15 OSBORNE HILL DR - BUILDING INSPECTION •5 ,
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 Official Use Only)
Building Permit Number. Date Applied: Building Official:
SECTION 1 LOCATIO (Please indl to lock If and Lot#for locations for which a street address is not available)
5 fwf ZM7 AZD d
No.and S6eet r. Ci oovn 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❑ 1 Alteration ❑ JAddition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑/ON F�l
Is an Independent Structural Engineering Peer Rev red 1 (� [ Y ❑ No 4T
Brief Description of Proposed Work: rt4f iCT IV t) Sinah. ! MI Il DitJP160 1
SECTION 3:COMPLETE THIS SECTION iRE)QSTING 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):
SECTION4 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)
SECTION 5:USE:GROUP(Check as applicable)
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ FI: HI Hazard H-1❑ H-2❑ H-3 H-4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ I-3❑ I 1❑ M: Mercantile❑ R Residential R-1 R-2❑ R-3❑ R-4❑
S: Storage S1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION'6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ 11110 HIA ❑ M [3 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit Debris Removai:
Water SuppI Flood Zone Information Sewage Disposal•
Public ls� Check if outside Flood Zone❑ Indicate municipal A trench not be Licensed Disposal Sire
required or trench or
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 S.CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code:_j8-th Use Group(s): Type of Construction: - Occupant Load per Floor:
Does the building contain an Sprinkler System?: NO Special Stipulations:
i SECTION 9: PROPERTY OWNER AUTHORIZATION
Name nd A )e, As Owner # I MA
4s�QL��i��T p0 ,x '180 L�In I �'I OtR�Fn
Name(Print) No.and Street C' /Town Zip
MProper Owner Contact Information: %41
,
_ I Xi s— 281- lq 7$l- ' ' 702Jo jnf �1
Tide Telephone No.(business) Telephone No. (cell) a-
mail addres
If ap licable,the proper owner hereby authorizes
Rd NY, 980 LI nuleu IM olgq
Name r Street Address ity/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 cu.ft of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Toy� -Iaiol 7&--3a —9ffi
me(RegM # m Tele hone No maWas Registration Number
Street Address Cibj. Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
B I)I M&Ls CS#271 �+�7 CorAA 'anv so(-
ame of Pe n Responsible for Construction ns Lic No. and Type if Applicable
O x # 760 � �19y-O
Street Address ity/Town Slate Zip
&� 7818�I�k-70210 �n i Sf, r2rnP- S, Gar'
Tele hone No. usiness Tele hone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152:§25C 6
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 47WBuilding Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ l ?ee appropriate municipal factor)_$
3.Plumbing $ iAA0
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) -
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I here under the and penalties of perjury that all of the information contained in this
application is true and accurate st nt ow and understanding.
M 1 �
Please print and si am # 0—H.R. L` Ti e� _ „ „Telephone No. Date
t)
Street Address Ci own State — Z1ti-pQi-U1-(v1
Municipal Inspector to fill out this section upon application approval:
Name Date
Fie TVs -
����,��Qo�
Professional Land Surveyors Er Civil Engineers
ESSEX SURVEY-SERVICE. 1,958 - 1986
OSBORN PALMER 1911 - 1970 '
BRADFORD & WEED 1885 - 1972' "
PLOT PLAN OF LAND
LOCATED IN
5'IZ,CN MASS.
fair« A
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4'l y i
N 8172 4g
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�LGSrE I hereby certify to the 5.4ISW
ZONE: Building Inspector that the, pro-
Q1 LOT AREA: /�Uy LOT FRONTAGE: posed construction shown conforms
to the dimensional zoning of
FRONT YARD: IS>T SIDE YARD: ICJFz REAR YARD: 11-1 546 11 Massa
SCALE$ b �O+ •„
DATE: Zoo
REFERENCE:1 BK PGWUrristopher. RAriiMe to PPLS) 3131vW`
'A No.31317 9/
104 LOWELL STREET - -- �%
PEABODY, MASS.01960
(978) 531-8121
FAXi(978)531-5920
'4� CERTIFICATE OF LIABILITY INSURANCE D DD/YYYY)
a/2/2z/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).
Y PRODUCER CONTACTNAME: Select Dept eXt 66807
Eastern Insurance Group LLC PHONE (506)651-7700 FAXNo, (781)5E6-8244
233 West Central Street r;&M",Lp,-.E.tlectwork@easterninsurance.com
. lectmork@easterninsurance.com
INSURE S AFFORDING COVERAGE NAIC9
Natick MA 01760 INSURERAAcadia Insurance Company 1325
INSURED INSURER B:
DiBiase Corporation, DUC Residential LLC INSURERC:
Osborne Hills Realty Trust WsuRERo:
p 0 BOX 780 INSURER E:
Lynnfield MA 01940 INSURER F:
COVERAGES CERTIFICATE NUMBER34aster 14-15 / GL Only 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.
INSR POLICY EFF POLICY EXP
LTR TYPE OFINSURANCE PODCY NUMBER MM/D MID LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE PREMI E E ocwence $ 250,000
A C1-AIMSd1ADE OCCUR LA0191229-17 /23/2014 /23/2015 MED EXP(Any one person) $ 5,006
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 1,000,000
X POLICY PRO LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accitlent
ANY AUTO BODILY INJURY(Per Person) $
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $
HIRED AUTOS NON-OWNED OS PROPERTY DAMAGE $
Per accident
UMBRELLA UAS OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION 0286788-15 /23/2014 /23/2015 WC$TATU- GTH-
ANOEMPLOYERS'LIABILITY YIN X
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 100,000
OFFICER/MEMBER EXCIA) NIA
(Mantld96 1 NH) E.L.DISEASE-EA EMPLOYE $ 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 500 QOQ
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If 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
John Koegel/KAB1
ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved.
INS02519n1nnml n1 Th¢aP.npn nam¢and Inn-aro roni¢brod mark¢nF Arnon
RECEIVED
INSPECTIONAL SERVICES
1819 OCT.- � A 0 42 CITY OF SALEM
ROUTING SLIP
New Construction !/
Certificate of Occupancy
IWW7 LOCATION
ASSESSORS AjW DATE /
93 Washington St.
`CITY4C'LERK Itw� r �'' ,� �Mffl Et��r` 3� n
,g wh'.ia P" % .ea. +vn.,aoJax.JCw7 SYx':u�.aw.A'{ki"".:.rJ �' xrm'yq,.rffF,e.� ,�siy
3 W'asfiington St.
PUBLIC SERVICES DATE 3i lq
120 Washington St.
WATER DATE t1
120 Washington St. �-
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNING DATE
120 Washington St.
CONSERVATION= DATE l
120 Washington St.
fE,;�LECut�t3s
T'RICAL&r!,:, ' m?222
7l w r� e ,
FIRE PREVENTION ll DATE zJ�
29 Fort Avenue
�20�Va3Firngton S:` ""�'°
BUILDING INSPECTOR DATE
120 Washington St.