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10 OSBORNE HILL DR - BPA B-14-882 T E - I -fig z Iv zz4xe d • 'rK .tee za- q g� The Commonwealth of Massachusetts fr9:8 D Q6 _ Of 9- 1 Department of Public Safety 1 Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Tw - it well' (This Section For Official Use Only) - Building Permit Number. Date,Applied: Buildmg.Official: SECTION 1 LOCATION(Please indicate Block'.# d Lot.#-for locations for which astreet a s' of available) No.and StJI City/Town Zip Code Name of Building(if applicable) ' SECTION 2-'PROPOSED WORK/ Edition of MA State Code used If New Construction check berelifor check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ I Demolition ❑ (Please fill out and submit Appendix"I) Change of Use ❑ Change of occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes Vr No ❑ZOM Ftl Is an Independent Structural Engineering Peer Rev ew r uired7 [ i Ye ❑ No q� Brief Description of Proposed' C,tOfL ru ��11) s1 @IP. 1 MII`/ itJPlimq# 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): Proposed Use Group(s): SECTION..4•BUILDING HEIGHT AND AREA Existing491 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.applieable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ R Facto F-1❑ F2❑ F.L• Lh Hazard H-1❑ H-2❑ H-3 H-4❑ H-5❑ I., Institutional I-1❑ I-2❑ 1-3❑ I-4❑ M. Mercantile❑ R. Residential R-1 R-2❑ Rti'❑ RJl❑ S: Storage S-1❑ S-2❑ 1 U-. Utility❑ 1 Special Use❑and please describe below: Special Use: SECTION'6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ RA ❑ IIB ❑ HIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE`INFO RMATION(refefto 780 CMR 3ll.0'for details on each item) Trench Permit Debris Removal: Water Sup�pl}l Flood Zone Information: Sewage Disposal• Licensed Disposal Site Public 4er Check if outside Flood Zone❑ Indicate municipal A wench w' not be P required or trench or p Private❑ or indentify Zone: or on site system❑ 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 comple d? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code:_8,—_Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: NO Special Stipulations: SECTION? PROPERTYOWNER'AUTHORIZATION Name nd Address Prope Owner sae �II� T__�P a.x q8o Un►l,�i �� MA ocg-o Name(Print) No.and Street C* /Town Zip Property Owner Contact Information: , Title Telephone No.(business) Telephone No. (cell) Aye-mail)a�d�d(ree g J� If applicable,the grope owner hereby authorizes `78 0 MA J_1 o Name a Street IDDo�ddress ty/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 CONTROU(Please fill out Appendix2) building is less than 35,000 m..ft'of enclosed s ace and/or not under Construction Controlthen check here O'and skip Section 10.1 �10.0..11�Re ' t''e''''reed PR �rofessiioonaatRes orisssiib�le for Construction Control,.- iiI��11'��aS''t�a(Re '��1ran,t) Q Tele hone No mail asl�trfg.�ss Registration Number Street Address City4own State Zip Discipline Expiration Dare 10.2 General Contractor , Company Name (111� J)b(,L -e- CS 2'� �rl COA q sof- ame of Person Responsible for Construction Lic ns No. and Type if Applicable 780 M OJJgo Street Address rry/Town State Zip _ u 781_V�}�k ►n1'o c �6� �>°,I�mes, coin Tele hone No.(business) Tele hone No. ceRI e-mail address SECTION.11:WORKERS'COMPENSATION INSUP.-ANCE AFEIDAWY 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 ls§86ce of the building permit. Is a signed Affidavit submitted with this application? Yes BK No ❑ SECTION.I2.CONSTRUCTTON COSTS'AND PERMIT FEE' Item Total Construction Cost from Item 6 =$ Estimated Costs:(labor and Materials) ( ) 1.Building $ Q Building Permit Fee=Total Construction Cost x_(Insert here 2 Electrical $ appropriate municipal factor)=$ 3.Plumbing $ Q Note:Minimum fee_$ (contact municipality) 4.Mechanical (HV AC) $ 0 5.Mechanical Other $ /�/�• Enclose check payable to 6.Total Cost $ �W (contact municipality)and write check number here SECTION 13:.SIGNATURE'OF BUILDING PERMIT APPLICANT By entering my name below,I here ttest under the and penalties of perjury that all of the information contained in this application is true and accurate es edge and understanding. 751 -1 Please print and sig J#�Q^ �•N•R T { Ti „� Telephone Date Street Address A CXJ City own !State Zip Municipal Inspector to fill out this section upon,application.approval:. Name Date .aco CERTIFICATE OF LIABILITY INSURANCE DAT /20 DIYYVY) a/2/zola 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 REPRESENTATIVE 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 endorsement(s). PRODUCER NAMEpCT Select Dept ext 66807 Eastern Insurance Group LLC PHAr ONE . (508)651-7700 FAX la.(7e1)5e9-8244 233 West Central Street E'MRIE .selectwork@ easterninsurance.com INSURERS AFFORDING COVERAGE NAIC d Natick MA 01760 INSURERAAcadia Insurance Company 31325 INSURED INSURER e: _ DiBiase Corporation, DUC Residential LLC INSURERC: _ Osborne Hills Realty Trust INSURERD: _ p 0 BOX 780 INSURER E: Lynnfield MA 01940 1 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. IL SR TYPE OF INSURANCE POLICY NUMBER MMIDDYEFF POLICYfYM EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea oc nence $ 250,000 A CLAIMS-MADE OCCUR 0191229-17 /23/2014 /23/2015 NED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENE AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP ADD S 1,000,000 X POLICY PRO- LOC $ R OMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per Person) S ALL OWNED SCHEDULED (Per accident AUTOS AUTOS )BODILY INJURY(P $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA UA13 HOCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ I$ WORKERS COMPENSATION CA0286788-15 /23/2014 /23/2015 x 'C STATU- DTH- ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICERNEMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,AddMonal Remarks Schedule,It more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. Salem, MA 01970 AUTHORIZED REPRESENTATIVE Ronald Cleaves/CMH2 ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(gmmsnt Th.ar.e)pn nam.and Inns aw..h,l rod mark.of ACF1Rn CITY OF SALEM ROUTING SLIP New Construction !� Certificate of Occupancy �LOCATIOND /yJ� /O/ jATE , ASSESSORS DATE a0/ 93 Washington St. e�, w 'P'^Yc�fa} �,^`�5�+ � ''3 vviaStlltjig On"*'St, "'�s^�1'Ss.�iv.� PUBLIC SER VICES _DATE N I 120 Washington St. VATER_ DATE !/ 120 Washington St. 6 ROSS CONNECTION V(p"` DATE 5 Jefferson Ave LANNING DATE_ �T4 120 Washington St. �ONSERVATIO E (� 120 Washington St. FIRE PREVENTION24. DATE �e, i 29 Fort Avenue — C BUILDING INSPECTO TE ja 120 Washington St. _ Professional.Land Surveyors 8 Civil,Engineers ESSEX SURVEY SERVICE. 1958 -, 1986 OSBORN PALMER 1911 - 1970 BRADFORD & WEED 1885 - 1972 PLOT PLAN OF LAND LOCATED IN SALEIYI MASS. 91� Lit 32 L 33 7*4715� s� of 0lQGQi fC 0 i D�rLL1�6 ti 1-lL� a� 4e� 2=Zo5 GS QDr( VL I�IZL L9AVr I hereby certify to the 5AL 10 Building Inspector that the pro ZONE: l LOT AREA: k0A1 � LOT FRONTAGE: 1Vj&L: posed construction shown conforms to the Aimiens'�onal zoning of FRONT YARD: 1� flr SIDE YARD: 1drT REAR YARD: 3dFy ilk LC/ Massa SCALE: r�Se of ras` DATE: Oct Z zoo REFERENCE: PZ BK 4OZ PG . l? Christopher R. Mellcj3 nr 311311 104 LOWELL STREET E ' PEABODY, MASS. 01960 (978) 531-8121 FAX: (978) 531-5920 , Professional Land Surveyors 8 Civil Engineers ESSEX SURVEY SERVICE. 1958 - 1986 OSBORN PALMER 1911 - 1970 BRADFORD & WEED 1885 - 1972 PLOT PLAN OF LAND LOCATED IN S a[�hj MASS. Ol'L ti SI�Cr D 9I 1�s lu1lZ 3QG=32 33 147 5f 561 Z06 ti0 I= ± GS 9691VL-: IVIZL VA(/Z= I hereby certify to the Building Inspector that the pro- ZONE: ( LOT AREA: &)AIE5 LOT FRONTAGE: lkobL- posed construction shown conforms to the�limens�i�onal zoning of FRONT YARD: /5 r-r SIDE YARD: IorT REAR YARD: 30ft SiJL L/'" Mass.;;, SCALE: / `= 40' �.SA +,A '1 DATE: DCL Z Z()1 3 REFERENCE: Y[ BK 40Z PG 7/ ,/f Christopher R. Mello'I\ \�o3T317a' 104 LOWELL STREET cr` PEABODY, MASS.01960 (978) 531-8121 FAX:(978) 531-5920 ,