23 OSBORNE HILL DR - BUILDING INSPECTION 1 -7
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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
(Phis Section Fof Qffici.1 Use Only)
Building Permit Number. Date Applied: Building Official:
SECTION 1 CATION(Pl ase)ndicate Block if an I iit#for locations for which a street address is no av Table)
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❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes Iff No ❑/Ou f,)
Is an Independent Structural Engineering Peer Review re#uired? [ Ye ❑ No
Brief Description of Proposed Work: ( n fU f � �) Sinale 1 (rll If �itl ��Ing.
SECTION 3:COMPLETE THIS SECTION IF.E)(ISTING BUMDING: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)
Total Area(sq.ft.)and Total Height(ft)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E. Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R Residential R-1 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 1B ❑ llA ❑ IIB ❑ MA IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7.SITE INFO RMATI N(refer to.780 CMR 111.0 for details on each item)
Trench Permit. Debris Removal:
Water Sup�pl} Flood Zone Information: Sewage Disposal: A trench not be Licensed Disposal Site
Public 4� Check if outside Flood Zone Indicate municipal required /trench or 'fy:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-wa . Hazard�tto Air Navigati MA 1-listurie Commission Review Process:Not Applicable Is Structure wi airport a oach area? Is their review comple d?
or Consent to Build enclosed❑ Y or No Yes❑ No V
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code:_� Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: NO Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name nd Address Prope Owner #.
0 civ� _[ T_�Pc�fax q8o L�n►-► I� , CIA ono
Name(Print) No.and Street C /Town j Zip
Proper Owner Contact Information: ,
Title Telephone No.(business) Telephone No. (cell) a-mail addres
If ap licable,the proper( owner hereby authorizes
P o. A 80 �fl�lA�q'LO
Name Street Address tty/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 endoseds ace-and/or not under Construction Control then check here 13 and skip Section 10.1
19.1 Registered Professional Responsible
�
le for C�onssttruucctioon Control
tybn�e ' ant) # ry OO Telephone No .,I mail as Registration Number
Street Address f O Cilty own State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
T 111 LBOi Slip, CS 2'1L�+�7 Cony on.�llhPty Sof
ame of Per n Responsible for Construction ^Lic No. and Type if Applicable
® I� x * 780 IT1 IMtih 01
(1LL_J40
1
Street Address ity/Town State Zip
Tele (tone No.(business) Telephone No. ceR e-mail address -- — �
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.1-.C.152§2SC 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 a lication? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $ 00
4.Mechanical (HVAC) $ Q 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 ttest under the ss and penalties of perjury that all of the information contained in this
is true an application ud accurate best f ge and understanding. Q �q q
Zh 7U1. - 101 1
Please print and si a d'• •R T Ti Telephone No. Date
7 1- M& —oleo
Street Address Citl Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
fiz��5 i 3
���40� bead ��]pDO� 0�3�30Q��40�3a BOQo.
Professional Land Surveyors Et Civil Engineers
ESSEX SURVEY SERVICE 195&° 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1885 1972
PLOT PLAN OF LAND
LOCATED IN
SALC7✓1 MASS.
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J S 66W A/E" MILL. 0 11i
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I hereby certify to the .501. --
r�� Lam • o Building Inspector that the pro-
ZONE
• /I • l� �L LOT FRONTAGE: kekZ posed construction shown conforms
/S/ SIDE YARD: 1DIT to the dimension zoning of
FRONT YARD:
REAR YARD: 3GST S9L��t Mass. .
SCALE:
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hrhs`,,
DATE: 10IZI �
i I OPHER Nr
REFERENCE: �L BK �Z PG 7,q Christopher fi 3I
,p No.31317 O
104 LOWELL STREET
PEABODY, MASS. 01960 513St ;''
(978) 531.8121
r V
, k.--- CERTIFICATE OF LIABILITY INSURANCE D/2/20DDIYYYY)
�� 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 NAME ACT Select Dept eat 66807
Eastern Insurance Group LLC PHONE (SOB)651-7700 ac a.(TB1)586-8244
233 West Central Street EfiIRIE .selectwork@easterninsurance.com
INSURERS AFFORDING COVERAGE NAIC s
Natick MA 01760 INSURERAAcadia Insurance Company 1325
INSURED
INSURER B
DiBiase Corporation, DUC Residential LLC INSURERC:
Osborne Hills Realty Trust INSURER D:
P O 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.
INSR AWL SUBR POUCYEFF POLICY UP
L TYPE OF INSURANCE POLICY NUMBER MMIO MMID UNITS
GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000
TO
X COMMERCIAL GENERAL LIABILITY A A S( RENTED
PREMISES Ea nence) $ 250,000
A CLAIMSWADE FxIOCCUR LA0191229-17 /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 LABILITY COMBINED SINGLE LIMIT
Ea accidem
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per actlentI $
HIRED AUTOS NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident)
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE 5
DED I I RETENTIONS 1$
WORKERS COMPENSATION CA0286788-15 /23/2014 /23/2015 X WC STATD- DTH-
ANDEMPLOYERS'UABILITY YIN
ANY PROPRIETORIPARTNER/EXECUTIJE E.L.EACH ACCIDENT $ 100,000
OFFICERIMEMBER EXCLUDED? ❑ NIA
(MandMory In NH) E.L.DISEASE-EA EMPLOYE E 100,000
It DySCRIPTIONunder E.L.DISEASE-POLICY LIMIT $ 500 000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I 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 j
Ronald Cleaves/CHH2
ACORD 25(2010105) 01988-2010 ACORD CORPORATION. All rights reserved.
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continuous ridge vent
10/12 asphalt roof shingle
lou er
8" boxed rake
hipped roof area .of laps/hip
crowned w.head
6._g RO ® ® ® 8'-0"
2824 2824 2 2824 2824
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lot
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PROPOSED FRONT ELEVATION
CITY OF SALEM 08"- 0/ 77
RO TING SLIP
.Nei Construction
Certificate orOccupancp /�
LOCATION D��✓11It/� �AfE
ASSESSORS DATE S ��
93 Washington St.
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/� Su glom St. � � raa kr c3a �.a a` d
UBLIC SERVICES DATE h
120 Wa
shington St. to
WATER I DATE 6 5 d� 6`r ' ` S °"1
120 Washington St.
CROSS CONNECTION _DATE LL K
5 Jefferson Ave
PLANNING DATE S �4
120 Washington St.
CONSERVATION DATE_ cZ 16
�120 Washington St. ' '
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48 Lalaj�'��"'tf"e St
FIRE PREVENTIO DATE_ /�/•
29 Fort Avenue
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BUILDING INSPECTOR � ] DATE
120 Washington St.