21 OSBORNE HILL DR - BUILDING INSPECTION I
(�-� lei a 1 osl�ne �lll 4r�
. C5 -1 q - -�
ct-- zqso AIIS-0
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:LOCATION(Please indicate Block tf and Lot If for locations for which a street address is not available)
�_ �� a1 �sloorfte Ni11 �(lve 5'at � mla tr�910
No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION Z 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 ❑ Addition❑ I 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 16 No ❑/ON f'l
Is an Independent Structural Engineering Peer Rev w r��ired?,1 (1 [ Ye ❑ No Yl
Brief Description of Proposed Work: (^,/1n (U(->— N ir) JI/IUI� f OfNI I� 1�) P1�It1Q
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUDDING 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 4:BUILDING HEIGHT AND AREA
Existing Proposed.
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) �/[, aAhV SF
Total Area(sq.It.)and Total Height(ft)
SECTION S:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
r F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 H4❑ H-5 CI
Institutional 1-1 CI ❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1 R-2❑ R-3❑ Rat❑
S: Storage Sl ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ HA IIB ❑ MA Eno rv ❑ VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water SuPPI Hood Zone Information: Sewage Disposal: Trench Permit. Debris Removal:
r Public 6/ Check if outside Flood Zone❑ Indicate municipal A trench not he 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 li isturic Commission R_v n_I'rncr>+
Not Applicable❑ Is Structure within airport approach area? Is their review comple d?�
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No
SECTION&CONTENT OF CERTIFICATE OF OCCUPANCY
Edifon of Code:_g Use Group(s): __ Type of Construction: Occupant Load per Floor _-
Does the building contain an Sprinkler System?:_ NO _Special Stipulations:
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
N/a�me,�nd Ad�dress�(Prope Owner . . IU� --I /� I ' MA
ee
_l1�►�-Q�1�C._LSL�_ — ),� L____
Name(Print) No.and Strt C`y /Town Zip
Property Owner Contact Information:
n�
Title Telephone No. (business) Telephone No. (cell) email addres
I(al, licable,Ne propert owner hereby authorizes
Name, Street Address tty/Town State Zip
to act on the property owner's 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.It 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
T yI Ii, OLao,
_ 781-3&--9919 I
�e # eNo7s0e hon maila s Registration%Number
Street Address Ci own State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
B III llsa.SP_ CS#?n I LI r1 N Sot
ame of Per n Responsible for Construction Lic ns No. and Type if Ap bcable
760
Street Address ity/Town State Zip
&&-�}—q�9g_ �-844-70ag G.. i�y�o���e��Tele hone No. usbmss Telephone 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 most 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 PERMTF FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $
Building Permit Fee=Total Constriction Cost x_(Insert here
2.Electrical $ 1,/,�P-QQ appropriate municipal factor)=$
3.Plumbing $
d. Mechanical (HVAC) $ i Note: Minimum fee=$ (contact municipality)
5.Mechanical Other $ g�� / ' q Enclose check payable to
6.Total Cost $ �JDOQU� (contact municipality)and write check number here _
SECT IO 3:SIGNATURE OF BUILDING PERMIT APPLICANT
Bv entering my name below, Fes
der t e pa and penalties of perjury that all of the Nformation contained in this
application is true and accuraow and understanding please print and si ameO.H.R.r Ti Telephone No. Date
Street Address Ci own State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
//
ha —''lao v® CERTIFICATE OF LIABILITY INSURANCE m2 WDD""""'
` a2ola
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 NAMTA
E.CT Select Dept ext 66807
Eastern Insurance Group LLC PHONE (508)651-7700 FAIC( ,,-(7B1)586-S21a
233 West Central Street -MAIL ,aelectwork@easterninsurance.toss
INSURE B AFFORDING COVERAGE NAICB
Natick MA 01760 INSURERAAcadia Insurance Company 1325
INSURED
INSURER B: _
DiBiase Corporation, DUC Residential LLC INSURERC:
Osborne Hills Realty Trust INSURERD:
p 0 BOX 780 INSURER E:
Lynnfield MA 01940 INSURERF:
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.
INSR I ADD[ POLICY EFF POLICY EXP
L TYPE OF INSURANCE INSRPOLICY NUMBER MMn) MWD LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES IEa s ce $ 250,000
A CI.AIMSWADE FxIOCCUR 0191229-17 /23/2014 /23/2015 MED EXP(Any one Person) $ 5,000
PERSONAL S ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ 1,000,000
X POLICY PRO LOG S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per E
AUTOS AUTOS ( )
HIRED AUTOS NON-OWNED PROPERTY DAMAGE E
AUTOS Per accl ent
E
UMBRELLA LIAS OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DELI I I RETENTIONE I $
WORKERS COMPENSATION 0286788-15 /23/2014 /23/2015 R WC STATU- TH-
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT S 100,000
MI OFFICEREMBER EXCLUDED? N 1 A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEf S 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE.-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If mom 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
Ronald Cleaves/CNH2
ACORD 25(2010105) 01988.2010 ACORD CORPORATION. All rights reserved.
INSn25,7n1nns)ni Th.Arnon name and Innn v¢roni¢lnrod ma�4¢of ACflRn
t
{� F'/Z795"- 1Z
�� 5�150t1ZL1 LJQl:.1 L�T+1 w
Professional Land Surveyors Et Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1885 - 1972
PLOT PLAN OF LAND
LOCATED IN
S11ZZ-W MASS.
BZ.o�
L4r 1Z
76 f?if
[4j
Z:'1 �7 9ti7
I hereby certify to the SJ�E1
Building Inspector that the pro-
ZONE: �l LOT AREA: LOT FRONTAGE:loll Z posed construction shown conforms
rr to the dimensional zoning of
FRONT YARD: SIDE YARD: REAR YARD: 3i Mass.
SCALE: AM
DATE: /Z'"b l� Lllr w p
1�p C R
REFERENCE: QL BK PG rt Christopher R 110
a.PLS 31317
MELLO
104 LOWELL STREET �
PEABODY, MASS. 01960
�c� -17srC,
`���VrYVYritY/..
(978) 531-8121
rn v. 1111M ro cnnn
al 65bme wl tar:-
�-laur�ho�rne. Model
CITY OF SALEM
ROUTING SLIP
New Construction 'v
Certificate of Occupancy
LOCATION 056b f\e-A,)i b-. DATE
✓SSESSORS DATE BUJ
93 Washington St.
i
.CITY [ faFuk 4 :„ DATE,`
�93
PUBLIC SERVICES _DATE l ft
120 Washington St.
✓WATER DATE
120 Washington St.
I/ CROSS CONNECTION DATE 14
5 Jefferson Ave
L /PLANNING DATE
120 Washington St.
VeONSERVATION - '__DATE
120 Washington St.
,,/FIRE PREVENTIO DATE—Z�`�
29 Fort Avenue
D lTE a Y
t20 Wash'rngtori° t;nti:x»w v xut .ewa t: —r":� S z •.a ✓
UILUINC INSPECTO r E �O
120 Washington St.
"Ilk
` 1=/Z795 iZ
• ���Qo� bn�d �a�oo� a��oQ���o�� ��Qa
Professional Land Surveyors B Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1885 - 1972
PLOT PLAN OF LAND
LOCATED IN
5;eZZ:7) MASS.
21.�a
/Z
76�9t�
lT.
Ok�A�seryJ
/kcFLUWI 'v
967
LLGS���t
I hereby certify to the I�OZ�fy1
ZONE: 1�1 LOT AREA: Building Inspector that the pro-
�6� LOT FRONTAGE:�i G� posed construction shown conforms
FRONT YARD: %jF SIDE YARD: A-r REAR YARD: � f to the dimensional zoning of
7�/4ZE/1 mass.
SCALE:
DATE: E� C/ Z<1iT 4 ct
REFERENCE: P.' BK -2 PC A-/ Christopher R41oP
104 LOWELL STREET 40 !'Tk n
PEABODY, MASS. 01960ti
(978) 531-8121
rnv. nvo cn. cnnn