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12 OSBORNE HILL DR - BUILDING INSPECTION Lci33 1?- osbarfuL %11 LY• I The Commonwealth of Massachusetts Department of Public Safety�u'u rt Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Fam'ly D Iling (This Section For Official Use Onl ) Building Permit Number: Date Applied: Building Official: SECTION 1: LOCATION(Please indicate Block p and Lot it for locations for which street ' able) AA 3� IL Oshctm}1t11 -I We- an 60D, 014-7D No,and Street City /Town Zip Code Name of Building(if applicable) SECTION 2•PROPOSED WORK 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 D Addition D Demolition ❑ (Please fib 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 16 No ❑/Ou 1:�1 Is an Independent Structural Engineering Peer Revy�w r cared?,` (� [ Ye ❑ No 4l Brief Description of Proposed Work: i��p�}f T 1V ) —sir* t aml II --I) P�I11lQ —ll."0 _— 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 C,BUILDING HEIGHT AND AREA - Existing Proposed No.of Floors/Stories(include basement levels)6r Area Per Floor(sq.k.) Total Area(sq.k.)and Tonal Height(ft) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-I ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 H4❑ H-5❑ 1: Institutional I-1 ❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-7 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 ❑ IIA ❑ IIB ❑ MA ❑ IIIB ❑ 1 IN ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water So Pi Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal: Public 5 Check if outside Flood Zone❑ Indicate municipal A trench not be Licensed Disposal Site Private❑ or indentify Zone: __ or on site system❑ required or trench or permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: MA Iiislunc Commission Rr_v u•.c Pm:',": Not Applicable❑ Is Structure within airport approach area? Is their review comple d7 or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No fit' SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code:_p Use Group(s): _- Type of Construction: __ Occupant Load per Floor: Does the building contain an Sprinkler System?:- NO Special Stipulations: .R SECTION 4 PROPERTY OWNER AUTHORIZATION MAName pl1d Address pt,Prope Owner �80 Name(Print) H,Ids No.and Street i1 C /Town Zip Property Owner Contact Information: ' Tide Telephone No.(business) Telephone No. (cell) e-mail addres If ap hcdble,die propen owner hereby authorizes Po. 980 _ �,�E�_MA o19'�0 Name. Street Address tty/Town State Zip to act on the property owners behalf,in all matters relative to work aut permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If budding is less than 35.000 cu.ft of enclosed space and/or not under Construction Control then check here O and skip Section 10.7 10.1 Registered Professional Responsible for Construction Control To L)I �iRia,SQ, 7$1-==&E�#=9F 1 lne(Re ant) # Telephone No I mail a r ss Registration Number kin Street Address Cit,4 own State Zip Discipline Expiration Date 10.2 General Contractor Company Name II B01 2)8fl s _ CS#Zq I H r] ame of Per n Responsible for Construction Lic ns No. and Type if Ap licable To. . x # 760 _ � 0 olgll0 Street Address ��oQ�I ity/Town (� I State Zip &2&� 2 iv( --044-702(D In k� C ibi SP,hornP S. C nM Tele hone No. usiness Tele hone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor d Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ approptiate municipal factor)=$ 3.Plumbing $ • -� d.Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)) 5.Mechanical Other $ `-^ ` Enclose check payable to 6.Total Cost $ ✓Q (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,l here t under the pa and penalties of perjury that all of the information contained in this application is true and accurate ne est no gEr3nd understanding. l. Aim `/ - —7- i--W----- Please print and si am # o. AT Ti Telephone No. Date — ��-- MA- -moo Street Address Ci own State Zip Municipal Irepetlor to fill out this section upon application approval: Name Date ,acoRo® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) �.-� 4/2/2014 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 CONTACT Select Dept ext 66807 Eastern Insurance Group LLC PHONE (SOB)651-7700 as 1,(781)586-8244 233 West Central Street EMAIL selectTrork@easterninsurance.coca ODRES INSURE S AFFORDING COVERAGE NAICd Natick MA 01760 INSURERAAcadia Insurance Company 1325 INSURED INSURER B DiBiase Corporation, DUC Residential LLC INSURERC: Osborne Hills Realty Trust INSURER D: 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. ILTR TYPE OF INSURANCE D POLICY NUMBER POLICYEFF MP�pCY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO PREMISE ERENTEre�rce $ 250,000 A CLAIMS-MADE OCCUR LA0191229-17 /23/2014 /23/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea amid.rr ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accitlent $ AUTOS AUTOS ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Peraccident 8 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LUIB CLAIMS-MADE AGGREGATE $ OED RETENTIONS I I$ WORKERS COMPENSATION CA0286788-15 /23/2014 /23/2015 x WCSTATLI OTH- AND EMPLOYERS'LIABILITY YINTQRY11MITq PP ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) E.L DISEASE-EA EMPLOYEE S 100 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Addi tonal Remarks Schedule,if more apace 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/CM H2 ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. IN5025 nniml n1 Tha annQn name and Inn.aro mn:efawd ma,La of Ar.nPn y F1279S 33 Professional Land Surveyors Et Croil Engineers ' ES$EX SURVEY SERVICE "€ r. 1958 - 1986- OSBORN PALME'R - 1911 - 1970 BRADFORD & WEED 1885 - 1.972 PLOT PLAN OF LAND. LOCATED IN , 914L E'M MASS. 6& k 5PACf �/� 32 a9 \ LET 32' 90 II' %�lGi0�5E0 ;� Dlvf2Cl,Ub' 1Z L=OU'l l7/Zz lJRI(/L% I hereby certify •to 'the S,�CE/y ; Building ZONE: Rl LOT AREA '::/yG�� LOT FRONTAGE: �otE construction Inspector that the pro posed con shown,conforms to the dimensional zone of FRONT YARD: l5rT SIDE YARD: Irr REAR YARD: 3Jr, Sf1LEl/I '+ class: SCALE: l/��U �a�►P*OSs DATE: 402/Z 3 2!Jl w REFERENCE: �( BK 9�Z Pc 7y Chr etopher R Mellt �PIyS3 ��317 104 LOWELL STREETc�G�« PEABODY, MASS.01960 (978) 531-8121 - - r_nv. imM l L6+433l 12 0sbornz 401 61ve- CITY OF SALEM ROUTING SLIP ,New Construction V Certificate ofOccupancy LOCATION 12 O tv'411`1 1\�/• DATE ✓SSESSORS DATE 93 Washington St. 3 Washngton St. �,. ✓PUBLIC SERVICES /YIL DATE 1l 120 Washington St. -- ,c'ATER DATE `7L4,11� 120 Washington St. VIC Ross CONNECTION DATE_ 5 Jefferson Ave - I �LANNING DATE �q V 12200 Washingto t.�� CONSERVATION t i? DATE / 120 Washington St. DX ih {• r } µ VRE PREVENTIO DATE 29 Fort Avenue 1"*II�WasMrgton S`t,.�,. > V IJILDING INSPECTOR �E 120 Washington St. w 498 h(g Professional Land Surveyors Et Civil' Engineers ESSEX SURVEY'SERVICE *1958 -%1'986 OSBORN PALMER Y911 - 1970 BRADFORD & WEED 1885 - 1972 PLOT PLAN OF LAND LOCATED IN , SAL E'M MASS. 5PA(C - �13 3�G9 Lr 32' QG II, ARuPGSE(I ,� 114i&2(GUb ZZ� L'l0'I,UG l//Z/ I hereby certify to, the -Sr�CFi�t , Building Inspector that the-.pro-. •- ZONE: Rl EDT AREA: g0) TAT FRONTAGE: �Go�� posed construction shoviri'coriforms FRONT YARD: YARD to the diinerisional SIDE zonuig of !U(7 REAR YARD: 3a 5,�Z W ' ' rlasa SCALE: 02i� 3 y DATE: � �f n N1Y REFERENCE: fl EK W7,�/ PG 7q Christopher R. MC 60 U. 104 LOWELL STREET ! r6 e . >,. PEABODY, MASS. 01960 =a. u (978)531-8121