Of Conditions - Premium Audit
L216 Contractual Liability Limitation Endorsement: Limited Forrut- Index A
S038 Arrienclinern of Liquor Liability Exclusion
Prenriurn is Adjustable & Subject to Audit
S040 Exclusion - Cancer
S261 Exclusion - Asbestos
L201 Excl-Exterior Insulation and Finish System
L219 Exclusion - Professional Services - Contractors
L236 Total Exclusion - Subsidence or Movement of Soil, Land. Bedrock or Earth
L238 Exclusion - Toxic Metals
L245 Exclusion - Overspray, Spillage, Leakage or Overflow
L266 Conditional Exclusions -Wrecking, Dismantling or Salvage Operations
maids 0!1,
I I I I J Li to 111 111
pj d k Pl
Clopillvilt or phase of dcveloprrenr, or
c. Aliv lvpC of structures e bellif, convened to individual residdniial ulin
(),ileisIlip not to exceed 10 LHIIIS per project
Ll Nc%N, Constilictiul, Ot "'Ole 111a11 10 dwellings PC] or 10 dwellings 11)
ijlti One ploiccl, de\elopinctit of subdivision; or
")'out Work" performed of: any snow lelllwal andror sllowplo�\ln CXpo"Lij,
A(Jcjjtiooal Conditions And EXCILIS1011S - C'OJIZJaCIOIS Subcontracted WOH.
L21)I Exclusion - Designated Constiuctiol, Operations
S1 IMECTIVITIES:
Subject to Satisfactory lusPcCli0l1
Signed Original Affidavit to be Received M OLH Office within BusinessDays
Quote based on Executive Supervisor payroll 01S?&.000 & Subcontincio, Cost "f$50MG
Signed Original Application to be Received in our Office within 10 Business Days
Prior to insureds signature, the Acoidapplications must be updated to match oi equal the coverages
and limits of this quote.
Please advise the Insured that this policy may be Subject to audit.
Annual Premium: $2,750.00
Inspection Fee: $150.00
Surplus Lines Tax: $110.00
Total: $3.010.00
In the event of cancellation or expiration of this binder without a policy or certificate being issued, the Insurers shall be
entitled to an earned premium for the time in force at short rate of the annual rate as charged by Insurers hereof if
cancelled by the Assured; and at the pro rata of the annual rate if cancelled by the Insurers.
NO FLAT CANCELLATIONS
�I.i.. i� li u•,il. I1. li.iiinu nl -r d" A0, t, _
14...n�I •:I,lienLhu�_ I<.�_n Liln.i l• iu�f �I.nnl.n•I�
101737
00
'BAN HOfVWINIK
20 WASHINGTON AVE APT 1
WAL!"HIAM, MA 02453 -`*t
SIIQ2012
...._._......___..._...__ -. 101737