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13 OSBORNE HILL DR - BUILDING INSPECTION �� 713- I `1 -16� 2 � 3o�z �t-�� QV The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This:Section For jDfficial V Building Permit Number. Date:Fkpplied: 6 Buildimg Official: SECTION 1:LOCATION(Please indicate Block If and'Lot#foijocations for which a street address iutot a ]able) a W --- rn Nn.and Street City/Town Zip Code Name of Building(TIpplicZAA SECTION Z-TROPOSED'WOW — Zm Edition of MA State Code used_ If New Construction check here or check all that apply in the two r6H -- Blow Existing Building❑ .t Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and sub Ap olx I) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: FRI, _ Are building plans and/or construction,documents being supplied as part of this permit application? Yes � Nc%. om Fcl , Is an Independent Structural Engineering Peer Rev'ew uired? Ye ❑ No Brief Description of Proposed Work: 0 .1^tj � � � 11 ��111�� -__-- SECTION 3:COMPLETE THIS SECTIONSFiEXISTINGBUILDING:UNDERGOING RENOVATION,ADDTTION,OR CHANGE-IN USE OR'OCCUPANCY Check here if an Existing Building Investigation.andEvaluafion is enclosed(See 780 CMR 34) ❑ - Existing Use Group(s): Proposed Use Group(s): SECTI0N-4i BUILDING HEIGHT AND AREA Existing - Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq. ft.)and Total Height(ft) SECTIONS:USE GROUR(Check as.applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 -❑ A-4-❑ A-5❑ 1 B: Business ❑ E: Educational ❑ R Fact F-1 ❑ F2❑ 1I: lligh':Hazard H-1❑ H-2❑ H-3 H-4❑ H-5❑ l: Institutional I-1❑ 1-2❑ I-3❑ I-4❑. M:'Mercantile❑ R. Residential R-1 R-2❑ R-3❑ R-4❑ S: Storage S-i❑ S-2❑ I U: utility 1 Special Use❑and please describe below: Special Use: SECTION&CONSTRUCTION TYPE(Check as applicable) IA IB ❑ ILA ❑ LIB ❑ MA ❑ II1B0 IV ❑ VA VB ❑ SECTION 7.SITE MFORMATION(refer to:780 CMR 111.0 for details on each item) Water suppI Flood Zone Information: Sewage Disposal: Trendy Permit Debris Removal: Public 6J' Check if outside Flood Zone❑ Indicate municipal A trench not be Licensed Disposal Site required or trench or p fy: Private❑ or indentify Zone: or on site system El permit is enclosed ❑ C�-( Railroad right-of-way: Hazards''#o Air Navigation: MA Historic Commission I:cvihc 11.xr_s: Not Applicable❑ Is Structure within airport approach area? Is their review comple d? or Consent In Build enclosed❑ Yes❑ or No ElYes❑ No SECTIONS:CONTENT OF'CERTIFICATE OF OCCUPANCY Edition of Code:-,$ Use Group(s): -, Type of Construction: !S• Occupant Load per Floor: Does the building contain an Sprinkler System?: hlO Special Stipulations: ��•t-� � t=tvlAlt,� 10�2� Y SECTION 9: PROPERTY OWNER AUTHORIZATION Name nd Address ope Owner ern Ilse # �18o "A --_ _olq_c_ Name(Print) No.and Street C' /Town Zip Property Owner Contact Information: C1 n� Title Telephone No.(business) Telephone No. (cell) e-mail addres. �4eS C If applicable,the property-owner owner hereby authorizes _� q8- M oLCKO Name F Street Address ity/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 1(k CONSTRUCITON CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.feofenclosed s ace grid/or not under Construction Control then check here 0 and sKik Section 10.1 10.1 Registered Professional Res onsible:for Coni&ftE ortContraI N me(Re ' ant) Telelihone No mail ass T Registration Number Street Address Ci own State Zip Discipline Expiratiat Date 10.2 General Contractor Co m anv Name J lbm—e C.- n"' NSor Tame of Pe Responsible for Construction Li No. and Type if Ap licable o— 4x�80 � � __OjnLo Street Address &ity/Town State Zip 81--�}—qn— 7_8 L-844-7o 2aD lit ome �o Telephone No. usiness Teile hone No..cell e-mail address SECTION IL•WORKERS',COMPENSATION INSURANCEAFFTDAVIT: .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. Failureto.providethis affidavit will result in the denial of the issuance of the building permit. A is a signed Affidavit submitted with thisapplication? Yes❑ No ❑ SECTION]2 CONSTRUCTiON`COSTS'AND PERmrr FEE Item Estimated Costs:(tabor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ &�2Q Building Permit Fee=Total Construction Cost x (Insert here 2 Electrical $ ,j G�Q appropriate municipal factor)_$ 3.Plumbing $ 496 4.Mechanical (HVAC) $ (f Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here _ SECTIONI3-SIGNATURE OF BUILDING PERMIT APPLICANT fly entering my name below,I her ttest and the p 'and,penalties of perjury that all of the information contained in this application is true and accurate th ies - f of a and understanding. Please print and sr am 0-HAT • T; Telephone No. Date Street Address Ci own State Zip Municipal Inspector to fill out this section upon application approval: Date/ Name CERTIFICATE OF LIABILITY INSURANCE °I 'M"°°_""" 4/212 Ol THIS CERTIFICATE IS ISSUED AS'A:MATTER OFINFORMATION ONLY AND CONFERS NO-RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYI{AMEND,,EXTEND OR'ALTER.THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES--NOT, ''CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED f REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE.HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,rthe policy(ies),must'beendorsed. 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 NAME CT Select Dept ext 66807 Eastern Insurance GroupLLC ".PHONE. . (S08)651-7700 FAX .(7e1)596-9244 233 West Central Street - o RE s':selectwork@easterninsurance.com INSURER 3 AFFORDING COVERAGE NAIC# Natick MA 01760 'INSURERA'Acadia Insurance Company1325 INSURED INSURERS: DiBiase Corporation, DUC Residential LLC INSURERC: Osborne Hills Realty Trust INSURER D: P O Box 780 1NSURER'E: Lynn£ield MA 01940. INSURER'F: COVERAGES CERTIFICATE NUMBER� ter 14-15 / GL Only .REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEENISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION .F ANY CONTRACT OR,OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY7PERTAIN, THE--INSURANCErAFFORDED:-BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCHPOIICiES.LIMITS'SHOWN;MAY HAVE.BEEN.REDUCED:BY PAID CLAIMS. TN—SR LTR TYPE OF INSURANCE POUCY'NUMSER:^. MMIODY:EFF �M/ODTYEVYP LIMBS GENERAL LIABILITY !MrED OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY acconence $ 250,000A CLAIMSAIADE OCCUR LA0191229-17 /23/2014 /23/2015 XP Arty one person) $ 5,000ONAL&ADV I NJURY § 1,000,000RAL AGGREGATE $ 2,000,000DEN'L AGGREGATE LIMIT APPLIES PER: UCTS-COMPIOP AGG § 1,000,000X POLICY PRO- LOC $AUTO MOBILELIABILITY INED IN LE IMIT Ea accident) ., ANY AUTO BODILY INJURY(Per person) S ALL ONMED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accitlent) $ HIRED AUTOS NON4WNED PROPERTY DAMAGE AUTOS Peramlrlenl $ UMBRELLA LMB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE § DED RETENTION$ $ WORKERS COMPENSATION �02867B8-15 /23/2014 /23/2015 WC STATU- OTH- ANDEMPLOYERS'LIABILITY YIN X L ANY PROPRIETORIPARTNERIEXECUTIVE $ 100 000 OFFICERIMEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT (Mandatory In NH) - E.L.DISEASE-EA EMPLOYE $ 100,000 DESCRIPTION OF Odo'PERATIONS balow E.L.DISEASE-POLICY LIMIT $ 500 000 OESCRIPTIONOFOPERAnONS/LOCATIONS/VEHICLES(AttacftACORD:1Ot,'Additicina[Remarks Sehtdule,tfm mapaeglsragUlmdl 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 John Koegel/KA81 ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025"ntnme ni The Artncin name>nd Innn am roniabrod m>r4e of annizi Y Professional Land Surveyors & Civil Engineers ESSEX SURVEY SERVICE. 1958 - 1986 OSBORN PALMER 1911 - 1970 BRADFORD 8 WEED 1885 - 1972 PLOT'PLAN OF LAND LOCATED IN MASS. Zof 0 la5,cd ti w Ln � �RsfGSFr, ^. O�i�ILrrU I hereby certify to the 9XZ6] L Building Inspector that the pro- ZONE: LOT AREA:hU LOT FRONTAGE: posed construction shown conforms . to the dimensional zoning of FRONT YARD: IS116 SIDE YARD: Id Fr REAR YARD: /Crl S,(LCM Mass. SCALES @X e DATE.. ULT 6 2DI� t s REFERENCE: !'L BK -16Z PG R Chefstopher R. Mellw PLSrFB1317 104 LOWELL STREET PEABODY, MASS. 01960 C,G/ T A .. 4"Y: V4'.x (978)531-8121 . FAX: (978) 531-5920 09 - 0177 � CITY OF SALEM ROUTING SLIP .Nevs Construction--,'-'�-- Certificate of Occupancy LOC A T 10 N X114OIZA T E ASSESSORS 49�� DATE_ZQtl5 93 Washingtod St. (5 77, io! PUBLIC SERVICES DATE 120 Washington St. WATER_ J�Ul DATE 20 7 1 Washing ton St. CROSS CONNECTION DATE t I(% 1�1•_ 5 Jefferson Ave PLANNING'17�� DATE �O S- 14 120 Washington St. I --CONSERVATION —DATE 120 Washington St. ,� 4�EL&G1,111,0m,w- ;mm-Fm,00,EM"E, FIRE PREVENTIONQL,Q �_ .DATE 29 Fort Avenue 'Mi A$" 13UILDING INSPECTOR —DATE 120 Washington St.