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34 OSBORNE HILL DR - BUILDING INSPECTION
34 C)Sbafa ML;rr re- Model clG 3 t ct z. 1750 The Commonwealth of Massachusett$UEIVED k It Departarentof Public Safety INSPECTIO�!E,I_ SERVICES Massachusetts State Building Code(780 CMR) O Building Permit Application for any Building other than a Oneff, = F 'ly w llin 0 - SeqtfonFor`OfticialUseOn1 )• Building Permit Number. paiia,App I.Building Official: SECTION 1:LOCATION(Please indicaWAIogk#andUdu for locations for which a street address is not available) OSbof eAN ak *&(, Saten Mot e) No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2c-PROPOSEuwo Edition of MA State Code used_ If New Construction check here Vfor check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or constructiondocuments-being supplied as part of this permit application? Yes No ❑ T Is an Independent Structural Engineering Peel Res�'�,ew r��#uired'� Yeg ❑ No 4( Brief Description of Proposed Work: isi-fu('1" 1�lClr) JIP'1fA'P IIV -I)WA�iflQ SECTION 3:COMPLETE THIS-SECTION IF:EMSTING BUII.DIIVG•UNDERGOING RENOVATION,ADDITION,OR CHANGEEV,USE.OR OCCUPANCY Check here if an Existing.:Building lnyestigandn;and:Evalualion is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): - Proposed Use Group(s): SECTION 4:BUILDING:TMGT3T AND:AREA Existing Pro ed No.of Floors/Stories(include basement-levels)&Area Per Floor(sq.ft) ' S5 Total Area(sq.ft.)and Total Height(ft) +— ( q 5 SECTION°5:USE'GROUP(Checkas:applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A4 0 A-4'0 A-5❑ B: Business ❑ F Educational ❑ F: Factory F-1❑ F2❑ I I-E lli - '.Hazard H-1❑ H-2❑ H-3 H-4❑ H-5❑ 1: Institutional I-1❑ I-2❑ I-3:13 1-4❑ A-::Mercantile❑ R Residential R-1 R ❑R-2❑ -3 R4❑ S: Storage S-1❑ S-2❑ U. 'Utility O Special Use❑and please describe below: Special Use: . - SECTION 6:CONSTRUCTION TYPE.(Check as applicable) IA Ill ❑ IIA ❑ H`BO MA ❑ IIIB ❑ IV ❑ 1 VA VB ❑ SECTION 7:SITE, (refer to 780 CMR 111.0'for details on each item) Water Sup Flood Zone Information: Sewage Disposal• Trench Permit-. Debris Removal: Public Check if outside Flood Zone 0 Indicate municipal A trench not be. Licensed Disposal Sire Private❑ or indentify Zone: or on site system❑ required or trench or permit is enclosed❑ Railroad right-of-way.- 'Hazards'to Air Navigation: MA Historic Commission Review P ewes 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 OFCERTIFICATE'OF OCCUPANCY Edition of Code: _Use Group(s): :EJ45, Type of Construction:Kfts. Occupant Load per Floor: Does the building contain an Sprinkler System?:--hkQ—Special Stipulations: SECTION 9: PROPERTYOINNER AUWORIZATION Name nd Address , rope Owner -# T_ P j g80 LinnPunk , MA oain tl Name(Print) No.and Street C /Town Zip PropeM Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) I e-mail addre If applicable,the proper owner hereby authorizes Poo r q8O - 2AML 019H4 .Name Street Address ty/Town State Zip to act on the property owner's behalf,in all'-matters;relative to work authorized;b .this building permit application. SECTION 10 CONSTRUOUOMCON TROT:(Pleasefrll out Appendix 2) b ding is less than 35,000 ca:R ofenclosed ace aril/,ornot under.Construction Control:theucheck here❑and skip,Section 10.1 10.1 Re 'stered'�Professional Res onsibl6 for Consti ctton`_.CoritroL' Xe a ant # 9�QQ o Tele hone No 'mail a Re tration Number Street Address own State Zip Discipline Expiration Date 10.2 Ggneral Contractor Coin any Name ^ T 11 MLN1y;-f C 2'714 '7 Cons v soC ,Name of Pe n Responsible for'Construction' rc No. and Type if Applicable Street Address Town State Zip 81_-�'�}_cBq �-�414 .7oap ��n G�� i - Se, omes. ,Din Tele hone No.- i sines Tel hone Noz.cell t e-mail address KE SECTION'11:-WORRS"'-cO ENENS' TIONImmA CE'AFFIDAvIT? G:L c.-152§25C6 A Workers'Compensation-liisurance:Affld avi't'from the IvIA`Departm'eirt-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 submitted with,#his a lication? Yes 13 No O SECTION 12' O $MUCTIp1 I COSTS'AND:PERMIT FEE Item Estimated-Costs (Labor - and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ O5- 60 O Building Permit Fee=Total Construction Cost x (Insert here 2 Electrical $ o o O appropriate municipal factor)_$ 3.Plumbing - $ a o 0 4.Mechanical (I-VAC) $ o j) Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost - $ 25 C2 O o I O (contact municipality)and write check number here SEC 1ON,U;_SIGPiAT[TRBO&BUII.DING:PERNITAPPMCANT By entering my name below,I.hereby attest,under the:panu-and,penalties of.perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding.9Q 1 �q T�11� /-7&� Please print ame n — - o.H.R:r Ti Tele hone No. Date P am. CX,X 780 L A —P QI LI+l�1 Street Address Ci own State Zip �7 Municipal Inspector to fill out this section upon_application.approval: Name Date AC ® DA7E(MMIODMM7 -lib CERTIFICATE OF LIABILITY- INSURANCE 4/2/2014 THIS CERTIFICATE IS-ISSUED'AS-A';MATTER OF,'INFORMATIONONLYAND CONFERS"NO-,RIGHTS:UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES s NOT AFFIRMATIVELY OR�NEGATP/ELY AMEND=-EXTEND OR.ALTER'THE'COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF,INSURANCE DOES NOT`CONSTITUTEIA^CONTRACT-BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE-OR PRODUCER=AND THErCERTIFICATE-HOLD"' IMPORTANT: If the certificate holder is an�ADDITIONAL INSURED the.policy(fes)must be:endorsed. If SUBROGATION IS WAIVED, Subject to the terms and conditions ofthe policycertain'policfes�roay.reguirean enAorsemontAstatement on this certificate does not confer rights to the v certificate holder in lieuof such endorsement(s).:-,- PRODUCER 'CO3 'CAME; Select Dept eXt 66807 Eastern insurance Group LLC PHONe - .;(.SOB),GS1-7700 FAX iT81)se6-azgq 233 West Central Street ti Re C Nss.selectwork@easterninsurance.com INSURERS`AFFORDING COVERAGE NAICA Natick MA 01760 "INSURERAACadia Insurance Com aiL 1325 INSURED 'INSURER:B': DiSiase Corporation, DVC Residential LLC �4NS.URERC: Osborne Hills Realty Trust sIN8U2erto: P O BOX 780 )INSURER-.E: Lynn£ield MA. 01940. .INsertERF COVERAGES CERTIFICATE.NUMBER36aetar`14-15 -/,GL-:Only RVASION'NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE.LISTEDSBELOW'HAVE'SEEN'ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANYREOUIREMENT TERM OR:CONDITION OE ANY CONTRACT OR BOTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY;_PERTAIN,THE;IN$URANCE AFFORDED%BY.THE.'POLICIES.DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS-SHOWN MA(,HAVEiBEEN:REDUCEO.6Y PAID CLAIMS. MSR LTR TYPE OFINSBRANCE POCICYNUMBER+ : `"M UDYEFF 'MM 1: EXP LIMITS_ GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY ER PR S Eoccuam $ 255,000 A CLAIMS-MADE ❑X OCCUR ' LA0191229-17 /23/2014 /23/2015 MED EXP Anyone person) g 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG E 1,000,000 X POLICY PRa LOC $ ;DED BILE LIABILITY OMBINED SINGLE IMIT Ee a cidem AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED OS AUTOS BODILY INJURY(Per amiden0 $ D AUTOS AUS NON-OWNED PPRO EeremIRd n DAMAGE $ AUTOS $ RELLA LIAS OCCUR EACH OCCURRENCE $ SS LIgB CLAIMS-MADE AGGREGATE $ RETENTION$ WORXER1 COMPENSATION 0286798-1'S ' /23/2014' /23/2015 WC STATU- OTH- $ AND EMPLOYERB`LIASTUTY YIN. X ANY PROPRIETORMARTNERJEXECUTNE $ iOO OOO OFFICERNEMBER EXCLUDED? NIA E.L.EACH ACCIDENT (Mandatory In Ord E.L.DISEASE- 1 OO 000 II as describe ontler EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Soo 000 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES(Attach ACORD.ID1;AddltlpnAi RemarAs.Schedt le;If more'areoe 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 John Koegel/KABl ACORD 25(2010109) ©1988=20t0 ACORD CORPORATION. All rights reserved. INS025 ruin m The anno 1 Ka Innn nro mnielernd moelre of 6Crlpn F/2795- 86 Professional Land Surveyors & Civil Engineers �S ESSEX SURVEY SERVICE. 1958 - 1986 OSBORN PALMER 1911 - 1970 BRADFORD 8 WEED 1885 - 1972 PLOT PLAN OF LAND LOCATED IN S�L�r1 MASS. aP� sD��r F 3�f !or 86 2017 IV Pl UY0 SED � , c Otu&'[LiAi6 P /L l� 3760 C1S1302at AZZ- VyJjVL CLLSl�R I hereby certify to the S/ILL-W �I q Building Inspector that the pro- ZONE: LOT AREA: LOT FRONTAGE: AVAIL posed construction shown conforms FRONT YARD: �S 0 SIDE YARD: IO� REAR YARD: 3,9 to the dimensional zoning of 5.9LL'-/r Mass. SCALE: /`An '!"1f11 DATE: aj Ill REFERENCE: UAL BK Q(jl PG 74 Christopher R. Me110 _. MK 104 LOWELL STREET PEABODY, MASS. 01960 (978) 531.8121 FAX! 1978) 531-5920 OF CITY OF SALEM ROUTING SLIP .New Construction Certificate of Occupancy `04- W 1;Co LOCATION39 O5bone- 4'11 DtYC DATE ASSESSORSA�m DATE 7' 1 S !S 93 Washington St. �Aik q PUBLIC SERVICES ,VW- DATE 120 Washington St. ,c WATER ) DATE w t� 120 Washington St. / CROSS CONNECTION _DATE 5 Jefferson Ave PLANNING DATE S 120 Washington St. CONSERVATION DATE d� 120 Washington St. IT c'�'� //�� FIRE PREVENTIO�T�e. ,,.,Q.DATE 7,�isIIr 29 Fort Avenue H'E I' I�x`i Fl ZO V1riigton Sf BUILDING INSPECTOR �i/% ATE 120 Washington St.