11 OSBORNE HILL DR - BUILDING INSPECTION The Commonwealth of Massachusetts
.:4. Department of Public Safety
) VYU Massachusetts State Building Code(780 CMR)
' Building Permit Application for any Building other than a One-or Two-Family Dwelling
(rhis,section For ffi l Use Only)
Building Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Pl se indicate to #- Lot#for)ocations for which a street address is not available)
z��4WAe All aM MzlwNo.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2-PROPOSEDWO.
Edition of MA State Code used_ If New Construction check here or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out ancimmubmifSppendix I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:Are building plans and/or constructioredocuments being supplied as part of this permit application? Y� ;p
Is an Independent Structural Engineering Peer_ Review�equired?� i n10 1 11
p2`,.ct-`'°t Q�
Brief Description of Proposed Work: Qp MILL
J 1 m
M
---- ttt n r ---rr
SECTION 3:COMPLETE THIS SECnON'•IF.L7QSTING BUILDINGiUNDERGOING RENOVATION,ADDITION,OR
CHA:NGEEV USEOROCCUPANCY
Check here if an Existing Building:Investigation:and,Etraluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): — I Proposed Use Group(s):
SECTION 4-BUILDING HEIGHT AND.AREA
Existing Proposed
c
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 1�
Total Area(sq.ft.)and Total Height(ft) 5'`•
SECTION S.USE GROUP(C'heckas.applicable)
A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A-4--13 A-5❑ B: Business ❑ E: Educational ❑
F: Fact F-1 ❑ F2❑ H:-High Hazard 14-1 ❑ H-2❑ H-3 P H-4❑ H-5❑
1: Institutional 1-1❑ 1-2 ElI-3❑ I-4❑ M:'Mercantile❑ R. Residential R-1 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility-❑ Special Use❑and please describe below:
Special Use:
SECTION 6::CONSTR'DcnoN TYPE(Check as applicable)
IA TB ❑ IIA ❑ IIB ❑ MA ❑ MB ❑ I IV ❑ VA ❑ VB ❑
SECTION 7:SITE�,INFORMATION(refer to.780 CMR 1170'for details on each item)
Water Suppl Flood Zone-Information: Sewage Disposal: Trench Permit. Debris Removal:
Public Check if oufside Flood Zone❑ Indicate municipal A trench not be Licensed Disposal Site
--Private❑ or indentify Zone: or on site system❑ required or trench or fy: —�—
-� permit is enclosed ❑ �C�` j n�}'
Railroad right-of-way: Hazards''to Air Navigation: MA Flistoric Qo"mission t:cv icy.I'ro_tcrs_.:
Not Applicable❑ is Structure within airport approach area? Is their review comple d?
or Consent in Build enclosed❑ Yes❑ or No❑ Yes❑ No
SECTION 8:CONTENT OFCERTIFICATE OF OCCUPANCY
Edition of Code:_$__Use Group(s): 41, Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?:_NO Special Stipulations:
i O ( Zq e_11kAI l.Z_ > � U S rn sytt_.e P rn
SECTION 9:=PROPERTY OWNER AUTHORIZATION
Name end Address Prope Owner
os rye �IIs T� o_&( TO —__O&c-
t Name(Print) No.and Street C' /Town Zip
i
Proper t Owner Contact Information:
���' _@�1i.�iaSe�aa4 eS C n�
Title Telephone No.(business)' Telephone No. (cell) e-mail adc res.
If ap licable,the prope owner hereby authorizes
Name Street Address rty/Town State Zip
to act on the property owner's behalf,in all.mattm relative to work authorized b this building permit application.
SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2)
1f building is less than 35,000 cu.ft of enelosied:spacearuljorn6r.under ConstructionControl then check here O and skip Section 10.1
/1000.11 Registered Professional-Responsible forConstruedi Control:
1µ1AM
Tele hone Noail�-s T Re tration Number�$0_ an V
Street Address Ci own State Zip Discipline Expiration Date
10.2 General Contractor
�ll�.J� _
Company Name f
C__.I"1a6clo') N sor
ame of Per n Responsible for Construction LTC s No. and Type if Ap licable
Street Address ty/Town State Zip
81- � . -044-7oao
Tele ,one
No.(business) Tele p hone No._ceIl e-mail address
SECTION 11a WORKERS`COMPENSATION INSURANCRAFP1DAVrr: M.G.L.c.152.§25C 6
A Workers'Compensation insurance.Affidavit from'the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure tolprovide_this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with0is application? Yes❑ No ❑
SECTIONi12•CONS'TRUCTIONCOSTS AND PERMIT FEE
Item Estimated Costs:-(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ AOL Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $ Qd
4.Mechanical (HVAC) $ Q� Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ O (contact municipality)and write check number here _
SE._ ON 13:SIGNATURE OF BUII DING'PERMIT APPLICANT
By entering my name below,I e t a ._ and r the Gins and penalties of perjury that all of the information contained in this
application is true and accurafi o e be of ! 1- le ge and understanding.
IT
Please print andsi a� X 7 O'.H.R l lt-.1-tom- 1111�eleph�on4q-c) Dare
Street Address Ci own State = ,Z'ipp
Municipal Inspector to fill out this section upon application approval:
Name Date
riz7g� 3g
! Professional Land Surveyors Er Civil Engineers
ESSEX SURVEY SERVICE 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD 8 WEED 1885 - 1972
PLOT PLAN OF LAND
S�tGEM TID IN
MASS.
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I hereby certify to the Ski
ZONE: LOT AREA: INDkt LOT FRONTAGE: Building he pro-
Posed construction spector hownat tconforms
to the dimensional zoning of
FRONT YARD: /9� SIDE YARD: !at? REAR YARD: Ar-7 Jr(Lk7r? Massa
SCALEI `q(/ �,�ro ,�ss
DATE: R7 Z0/
Kf-` vIN
REFERENCE: N EK GZ PG 7 q iefopher R. 1 q0. 73�
104 LOWELL STREET
w`
PEABODY, MASS. 01960
(978)531-8121
FAX: (978) 531-5920
!)9-030 3
CITY OF SALEM
ROUTING SLIP
.Neil Construction (/
Certificate of Occupancy
1,0CAT10N
ASSESSORS DATE 0 S
93 Washington St. ✓@sses&
'Cw1TwY CAI ER*k ka " ��'Ts £ D W17 a
I ✓ :L''�d.' ' .a mf.Ftw t.k�u.wu �
9� VVI
a hrngtom t.
PUBLIC SERVICES ' --DATE �6 (f LLI
1120 Washington t.
WATER DATE �� (f t4
120 Washington St.
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNING DATE tO • I S • 1 q-
120 Washing t.
CONSERVATION DATE lU /
120 Washington St.
E;LEC�TRfC,A yNvggaor '4'
FIRE PREVENTION0_g�DATE la _
29 Fort Avenue
llfE` Ir 8 " tt� �g 9F51 01111
fb✓rti�`y'InffR;tii:".r oawewnu wm •*r<,w..�Ko�.d.+�aAmfnk4lm's�1La. .,„ .. '�'
W'asti"rngton St.
BUILDING INSPECTOR DATE
120 Washington St.
t