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30 OSBORNE HILL DR - BUILDING INSPECTION 10 LA-4 `( I �K 32 cti��©6a q� The Commonwealth of Massachusetts JF Department of Public Safety r 1 Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling Section For Official Use Onl • Building Permit Number: Date Applied: Building Official: I SECTION 1 LOCATION(Pleaselindicate`=Bloe_k 4f'arid-!W,49.for'locations for which a street address is notijailable) Ul 3 a Osborne 4-t1 k. A.0+* 4q !T 1 ow-)D = No.and Street City/Town Zip Code Name of Building"Lif appE&!? ) t SECTION M PROPOSED'WORK t�'n Edition of MA State Code used_ If New Construction check here or check all that apply in the two baw{s below _ Existing Building❑ Repair❑ 1 Alteration C Addition❑ Demolition ❑ (Please fill out and sutWt A¢p�a�dix 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 Nrj:�O N Fr1 Is an Independent Structural Engineering Peer Review required? i Y 0) Ndj Brief Description of Proposed Work: !`tpn, fU('r" 1�6eL- + 'e,lM11V , waling SECTION 3:COMPLETE THIS SECTION-IFIMSTING BUILDING UNDERGOING RENOVATION,ADDIT16N,OR CHANGE,IlV USE-OR OCCUPANCY Check here if an Existing.Building Tnveatigaft wind Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION C-BUILDING HMGW AND:AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.fL) 1 Total Area(sq.ft.)and Total Height.(fL) s.4, SECTIONS.USE GROUP jCheck asap licable) A: Assembly A-1❑ A-2•0 Nightclub ❑ A-3 ❑ A-41❑ A-5 W7 B: Business ❑ E. Educational ❑ F:—Factory F-1❑ F2D ?.FL•:`Hi Hazard H-1❑ H-2❑ H-3 H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M::'Mercantile❑ - R: Residential R-1 R-2❑ R-3❑ R"4❑ S: Storage S-1❑ S-2❑ il: utility-❑ Special Use❑and please describe below: Special Use: . SECTION 6:CONSTRUCTION TYPE.(Check as applicable) IA ❑ IB ❑ IIA ❑ 1113 ❑ MA ❑ MBL ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE mwoRMATION(refer to 78o CMR 111.0`for-details on each item) Water Suppl Flood Zone Information: Sewage Disposal• Trench Permit:. Debris Removal: Public� Check if outside Flood Zone❑ Indicate municipal A trench not be. Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ required cl trench or permit is enclosed❑ Railroad fight-of-way: Hazards to Air Navigation MA Iiistoric Commission Review I'rexrss: Not Applicable❑. - Is Structure within airport approach area? Is their review comple d? or Consent lu Build enclosed❑ Yes❑ or No❑ - Yes❑ No SECTION&CONTENT OFCERTIFICATE OF OCCUPANCY Edition of Code: 84A Use Group(s) Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?:_440 Special Stipulations: i' • SECTION 9: pikgww Y'UINNER 80 AUTHORIZATION Name nd Address pe Owner oafn Name(Print) No.and Street /Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No, (cell) e-mail addres If ap licable,the props owner hereby authorizes Pia. fxx `780 �v"�fl(1A�1910 .Name Street Address ty/Town State Zip to act on the property owner's behalf,in aRmatters relativewto:work authorized.by this building permit application. SECTION 10 CONSTRUCTION CONTROL(Pleaae fill�out Appendix 2) (Ifbuilding is less than 35.000 cu.ft.of enrlosed s aceai d/or not�mdes Construction Contiol.thencheck here 13 and skip Section 10.1 10.1 Registered'ProfessionaLRes" onsibwfo rdittuctronContml ryyn (Re ' ant) -o Tele hone No =mail a s Registration Number Street Address Ci ''- -own State Zip Discipline Expiration Date 10.2 General Contractor - Company Name C 2 �Q) -t�l.(�� S 71 L4r7 Cn�� on.�UMN SDI ame of Pe n Responsible for Construction' �I.ic No. and Type if Applicable X * 750 t' `1 f Sttr�eet Address( 7Q @ �1 'fy/Town State Zip �( Telephone No. usiness Telephone No::.cell e-mail address SECTION"1L•=WORKER$L'COTdPEN5''TIONIhMMA CE, AV1Ts G.1-c.152§25C6 A Workers Compensatiori insuranceAMdavi"t fide the=MA1 DL-partuient of'Industrial Accidents must be completed and submitted with this application. Failure to provide-this affidavit wl result in the denial of the issuance of the building permit Is signeda. Affidavit sulrniitled"with",application? Yes❑ No O SECTIONIZ CO1V$ 'RUCIROIV COSTS AND PERMIT FEE Item Estimated-Costs:'(Gabor - and-AUtenals) Total Construction Cost(from Item 6)_$ 1.Building $ aos0000 Building Permit Fee=Total Construction Cost x_(Insert here 2 Electrical $ C p D appropriate municipal factor)_$ 3.Plumbing $ p 4.Mechanical (HVAC) $ o Note:ivlinimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ ZS0' C 0 , :(contact municipality)and write check number here SECTI 13:-iSIGNATU,REOFBUILDINGPERMITAPPLICANT By entering my name below,I.he a th and,penalties of perjury that all of the information contained in this application is We and accurate e- }' y - ge and understanding. '7Qu �q q /c�1_�'7' 10 11 Please print and si ar 44: o'•)"i.R.1. t Ti _ _ _Tel-ephh(o�'n{tee N000.�-/�� Date 111nStreet Address `f.\ CJ CiL own State Zip Municipal Inspector to fill out this section upon.applicationapproval: `70'r✓'1 7/110 Name Date A2 r CERTIFICATE Of LIABILITY, INSURANCE DATE(MM/ODVYYyI ,.... .. 4/2/2014 THIS CERTIFICATE iS ISSUED AS-'A`MAMftR OF INFORMATION ONLY:IAND CONFERS'NO:RIGHTS='UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR=NEGATIVELY AMENDs-,EXTEND,OR ALTER:THE.�COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCEgDOES NOT;CONSTITUTE'A-•CONTRACTBE7WEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE-ORrPRODUCER;.AND'THE CERTIFICATE;HOLDER.: IMPORTANT: If the certifl eta holderis an ADDITIONAL INSURED-,tho,pollcy(ies)must be-endorsed. If SUBROGATION IS WAIVED, Subject to the terms and conditions of the Policy;;certain Polieles;may�requlreran endorsement A sta[ernent on this certificate does not corder rights to the certificate holder in lieu of such endoisemerd(s)::r: PRODUCER ':-NAM-ACT-501'eCt Dept ext 66807 Eastern Insurance Group LLC -PHONE y;"(SO`B)r.653-7700 FAX AID N .(7B3)SS6-8244 233 West Central Street � ErM RE s.selectmoak@easterninsurance.com INSURERS'AFFORDING COVERAGE NAICN Natick MA 01760 'iriSGRE�RAAcadia Insurance Com an 1325 INSURED 1NSURER B': Di$iase Corporation, DVC Residential LLC -. -INSURER4: Osborne Hills Realty Trust :`INSURERD: P 0 Box 780 INSURER,E-: Lynnfield MA. 01940. INSURER COVERAGES CERTIFICATE'NUMBER34aeter 14 15 1 GL Only REVISION'NUMBER: THIS IS TO CERTIFY [MAT THE POLICIES OF INSURANCE LISTED;BELOW HA'''I I 11 ISSUED TO THE'INSURED-NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT;:TERM OR.,CONDITION OF-ANY CONT CERTIFICATE MAY BE RACT OR`-OT.HER:DOCUMENT WITH RESPECT TO WHICH THIS ISSUED OR MAY;PERTAIN,.7HE-INSURANCE AFFORDEWBY THE POLICIES-DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH:POLICIES:.UMITS SHOWNWAY HAVE;B_EEN REDUCED By PAID CLAIMS. ILTR iYPE.OFINSURANCE - POIJCY!NUMBER� ;MO DICY:EFF' -'MM DOI EXP GENERAL LIABILITY ry LIMITS EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY $ 1,000,000 R occc m $ 250,000 A CLAIMS-MADE $ OCCUR ` 0191229-17 - /23/2014 /23/2015 MEDEXP Any one Person) $ 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,006 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG S 1,000,000 X POLICY PRO- LOC $ AVTOMOBILE LIABILITY OMBINE SINGLE IMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AlJT05 BODILY INJURY(Per eccident) $ HIRED AUTOS NON-0WNEO PROPEPera�RTY nt AMAGE $ AUTOS UMBRELLA LIAB OCCUR $ EACH OCCURRENCE $ EXCESS LIAB CLAIMSMADE AGGREGATE $ DED RETENTIONS WORKERS COMPENSATION 6286788-15 - /23/2014 /23/2015 VO STATU- OTH- $AND EMPLOYERS'LIABILITY YIN. x ANY PROPRIETOR/PARTNER/FItECUTNE 1O0 000 OFFICERIMEMSER EXCCUDED4 NIA E.L.EACH ACCIDENT g (Mandatory In NH) 100 000 Ir(Mandator, unear E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ Soo 000 DESCRIPTION OF OPERATIONS I LocxnONSI VEHICLESI(Anach ACORD 101,AddRlonal RemaHia'ShciEdula,H more a ace le p 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 AUTHORIZEDREPRESENTAnVE John Koegel/KAB1 �5,?^�,.y ACORD 25(2010105) 019884010 ACORD CORPORATION. All rights reserved. INS025 nmm�sm The Arrian nA 1,....,ire rnn;etn.aaa.aaa.4a.nP AP..rlPn FIZ7T I/ Professional Land Su'syors b Civii Engineers ESSEX SURVEY SERVICE 1958- 1986 OSBORN PALMER 1911 . 1970 BRADFORD 8 WEED 1885- 1972 PLOT PLAN OF LAND iX)CATFD IN 5ALEM MASS. U PL)r `rQCF G s2,�c I.ri s17 dZaO'p 31� f ZW_£9 OnO�srn .v O4.CvyUAY. a a Q U rPZJG N1.l Yet Ail-' OS/3oRl C f/7LL PleIPG- n I hereby certify to the T `ALE?•' pro- ZONE: '<� LOT AREA: /PC LOT FRONTAGE: AIOVc posed consttrrupector co ction shown e Q` nfarmz to the dimensional zoning of FRONT YARD: 16'H SIDE YARD: )O A", REAR YARD:. All/; iig&y Mass. SCALE: / ^ 411, // C-�A DATE: /lffin/r Z4 Z<.I i REFERENCE: A EK 4al PG 7y Christopher R. Mello FLS:31317 104 LOWELL STREET PEABODY,MASS.01960 (978)531-8121 � FAX:(978)531-5920 " CITY OF SALEA4 MASSAC HUSETIS BurLDM DEFARMANr 120 WA9MYG7 NS7REET,3MDFlooR 7 L(978)745-9595 KINMERLEYDRISQ7LL FAx(978)740.9846 MAYOR 71i(1 w ST.Pmw DIREcroRoFrlmIJcPjtcn Tr/BuaDjNcoD1a (sSIo1,R Construction Debris Disposa/Affidavit (required for,all demolition and renovation work) in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL 00, S 54; Building Permit g is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) s!1 ALID�CI CAJJ Q, Signature of applicant Date CITY OF SALEM ROUTING SLIP New Construction_ Certificate of Occupancy LOCATION v K, OI 113/t DATE ASSESSORS DATE 7h1W7 93 Washington St. T,24ovldE4z 7� p"stil'h'k 93 V ha�grton fit. PUBLIC VICES DATE �S 120 Washington St. WATER DATE 0 120 Washington St. ��nn CROSS CONNECTIONW�_DATE Jefferson Ave Q PLANNING —Z DATE '71V4E: 120 Washington St. CONSERVATION DATE lv 120 Washington S AbEfi,48 Lall FIRE PREVENTIO DATE l 29 Fort Avenue L"BUILDING INSPECTOR DATE 120 Washington St. FiZN5-97 Pmfessional Land Surveyors&Civil Engineers ESSEX SURVEY SERVICE 1958- 1986 OSBORN PALMER 1911 - 1970 BRADFORD 8 WEED 1885-1972 PLOT PLAN OF LAND LOCATED IN 5AZEZ0 MASS. Gl�l-fir VJZ,- F 81,aG LrA7 Lar69 ` D//0c3Eu nuzcmr. j 3 Q 1 aG� t:a a � rc 05861241 -� ///LL D/2/PZ- �I I hereby certify to the !/1ZE74 ZONE: 1<l LOT AREA: AeAL TAT FRONTAGE: 11Z0UE posed consBuilding truction sector hown conforms NT YARD: /AFT SIDE YARD: ID k> t the pro- to the dimensional zoning of FRO REAR YARD: 7iGP; �ifL��/ Naas. SCALE: /%/(w/(91 DATE; L�// Zr Zvi/J'` PFFERFNCE: MG BK Q01 PG N Christopher R. Mella FIS 31317 IN LOWELL STREET PEABODY.MASS.01960 Z (978)531-8121 FAX:(978)531-5920