7 OSBORNE HILL DR - BUILDING INSPECTION (3) `
t� �O`-` � ��
� The Commonwealth of Massachusetts �WE(J
� Board of Building Regulations and Stan��Q��� SER���� CIT'Y OF
Massachusetts State Building Code,�AP SALEM
� �t� evised Mar 2011
Building Permit Application To Construct,Repair,Re�,q�at�r��m�'Fsh"� �
One-or Two-Family Dwelling �U�
This Section For Official se Only
Building Permit Number: Date plied:
� . ~ °� >
� ��
� Bmldmg Official(Prmt Name) Signature ���(�
SECTION 1: SITE INFORMATION
� 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
� 7 0S�3tlRwE 'H/U, @��✓E.
I n 1.1 a Is this an accepted sVeet?yes no Map Number Parcel Number
�J / 1.3 Zoniug Information: 1.4 Property Dimensions:
� i�, otiU /�23 �
4 Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
(� 1.5 Building Setbacks(ft)
( �-1 Front Yard Side Yards Rear Yard
� Requ'ved Provided Required Provided Required Provided
,�(o " � - io ` � 6 .,
1.6 Water Supply: (M.G.L c.4Q§54) 1.7 Flood Zone lnformation: 1.8 Sewage Disposal System:
Public Zone: _ Outside Flood"Lone?
Private❑ Check if yes� Municipal� On site disposal system ❑
SECTION2: PROPERTYOWNERSHIP'
2.1 Owner'of Record: �7 ���,� ,� n
��YPnTJRd/JD�t c��te,Zi��P�'L �� .�i4�?7 J�'��7
7 033o✓LN6 N/GC �RIVE 97�'-Syb'-8s7'�
. No.and Sheet Telephone Email Address
� SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Ocwpied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify: /N �rft1/a0 �lAL
Brief Description of Proposed Worl�:
1�e.Fv,�iroK, An,O CouSr�2vcrlo,�/ aG /r9�r '3o ' S��c. c�9u. �c,Grovnro
�'r.�� ,4 ,.,�- Fce.>t
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1. Building Permi[Fee: $ Indicate how fee is determined:
2.Electrical $
❑Standard City/Town Application Fee
❑Total Project Cost�([tem 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ � . �
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3 �� UV V ❑paid in Full ❑ Ouutanding Balance Due:
r��..� , f-\, o . ! Dt�.,S�� q"1e -S� 8 - �� � �I
C.f�u.��r7 , i��,s�.�s'r� �� (�3
SECTION 5: CONSTRUCTION SERV[CES
5.1 Construc6on Supe�visor License(CSL)
LicenseNumber ExpirationDate
Name of CSL Holder �
List CSL Type(see below)
No.and Street Type Description
U Unrestricted Buildin s u [0 35,000 cu ft.)
R Restricted 1&.2 Fatnil Dwell'
City/Town,State,ZIP M Maso
RC Roofin Coverin
WS Window and Sidin
SF SoGd Fuel Buming Appliances
I Insulation
Tele hone Email address D Demolition
. 5.2 RegisteredHomeImprovementContractor(HIC) 6 2� /�
/ /onl60tf
�T[�if%v✓t(, SuQfSI/)F �GbC.S �/CH9Ri1 �Y��TA/C. MC Registration Number Expvati Date
HIC Comp�y Name or FiIC Registrant Name
139 cLiN�viS��-C, Sr /1�cKH�S�n�si.DEl�nCeortVAuy��e
N and Sheet Email address
�irc�v/3�2-U l`lA o/��0 978'-�3�Fa�7�62
Ci /Town,State,ZIP Tete hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be wmpleted and submitted with this application. Failure to provide
this affidavit will result in the denial ofthe Issuan of the building pertnit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEIV
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUII,DING PERMIT
I,as Owner of the subject property,hereby authorize j Co T7 /�l ho��F Sk V /SyC/�S/t� �00(,S
to ac[on my behalf,in all matters relative to work authorized by tlils building permit application.
Prin[Owner's Name(Electronic Signature) Dafe
SECTION 7b:OWNER'OR AUT}IORIZED AGENT DECLARATION
By entering my name below,l hereby attest under the pains and penalties of perjury that all of the infonnation
contained in this application is true and accurate to the best of my knowledge and understanding.
S�eoTr /a RalloFSk� SNzFsip6 /�0'6(5 [/ � � 1 S�
PriM Owner's or Authorized AgenYs Name(Elech�onic Signature) D—�
NOTES•
1. M Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(I-IIC)Program),will not have access W the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
Infortnation on the Construction Supervisor License can be found at
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemenUattics,decks or porch)
Gross living area(sq.tL) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of woling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Projec[CosP'
e
. � .
l
� ��te �po�y,��o�u�e�a;� o�C�2�acjutQeCta�
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massach�setts 021 l6
Home Improvement C�tor Registration
�� �
F=-====`=•�=.�-=' Regietratlon: 101005
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I i`�-:� �__.:�_ . TYDe: Prfvate Corooretbn .
r�S�=LG_' � T + i
w::, _- �-- wl.� ������,: srz,�o,e T�. z���
FITCHBURG SURFSIpE POOLS, I1���-=""� '�=-�: ��.
RICHARD HAJJAR '�1 ='' �- `��-�� ,;"t —
.� �' � =r_I ��o:.
139 Lunenbur Street ���,r==•`
9 e.. ,`-='� � �I��!
Fitchburg, MA 01420 Ri� ���"-�� -•��'` :T1
i �, � . r
��j`Y'r
?f`,N�J.:�.Upd�te Addraf�nd rctarn ard.Mark na�oa tor ch�a�e.
� � et�+ 4 za►wsm .... - ❑ Address � Henewal C Empbymeet L] I.aRC�rd
� . --- C-j/�s�mwmnoucwaQ�4 o�O��n'aaa�✓waello -�-- �� -�- - �
011ke ot Coe�u�er AIUin&Butba�Re;ulaHoo Lieeoae or regi�tradon viHd for fndividnl we oely
' ME INPROYEMENT CONTRACTO(� beforo the e[pintbn dote. If found red+m b:
���a�; �y�; 016ce of Coos�mer Afldra and Budoen Regol�tion
+ ratlon:��� Privete Corparetion 10 Park Plazf-Su3oe S176
�r� '��}`��`--�i;� Bmtoq MA 02116
FITCHBURO 3URF$'y(�3��N��.
i:r,�:_ °��`:_�';�
. . `44 .�r�"�
- RICHARD NAJJAR ,Y�:�-`�k��>,GiJ
�sTi"
„ 139 Lunenbury S1reN�C�.;.��,,:,=,:v�.✓ �—'--a-a- .
`..:nN,';::�yv — �—a'—
, Fltchburg, MA 07420 �`- U�deneereury � � NM valW w�itliout�iye
• • � . •
� The Commonwealth ofMassachusetts , ,
Department oflndustrial Accidenis
' Office oflnvestigations
' 600 Washington Street
. �` Boston, MA 0211I
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Apalicant Infarmation Please Print Leeiblv
I N3IT1C (Business/Organization/Individual):���h,��C� ��(i�, (A
Address: /35 �v�..���-�Qu� S,—
City/State/Zip: �� r��-��v!?G I��} 0/`��v phone #: �17�'' 3 5�� -��Z
A,r_,e_,y/ou�n employer?Check the appropriate box: Type of project(required):
1.�y'I am a employer with �6 4. � I am a general contractor and I
employees(full and/or part-time).
s have hired the sub-contractors 6. ❑New construction
2.� I am a sole proprietor or partner- Iisted on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, � Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.
$ 9. � Building addition
required.J 5. � We aze a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing a11 work office�have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL �2.0 Roof repai
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.��Other C/v
comp. insurance required.]
y appticant lhat checks box#1 must also fill out the secfion belaw showing their workers'compensalion policy information.
meowners who submit this atTidavit indica[ing they are doing a(1 work and then hice outside conVactors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional shee[showu�g the narne of the sub-conVactors and state whether or not those entilies have
employees. If the subcontractors have employees,they must pmvide their workers'comp.policy number.
I am an emp[oyer that is providing workers'compensation insurance for my employees. Be[ow is the po[icy and job site
information. �V
Insurdnce Company Name:,�sso e.i�r�o L M p�o y E✓L�S l..,O �
Policy#or Self-ins.Lic.#: W�'G -�U� swy� 2� a��SVg Expiration Date: y��/�/�
Job Site Address: 7�s�� ����-C �� � City/StatelZip: ��-`� �r J
Attach a copy of t6e workers' compensation policy declaration page(s6owing the policy number and expiration date).
Failure to secure covernge as required under Section 25A of MGL 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 fonn 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 coverage verification.
I do hereby certify nd the pains a enalties pery'ury that the injormation provided ab ve is ue and conect
Si ature: Date: �( ( � � �
Phone#: -/��` o�'� — �� �
Official use on[y. Do not write in this area,to be completed by city or town'ojficiaL
ity or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
�t Gyo�us �,,uq,ue,✓{c.
Surfside P . � �
. 738 No. Main Street 139 Lunenburg Street 33 W. Boylston Street Summer Street � 111 Fte. 101A 517 Nagog Park
Leominster, MA 01453 Fitchburg,MA 01420 W.Boylston,MA 01583 Chelmsford, MA 01824 Amherst, NH 03031 Acton, MA 01720
978-537-7223 978-342-7362 508-835-4886 8-250-0106 s 603-889-3100 978-263-5144
Date �
Contract between Surfside Pool Co., and��f �T A-N Ta�j
hereinafter called the customer, residing at � e-�`��� �'��� lJi�- L�� /y� (��!�L�
Home Phone ! /�� 7 7 ✓���' Bus ness/Phon�L 8 `� �� d s Z�
TY. ITEM MEiiCHANDISE PRI E
� POOL 7' ON� � IZl6-hf'T � . �1 �� '
SELLING PRIC �-
I STAIRS 2�D/(,{S s]�yp SALESTAX ��`���
I LINER/PLASTER �7 �7 ��� /�✓� S��(,I,��4A/ TOTAL �� i Sv / `
FILTER/PUMP ,�� ����1� . �fP �/r('( S, (�QQ, �
op DOWN PAYMENT �
� HANDRAILS �� � [ Z �
TERMS:
� .VACUUM � ��./�" f']� CREDIT CARDS NOT ACCEPTED
! 1 � � C'2 .
/ CHEMICALS (� �`% $ lU O U• U� DEPOSIT
C� �
AUTOMATIC �� Y11� � � -� �
CHLORINATOR W _ $ UPON DELIVERY
p /, /J /� GUNITE
� POOLCOVER SA�G'1'1 C�V .f NJ ����uS SO�/
$ UPON LINER
. � DIVING BOARD � � INSTALLATION
PLASTER
� POOL LIGHT a �
^ _ $ UPON POOL
/ POOL HEATER �p�� � �� f'D A " . COMPLETION
V
MAIN DRAIN /� Q /�. $ � �� ��''� FENCE
O� �F^ � N COMPlETION
LADDER �� .� � �
$ � r�r�� CONCRET
�' COPING ��,�,j��i/ COMPLETION
F—�U�� V ���
` �i C.� cxJ�f� �r�f�� �1� $ ��S w��c.E,.f.,�,�....
�it� �'f dr9-L s/�'lJQ � �Etl�_�R��f.
$.ao���c �r�„� -f�0— ru
�o �rioao9t- �X PA v�g-7r�eU /F L�� C311.C:�v � $T�����
� % .�5'� Pca2 �o-v ,
TO
�Q 1?YdAJ✓�4- � � �
d� � g � ADDITIONAL COST IF WATER
ENCOUNTERED DURING
, -S i�-,4/.,�C� l��t.c., �/� r3,�cL'��i� G,.Yc� �4� ,P�� EXCAVATION
� / CUST.INITIALS �
1. (Completa Installation)Vinyl-Excavate for pool,level and ered panels,install liner,install inlet and ouHet fittings.Connecl all plumbing lines from pool
tilter,connect and assambte valves and pump to filter tank,install coping antl backfill,rough grade within 4'area all arountl pool,test pool tor water circulation and
skimmer operation,(Electrical connections not included.)
2 (Gunite pools)-Excavate-steel pool with rebar 12"OC-plumb pool-Gunite sheli-to torm a 12"beam,9"walls.Backfill,tile and plaster and chemically balance pool.
3. (Fiberglass)-Excava�e for pool,place sand bed in pool hole,install pool shell in ho�e,level shell,connect plumbing,backfill,rough grade within 4 fl,test�or waler circulation.
4. 7wo year guarantee on workmanship.
5. Customer must Furnish nwn water.
6. Ii water is encountered in some cases ihe use of a Drywell will be necessary. Sutlside Pool Co will not ba liable if not usetl when recommentletl.
7. If ledge,sWmp tlumps,or unsuitable material is encountered on axcavation,additional charges for labor,
materials and machina time will occur
8. B hrs.excavating,8 hrs.backfill.
9. Terms of this agreement shall be governed in accortlance with ihe laws ot the Commonwealth of Massachusetts.
10. Customer responsible for certified Plot Plaa �
11. Surfside Pool is not tesponsihle for damage to driveway or lawns 1 y quipment.
_ CUST.INITIALS APPROVED.b -
COMPLETE COVERAGE ON WORKMEN'S COMPENSATION AND PUBLIC LIABILITY II SURANCE
FROM A TO: FROM B TO: FROM C TO: FROM D i0: FROM T TO: FROM U TO:
D 35'-03/4" C 35'A3/4' B 35'-03/4" A 35'-03/4' N7 17'-87/2' N7 22'41/4"
Ni 28'411/2' Nf 30'4" N7 13'S il4" N7 18'-17 12' P 9'-11 1/4' P 27'-51/4'
P 11'-01/4" P 22'-�t@' P 14'A112" P 23'-00" P1 12' P7 22'-53/4'
Pi 9'-6 1l2" Pf 21'-3 1/4" Po 17'S 1/4" F1 25'-9 12" R 9'-7 3l4" R 21'-3 3/4"
R 1 T-1 3/4" N 25'-]" R 9'-8" R 21'-3 3/4" R1 1 P-2 3/4" R1 22'.0 3/4' .
Rf 19'-01314" Ff 29'-fi3/4" Ri 9' Ri 21'-01/4" S 19'401/2" 5 12'-51@"
S 25'-51/2" S 2D'-21@" 5 19'A1/2" S iT4' .
T N'4 V2" T 32'-0 t/4' i T T 30'-70" �
U 32'-01/4' U 11'-112" U 30'-00" U 7' -
30'-bd"
7'RADIUS
B �. CUDDLECOVE A
� 4RR 4RR �
3'4 1/2" 3'4 1l2"
7R \ 41 /
3'9 3/4" P,� 7R
6�3"
3�_Z��
7'R x 13'W
STEEL � j,� 2'�3"
STAIR 40�� m 4 q P 6. 4
� DEEP `° �a a� DEEP 7R �g'_�Z"
q 6�3"
71'-04" 2' 2' 2' 2' 2'-�-6' 3'
V - - , F - - ¢N -���- E R4 - r �a�
�r< '�' �
M � �
�d,< a R �,_��4.
` iN
R�, S R7'
3 3�'3�� 7R
� Bd� \ 70RR /Z� 6'3"
D sa C
7R 10RR R10, 7R
5'3" 3'4 7/2" � 6'3"
R70' 1,-5g"
N1
3'-4" 3._��.
H e'
I ��,_�.
C'CONCRETE DECK �aciNc 10' � 6'—�—3'
.if' .,,r f..,. .
s BPCKFILL WRM LB'0 BOLTS
c��E°�� vuiEiENo Fae Nun�seR: 15041319 THIS POOL CONFORMS TO WSTOMER SIGNATUREREOUIRED DATE
APSP/ANSUlCGS 2011 STANDARDS I
cavcaErE p.FRqMEBRACE FORRESIDENTIP.LINGROl1ND I
co�aR Perimeter: 79'-3" SWIMMING POOLS
(YSWpeI) VINYLLINER
. HORROIRAL Surface Area : 400.37 s ft 33 Wade Rd. • � DEALER __
srAKE . a��E Q �Imper�al NAME:
z aoo� Latham,NY 12I 10 CUSTOMER
a�**�M Volume : 11250 gal P�OLS "— j
phn:518-766-1200 NAME:
� DRAWN CSCOH � n/a fax:518-786-0954 - '
�—r.s• Bv:
� � "I CERTIFY THAT AN ACTUAL ON GROUND
OPEN SPACE AREA INSTRUMENT SURVEY WAS PERFORMED ON
���� �gx3p �y. APRIL 15, 2008 AND THAT THE RESULTS
ARE SHOWN HEREON." � p � ')
—_��—"=�--=
STAKE dc NAIL IRON ROD RALPH W. REID P.L.S.
set b )
� � N60'13'00"E (set
� 123.00' / — � � —j
/'� � OF Y4f,p� . I
o \q yE \ � �
GR D � � Z yy��yy1M �,
L--1 POOL � � REtD �?�x�
LOT 4 � a�-. ; Q LOT 6 �. z9,�
FESS
11 ,070f SF � . — % � w s `�° .
DECK ' . ,
! ',, GRAPHIC SCALE -
STAKE dc NAII 52J' �—� ,--- 2 p� i STAKE dc NAIL ,-
(set ot midpoint) — — — — — — i � , (set•o� midpoint) p � a �o � b �
w
3 2 cnR 2 STORY: ` o o ( [x �er )
0 o GARAGE VINYL :o �� 1 inch = 20 fk ;
o #
rn
�� rn _ _ 52.8' _ _ 7 N
LOT 3 Z �-� / F N
J
I NI N = SALEM MASSACHUSETTS
� �
STAKE dc NAIL "� NI ,o� ; ,o� PLAN OF LAND SURVEYED FOR:
a ''' cs`t> ,23.00• � , RAYMOND H . &
o S so-,3�00" W STAK`9�Na� C H R I STI N E L. DAN J 0 U
0 7 OSBORNE HILL DRIVE
0
N
� OSBORNE HILL DRIVE PaRCE� i� 09_0301 _0
�
� REID LAND SURVEYORS
0 365 CHATHAM STREET ��
o LYNN, MASSACHUSETfS
3 DEED REFERENCE: S08-001
� BooK: 272�s PAGE: 62 RWR/BLB DATE: APRIL 15, 2008 SCALE: 1 " = 20'
0
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