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18 OSBORNE HILL DR - BUILDING INSPECTION (2) 6 50-i The Commonwealth of Massachusetts r Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR L Revi SA r410i1 w Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date pplfed: ,Grp M/Jo Building Official(Print Name) . Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: + 1.2 Assesso Map& Parcel Numbers I Sl DSbofng •� %At ZYt�e— 7 1.la Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: ! , / 1.4 Property Dimensions: / Zoning District Proposed Use I Lot Area(sq It) Frontage(11) 1.5 Building Setbacks(fl) Front Yard Side Yards Rear Yard Required Provided Require) Provided Required Provided 1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone'? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record• or flp, ' 1V Q,pa —�ak, ( )4A^Axa PA 61 q 4 b game(Print) City,State,ZIP P. D . 6ey �ko ��- 33�-qs�� 1n�o�a't b��ehmLes corn No. and Street 'telephone Email Address ' SEC N 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction K Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of P/ wsed Wor ��fJ/ �« Q SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ ❑Standard Cityfrown Application Fee ❑Total Project Cost'(Item 6)x multiplier x t 3. Plumbing $ 2. Other Fees: $ E 4. Mechanical (IIVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: (). Total Project Cost• $ 1"�Ienv V 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /le,_ �1T Yn ut.A 4�� ,� Liic�cee--nose Number 1 . 1 Expiration Date Name of CSL 1-lolder P. 0, n �x �c List CSL'I'Ype(see below) No.and Street l� O Type Description 11A al e't 1 r1 U Unrestricted(Buildings up to 35,000 cu. ft. R Restricted 1&2 Family Dwelling Cityrl7o�lrn,State,ZIP M Mason ry RC Rooting Covering WS Window and Siding 3�� G I� 1?S1bI�ehOd SF Solid Fuel l3umingAppliances 12S'_I t Insulation ele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(RIC) PIIC Company Name or I IIC Registrant Name HIC Registration Number Expiration Date No.and Street Email address City/Town,State,ZIP 'telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) Workers Compensation Insurance affidavit 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. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, I her attespqder the pains and penalties of perjury that all of the information `contained in this application is true and c ate t the est of nowle and understanding. Print Owner's or Authorized Agent's me(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program.can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 2. When substantial work is planned, provide the information below: Total floor area(sq. Il.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system_ = Number of decks/porches Type of cooling system Enclosed___Open 3. "fatal Project Square Footage" may be substituted for"Total Project Cost" fig) n l , \ \326 5 \ "ROP. E TfOO l , 1 T 1 \ EI /'IEI V \ \ , l srol I FACILITY v E h 1 \ \ \ _A, EI6 � 85 88 ✓i A 1 �SE SHEE1 40 , \ix E15° E22° \ E23� E13 3x \ 9v E24� \ \ \ \ \ O \ E201 �• •, \ \� \ �Q \ 4EI22 \ I06x a\ �v� JE26°\ 90 f0px E27 E28 Es RESOURCE ARE 90 — � \ E8 _ \ \\ cE7 /00 \ �.� liL J \ \ E6 tlsx\ . QO AFOdT �U ERv \. \ E5 `� \ \ ` I \ a 1 12i \ l� i� JOB '' SBoS+LN£ r�rr t SvBOrdrsraN ROOME & GUARRACINO, LLC SHEETNO. 4r'FM of Z o�Z Structural Engineers 48 Grove Street CALCULATED BY �/ DATE 31107 Somerville, MA 02144 'e Tel 617.628.1700 Fax 617.628.1711 CHECKED BV DATE SCALE /• ,�tV86G6i.SToN . WA24 sMfrGG....B GoNs> /cTO of .ROIIGHGy s/G�P,�D SYoNES lfl/D 1N/THQU7` .IE¢Ul1.RtT}� QF CoURsINC� BUT WELL L BoN�60 i FrTfEl7 T4ETN�R To. FoRM._W�U VefINED ?'prN7"S, 2.i.I'�(t884E STONE IV k SMtw HA-✓� .oN.� BoN4El$. 4Nir'. >aa2.��GN 0� ¢vAGI suREAGE oN..BgtH £/DES. 6046A UNITS SNA , .EX`TEND ;Nor. _.GEss TN�r!_.4," it-0 �.a mct lNG c✓ k-f , 12n ttir/ FcR N 6r E[N R✓1uE 24°n N tort - - WpI,L,Hr M,nr {v�otir ;. $ro )0 6 Oil. . ! r0 Tn•L¢. 7 I '.... ._. _ ._. �\\ OA GUARRACINO STRUCTURAL i.' No 401 .......I/ . ...._ -..r .... I .._... .. . W r N rl /1 n n✓£rrlan! /A. AND tif, fl 8m., Sl rgE .�✓AL /{ PRcsuM, oTjvE, BEANN4 GAepuT'y Qf ANDAN A:.CtlU� CATraAL 9417M P ssuRE c�.EFF/GrEN.T �a -i=. 0<33 jA BEEN ASfan D ,' %© BE VE14F/Eo ArInriE aF a)R5 U6r/,W1 CITY OF Si1LEM, NL-1SSACHCSET B a��, BUILDING DEP3RT\LF—NT •3 �� ¢ r�5,t 120 WASHCVGTON STREET, 31a FLOOR TEL. (978) 745-9595 Ru<(979) 740-9846 KI\tBERLEY DRISCOLL �L'tYOR THOMAs ST.PMUE DIRECTOR OF PLBLIC PROPERTY/BLUMNG CONNISSIONER Workers' Compensation Insurance AfTidavit: Builders/Contractors/Electricians/Plumbers Applicant information- More tnusin¢ss0 banizatiom'Individmtl): j �ktC� � Address: !/ 0 City/State/Zip: phone Il: Are you an employer?Check the appropriate box: 'ry at project(required): 1.❑ I am a employer with 4, ❑ I am a general contractor and 1 6. Lo�7 New construction employees(full and/or part-time).* - have hired the sup-contractors 2.❑ 1 ran n sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working Iilr me in any capacity. wokers'camp. insurance, y, Building addition [No workers'comp. insurance S. ❑ We are a corporation mid its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.El Plumbing repairs or additions myself.(No workers' sump. C. 152, §1(4),and we have no 12,(] Roof repairs insurance required.] t empluyees. (No waikcrs' comp. insurance required,) 13.ElOther. A. applioanLtlut chucks bus rl must also rill ual the sccnon below ihowina their workers'compensation policy inli,rmnlion. 'I h,meow Knx who.whmir this stBrtnvit indicating they arc doing all work and then hire uattida mmmctora most sohmit a new alrWavit indicting such. t••�ntmewn thus chock this box mtun anachco an addiii-nal-hoot showing the mmne otihe mbauniraeton and their worltrrs'comp.pulley intermalien I um an rutpluyer that is providing)vorkrrs'cumpensatlun iu.ruruoceJ•or my empluyrrs. Aulo)v!s lbe policy and job silo iujianuutinn. Insurance Company Name: Policy 4 or Sclf-itcv, Lic, it: _._._ Expiration Date: lob Silt:Address: City/Stale/Zip: Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the it of criminal penalties of a line up to 31,500,00 und/ur one-year imprisomncnt,as well as civil penalties in the term of a STOP WORK ORDER and a lino OF up to S250.00 a day against the violaror. 13e advised that a copy of this statement may be forwarded to the Oflica of Invr>tigatiuns of the Of or insurance coverage veriticalion. /du/mrri i rerrli I'd r the uln ud I ojprrju t/ t the )t`urululion provided ubov cr rand c•urrrct. r / Data: - Of i Iul use unly. Do not write in this area, to be completed by city up town njJle•iul Ciry ne Town: _ - Per mit/Lice rise N Issuing,Authority (circle une): -- --- --- - -- I. hoard of Health 2, Ilwldhtq I)cl)artllterlt I Cllyfruwn Clerk 4. Electrical (uspcctur 5, Plumbing luspecrur 6. Other Contact Person: Phone S: A� CERTIFICATE OF LIABILITY INSURANCE °/2/20 °"YYY' a/z/2o1a 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(iss) must be endorsed. If SUBROGATION IS WANED,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: Select Dept ext 66807 Eastern Insurance Group LLC PHONE - (5OB)651-7700 FAQ (7e1)536-8244 233 West Central Street u a` aelectx rk@easterninsura ce.com INSURERS AFFORDING COVERAGE NAIC 0 Natick MA 01760 wsURERAAcadia Insurance Company 1325 INSURED INSURER B: DiBiase Corporation, DUC Residential LLC INSURERC: Osborne Hills Realty Trust INSURER D: _ P 0 BOX 780 INSURER E: -Lynn£ield MA 01940 INSURER F: COVERAGES CERTIFICATE.NUMBERMaster 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 OFANY 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 im POLICY NUMBERPOOL SUER — MMIDCYEFF MWDDYEXP LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL ABILITV PREMISES Ea occurrence $ 250,000 A CLAIMS-MADE FZ OCCUR 0191229-17 /23/2014 /23/2015 MED EXP(Any one pown) S 5,00 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 1,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per parson) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON OMED PROPERTY DAMAGE - AUTOS Peramidera $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED.I I RETENTIONS $ WORKERS COMPENSATION CA0286788-15 /23/2014 /23/2015 X WC STATD- OTH- AND EMPLOYERTUABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMSER EXCLUDED? NIA 100,000 (Mandatory In NH) E.L.DISEASE-EAEMPLOYE $ 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,I1 more apace Is 1W.hed) 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, HA 01970 AUTHORIZED REPRESENTATIVE John Koeglel/KABl ACORD 25(2010105) 01988-2010 ACORD CORPORATION. All rights reserved. INSO25 rgmnnel ni Thn anon nomn and Irmo aro ronicferod marLa nF anr%pn