32 OSBORNE HILL DR - BUILDING INSPECTION (2) t.� 9`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
(This Seelion:For Officiafuse only)'
Building Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate'Bloek#'and LbLA for locations for which a street address is not available)
1 �« �Xl l\ '�f: tol-�k 81'► � rn� of y'7D
No.and Street City/Town Zip Code Name of Buildig(if apAcable)
SECTiON2•=PROPOSED WORK
t Edition of MA State Code used_ If New Construction check here or check all that apply etthe tw�s below
Existing Building O Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit)qWendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: �'o
l— Are building plans and/or construction documents being supplied as part of this permit application? Yes No;❑/ON Ftl
I` Is an Independent Structural Engineering Peer'Review re�qu�v� ed?``�,, ('') iI 1�Y�y�7y ty�pJ
Brief Description of Proposed Work: �jQa5hcucJ-- tAeAlt) Isin lFl �ilYtdq IJiJP1�1C1Q n n
SECTION 3:COMPLETE THISSECTIONIF'EXISTING:BUIIAING UNDERGOING RENOVATION,ADDITION,OR
CHANGE 414,USE,O W OCCUPANCY
Check here if an•Existing Building Investigation:and IEvaluation 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) 1'vo
SECTION-5:USE GROUP:(Ct;Tkas:applicable)
A: Assembly A-1❑ A-20 Nightclub ❑ A,.,'� ❑ A-40 A-5❑ B. Business ❑ E: Educational ❑
F. Facto F-1 ❑ F2❑ 1=-H:'Hi `Hazard H-1❑ 11
-2❑. H-3 H- ❑ H-5❑4omI: Institutional I-1 ❑ I-2❑ I3❑ I-4❑ M ❑ R-4❑
S: Storage S-1❑ S-2❑ Lk?Utility❑ Special Use❑and please describe below:
Special Use: .
SECTION&CONSTRUCTION TYPE(Check as applicable)
IA M ❑ I1A ❑ HB0 IIIA ❑ = ❑ I IV ❑ VA ❑ VB ❑
SECHON 7:STTE:INFORM 1TION:_(n!fer to 780.:CMR UI.Ofm details on each item)
Trench Permit. Debris Removal:
Water Suppl Flood Zone Information: Sewage Disposal• -
Public Check if outside•Flood Zone'❑ Indicate municipal A trench not be. Licensed Disposal Sire
required or trench or F.
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA 1-listoric Commission Rev icw P v•s
Not Applicable❑. Is Structure within airport approach area? Is their review comd?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ Nov -
SECTION&:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code:_LL—Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?:, Special Stipulations: __
SECTION! PROPERTY OWNER AUTHORIZATION
Name nd Address pe Owner �#
9sz��eTx q80 Lin 14` MR Oftfn
Name(Print) No.and Street C /Town Zip
PropertyOwner Contact Information
Bl 3%9i se_ 7M31- i�$9� Z81 z, mPS C r1�
Title Telephone No.(business) Telephone No. (cell) e-mail addre
If ap licable,the propert owner hereby authorizes
, Rb, PAX 98O flA O
. Name Street Address ty/Town State Zip
to act on the property owner's behalf,in all matters relative.to-work authorized-by this building rmit application.
SECTION AD;CONSTRUCTION CuONTROL':(Rleasef`il]Qom Appendix 2)
hWding is less than 35,000cu_ff.of enclosed s ace`and,or;not:under`Construction Control then check here 0 and ski Section 10.1
10.1 Re 'stered=Professiortab-Res onaible'for C'ottstiichoa>Cont`ol'.
yame(Re ' ant) t
# ^0 Tele hone No '�maila a Registration Number
Street Address n �G't o State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
B UI CS 2'71149
�Name of Pe n Responsible for Construction' r No. and Type if Applicable
®. .��c # 780 Mh Q19yo
Street Address^ 'ty/Town n State Zip
Tel e hone No. usiness Tel hone No: cell 1 e-mail address
SECTION.lif WORKERS CONTENSATIONl NCE'AFF1D E Gi1-c:152§25C 6
A Workers'Compensation insuiance.Affidavit fxgi<t tlie'Mr1 peparlment of Industrial Accidents must be completed and
submitted with this application. Failure to'provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit subnutted with this[a . lication? Yes❑ No 0
SECITONi2.CO1VS tRLICTIOIV COSTS'AND PERMIT FEE
Item Estimated-Costs:(Labor . .
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ O S O O Building permit Fee=Total Construction Cost x_(Insert here
2 Electrical $ s o o U appropriate municipal factor)_$
3.Plumbing $ I d O
4.Mechanical (HVAC) $ oo D Note:Minimum fee fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ SO D a(� (contact municipality)and write check number here
SECTION 13;-SIGPTATURE lv au :Dwc PERmcr APPI:ICANT
By entering my name below,I.hereby attest.under"the pains:and`IxIties of perjury that all of the information contained in this
application is true and accurate to the--'bestofmy'knowledge-and understanding.
Tr)ls78_ll �
Please print and sigrllt�me ��X�o^ Q.H.R.�. t Ti - _ _Teleep-hone No. Dale
Street Address 'IU C7C J Ci y own Y1SStaattee Zip
- /
Municipal Inspector to fill out this section upon,application approval: _
Name Date
1ACC>iJCERTIFICATE L, ,IAB,.ILITl( INSURANCE DA�IMM/DD YWV)
4=212014
THIS CERTIFICATE iS-ISSUED AS A MATTER'OF,INFORMATION ONLYi-ANOCONFERS'NO:RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR.NEGATR/ELY AMEND;:EXTEND OR-'ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE�DOES NOT,CONSTITUTE'IA;'.CONTRACT'BETINEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR-PRODUCER,-AND-THECERTIFICATE HOLDER.-
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED the!policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the Policy,eertaimpolioies maytrepulre•an:epilorsoment'A statement on this certificate does not confer rights to the
certificate holder in lieu of'such endoreement(sj.,r<
PRODUCER NAMEACT Select Dept: axt 66807
Eastern Insurance Group LLC PNDNe
. "(508)651-7700 FAX
.(781)586-8244
233 West Central Street 'EppRIE s,selectmoikAll
@easterninsurance.com
INSURER S'AFPORDING COVERAGE NAIL e
Natick MA 01750 _ -]NSURERA�iACadla Insurance Com an 132$
INSURED
:INSURER"B:
DiBiase Corporation, Di Residential LLC wsulll C,
Osborne Hills Realty Trust ;4INISURERD:
P 0 Box 780
Lynnfield MA, 0194D INSURERPe
COVERAGES CERTIFICATE;NUMBER3taster,. 14 15 ./ GL,.Only- REVISIORNUMBER:
THIS IS 70 CERTIFY THAT THE POLICIES OF LISTED
BELOWHAVE BEEN)ISSUED TO THE:INSI1 1, NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT,;TERM ORiCONDIT10NtiOF,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 SUCWPOLICIES',LIMITS SHOWN''-IMAY HAVE BEEN REDUCEO'BY.pAID-CUWIMS.
NSR
LTR TYPE OFINSURANCE - `POLICY'NUMBERr MOLOYEFF• 'POLI EXP LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 11000,000
TC0MMER,CI,AL GENE5 ' ocean ea $ 253,000
ACLAMADE a OCCUR ' I:A0191229-17 /23/2014 /23/2015 MEO EXP(Any Ona Ron) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
Gi AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPAJP AGG $ 1,000,000
X POLICY PRO- LOG $
AUTO MOBILE LIABILITY 0 RINED INGLE MIT
EA ac itle I
ANY AUTO BODILY INJURY(Per Person) $
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per emitlent) $
NON-OWNED
HIRED AUTO$ AUTOS PROPERTY DAMAGE
Per emltla nl 8
UMBRELLA LIAB OCCURId EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE
AGGREGATE $
DEL) I RETENTION
WORKERS COMPENSATION $
-0286788-f5 /23/2014 /23/2015 WC STATU- OTH-
ANDEMPLOYERS'LIABILnY YIN.. X
ANY PROPRIETORMARTNERIEXECUTNE J
300 000
(M
OPP ERNEMBER EXCLUDED? NIA E.L.FACH ACCIDENT S
e do In NH) EA EMPLOYE S 100 000
If yess tlasgibe, antler E.L.DISEASE-
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS IV EHICLES IAttaeFACORD.t01,:A4tlNIonal,RemarNs"Senetlule1 Nmoie apace Is repulreEl
CERTIFICATE HOLDER - -;CANCELLATIONS
SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
'THE EXPIRATJ DATE..THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem ACCORDANCE iAM THE POLICY PROVISIONS.
Salem, MA 01970
AUTHORREuREPRESENTATNE
John Koe"l/AABl
ACORD 25(2010105) 01988-2070ACORD CORPORATION. Al rights reserved.INS025 mm�nslm Th.April mm>and Inns>m ronlatemd ma�4a n4 ACf1Rn '
Professional Land Surveyors 8- Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD 8 WEED 1885 - 1972
PLOT PLAN OF LAND
LOCATED IN
5 Z,�51yf MASS.
�ZOG
�OT 8 9
y
�Zov �sr
0
�,,, ` .
LT .a Liz 47
tnRon�ft d
D&r11J/•� ti
u:l
�Z.UG
OS�l�27v H/L L UrZ/ (/L
I hereby certify to the hALt/�1
Building Inspector that the pro-
ZONE: f LOT AREA: CVY LOT FRONTAGE: kotzz posed construction shown conforms
to the dimensional zoning of
FRONT YARD: l5r-, SIDE YARD: _ IGry REAR YARD: 3vF mass. .
SCALE:
DATE: °/Z/L / ZG%c
REFERENCE: PL BK 4oZ PG 7C; Chr#Ttopher R. -Melloi PliSi'31317"
104 LOWELL STREET
PEABODY, MASS. 01960
(978) 531-8121
FAX:(978) 531-5920
aQ7Y OF SALEA MASSACHL SEM
BLUIDMDEPAR7MENr
120 WASIMSCTON STRUT,3xD TWOR
7kL(978)745-9595
KRaERLEYDRISOOLL FAX(978)740-9846
MAYOR TrIOMAS ST.PIERRE
DIRECTOR OF PUBLTCPROPER7Y/BumD M comassIONER
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 c40, S 54; Building Permit f/ 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, 5150A.
The debris will be transported by:
Nd M ►si dP
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
—T�J
Date
!r� 3 7
CITY OF SALEM
ROUTING SLIP
.New Construction
Certificate of Occupancy
Lo+ 4-9 7 *�
LOCATION ,�0*at� 4A I tVe- DATE
ASSESSORS �'K DATE )'S�
93 Washington St. tvu sue.
+
9 RAi,rfgi�on t`.
PUBLIC SERVICES DATE
120 Washington St.
WATER DATE
120 Washington St.
CROSS CONNECTION �'Fst^ DATE �� (r t �� S"h«
5 Jefferson Ave �q Q p
PLANNING L/✓ DATE 0
120 Washington St.
CONSERVATION TE l c
120 Washington St.
l
FIRE PREVENTION P& DATE 1
29 Fort Avenue
sh�
Y�i'ig of n Sf'„ ' ',�"'�'�. •.�.,'.
BUILDING INSPECTOR DATE
120 Washington St.
x
i "
Professional-Land Surveyors 8 Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSESORN'PALN1fR 1911 - 1970
BRADFORD_&.WEED 1885 - 1972
PLOT PLAN OF-LAND
LOCATED IN.
SALCM MASS.
`�200
far g 9
o
k6P"fe0
Dist11�/.6 �y
L -
DS(�r2�c ///z Doi UL-
(L LS f C(2 I hereby certify to, the SELL-"M
fn7 , Building Inspector that the:.pro-
ZONE: K 1 LOT AREA: AfAC CLOT FRONTAGE: kobg posed construction shown conforms
FRONT YARD: ��(Lr SIDE YARD: _ /G� REAR YARD: 'jOp" to the dimensional. zoning of
S1 A/ Mass..
n
SCALE
DATE: s�l1/L / ZGI6 yx�ar ,t, HER G
REFERENCE: PL BK 9OZ PG 7,1 Chr4glfopher R.
orsT,4 `
F
104 LOWELL STREET -
PEABODY, MASS. 01960
(978) 531-8121
FAX: (978) 531-5920