37 OSBORNE HILL DR - BUILDING INSPECTION ` 3q ` kWj Sulam the 3 ! C1 I
RECEIVED
i SERVI�F
The Commonwealtl� 5��%ITasCSYS'c��iusettS�
Department of Public Safety
�,,�p,, !� , S
Massachusetts State Buildijj'&&�tl0'I-a'
Building Permit Application for any Building other than a One-or Two-Family Dwelling
:(This Section For Official Use Onl )
Building Permit Number. Date.Applied: - Building Official:
SECTION L•LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
50 lem alb
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2-PROPOSED-WORK
(� Edition pf MA State Code used If New Construction check here or check all that apply in the two rows below
Existing Building❑ fRpair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑/Ou f%
Is an Independent Structural Engineering Peer Rev w reyuired?,1 (''� Y ❑ No v
Brief Description of Proposed Work: (",M ud— Dell Sinale�IN �IYA.
SECTION 3:COMPLETE THIS SECTIONlF.:EMSTING:BUILDING UNDERGOING.RENOVATION,ADDITION,OR
cHANGE'IN:USE OR OCCUPANCY.
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 Ov R 34) ❑
Existing Use Group(s): I 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) 19,1qD
SECTIONS:USE.'GROUP;(Check as ap licable
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ All❑ A-5❑ B: Business ❑ E. Educational ❑
F; Facto F-1❑ F2❑ H: Mgh Hazard H-1❑ H-2❑ H� H-4❑ H-5❑
h Institutional 1-1❑ I-2❑ I-3❑ Ill❑ M: Mercantile❑ R: Residential R-1 R-2❑ R$❑ RA❑
S: Storage S-1❑ S-2❑ U. Utility❑ Special Use❑and please describe below:
Special Use:
SECTION'6.CONSTRUCTION TYPE:(Check as applicable)
IA IB ❑ IIA ❑ J11B0 MA ruB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7-.SITE INFORMATION:(refer:to:780 CMR 11LO for details on each item)
Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal:
Public V Check if outside Flood Zone❑ Indicate municipal a trench
ired `'`o,not be - Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required H cl trench or
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA I4istoric Commission Review Fnxess;
Not Applicable❑ Is Structure within airport approach area? Is their review comple d?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No -
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code:_�_Use Group(s): MS, Type of Construction Occupant Load per Floor.
Does the building contain an Sprinkler System?:�t�Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name nd Address, Pro Owner
NT. i�(3 ,x �18o LA MA_ 04n
Name(Print) No.and Street ] /Town Zip
Proper Owner Contact Information:T; U'C' �L ,
e -�1 9Ct 1,�1 0 @ pMe5s rA
Title Telephone No.(business) Telephone No. (cell) e-mail addresd
If applicable,the propert Towner hereby authorizes (�
, P,o. NY, q8O ��hl� MA�n p
�d
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 permit application.
SECTION 10.CONSTRUCTION CONTROL(Please-fin out Appendix 2)
building is less than 35,000 cu.ft.of enclosed s aceaud or not under Construction Control then check here O and ski Section 10.1
10.1 Registered Professional Responsible for Constructioon C—=—Olr-
TD' _I)e�al Lf21•R L - , OM
I�l�me(Regi, •ante n o Tele hone No I ma>7 s Registration Number
Street Address n Cit own State .Zip Discipline Expiration Date
10.2 General Contractor
Company Name
COQ Qn-sbbe Visor
�ame of P n Responsible for Construction rc No. and Type if Ap licable
O. oX # 780 PC o�gy4
Street Address ity/Town State Zip
-70
6,6_
Tele hone No.(business) Telephone No (cell e-mail address
SECTION iL-wORKERS'`COM .ENSATION INSURANCE-AFFIDAVIT: G.L-.c.152 25C 6
A Workers Compensation Insurance Affidavit from the MA Department 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 pernut.
Is a signed Affidavit submitted with this application? Yes O No O
SECTIONt12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ O 5-02O O Biding Permit Fee=Total Construction Cost x_(Insert here
2 Electrical $ ad, O appropriate municipal factor)_$
3.Plumbing $ v O
4.Mechanical (HVAC) $ e 6 Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Inclose check payable to
6.Total Cost $ a5"t7 O eUU I (contact municipality)and write check number here
SECTION 13:SIGNATURE:OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains 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.
1614�p 781 -724--9-ftq
Please print and i Q•H.K-1 Ti Telephone No. Date
F.
s ame p
L
Street Address CityAown State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
A CERTIFICATE OF LIABILITY+INSURANCE D/212' 14 Yp
a/2/zo14
THIS CERTIFICATE 1S ISSUED AS-A:�MATTER'�OF INFORMATION ONLY�AND CONFERS'NO RIGHTS:=UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT�AFFIRMATIVEL. 'ORrNEGATIVELY;AMEND,?EXTEND OR:ALTER:THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE-'J30E5 NOT CONSTITUTE A-CONTRACT 6ETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR`PRODUCE R�AN15414E.CEI00ICATE;_L90LDER:-
rsIMPORTANT: If the Certificateholder is an ADDITIONAL INSURED the policy(Les)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy;•certain:policies,mLiy�reguire-amentlorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such er dorsement(sj-;; _-
PRODUCER `.NAME AIDT SeTeM
66807
Eastern insurance Group LLC 'PHONE .''(5 FAX
233 West Central Street '''E-MAIL AIC (191)586-5244
-� D R -Beleernineura ea.com
DING COVERAGE NAICeNatick MA 01760 `tesuRERAP:cace Com an 1325
INSURED --.@ANSURER:B?
DiBiase Corporation, DVC Residential LLC ANsuaeRC:
Osborne Hills Realty Trust :=1nsuRERD:
P G BOX 780 [INSURERS:
Lynnfield HA, 0194.0. E.YINsURER'F:
COVERAGES CERTIFICATE NUM8ER3taeter ,-14=;1�5,'/ GL;.Only: 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 4, 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'SHOWNMAY HAVE.BEEN$EDUCED BY•PAID'CLABNS.
INSR - 7 - - - '"
LTR TYPEOF'INSURANCE - POLICY NUMBER M OCYEFF ON Y,EXP LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY P eo $ 250,000
A CLAIMS-MADE OCCUR LAO191229-17 /23/2014 /23/2015 MEDEXP Any one person $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000
X POLICY PFQ.TRO- .LOC
AUTOMOBILE LIABILITY OMBINE IN LE IMIT
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS- BODILY INJURY(Pereccitlent) $
HIRED AUTOS NON-OWNED AUTOS PRO ERTY DAMAGE
Per ecc(tlent $
$
UMBRELLA LIAa HOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMSWADE
AGGREGATE $
CEO I I RETENTIONS $
WORKERS COMPENSATION CA0286768r4:5 /23/2014 '. '/23/2015 WC STATU- OTH-
AND EMPLOYERS'LIABILITY YIN, X
ANY PROPRIETORIPARTNERIEXECUTIVE lOO 000
OFFICERIMEMSER EXCLUOED9 NIA _ E.L.EACH ACCIDENT $
(Mandatory In NH) E.L DISEASE-FA EMPLOYE $It ea,descrlbeunCar 100 000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Soo,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE$lAttsch ACORPA01;FddIU NN,I Rend,"SdN¢4nle;if mmc'spaee la requlied)
CERTIFICATE HOLDER .,;CANCELLATION
SHOULD ANYOF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem ACCORDANCE WRH THE POLICY PROVISIONS.
Salem, MA 01970
AUTHORIZED REPRESENTATIVE
John Koegel/KABS "'-- —' � ..�._
ACORD 25(2010/05) 019884010 ACORD CORPORATION. All rights reserved.
INS025 mmnnel nr Tiae A7 hnn name evil innn ero ren:alered mer4e ni Arnpn
- �i��3�01�!] bind �OpDO�J G��3�OQ��40�3a L1�C�o
Professional Land Surveyors & Civil Engineers
ESSEX SURVEY SERVICE. 1 958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD 8 WEED 1885 - 1972
PLOT PLAN OF LAND
LOCATED IN
SgCL�M MASS.
LC
70,UG 2
m
c
0
�S �c�2ti1 ///Zz
I hereby certify to the SrAL� /
r1 Building Inspector that the pro-
ZONE: 1< r LOT AREA: LOT FRONTAGE: ��� - posed construction shown conforms
to the dimensional zoning of
FRONT YARD: /51--7 SIDE YARD: !G, / REAR YARD; 30 Yr 49Zz:-GJ mass.
SCALE: 4I1
7
DATE: A &2711 L i c'JIS
REFERENCE: pl BK 4G2 PG 7l Christopher R. Mello PLS 31317
'l G;
104 LOWELL STREET
PEABODY, MASS. 01960
(978) 531-8121
FAX: (978) 531-5920
Professional Land Surveyors 8• Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD 8 WEED 1885 - 1972
PLAT PLAN OF LAND
LOCATED IN
\S�1LL M MASS.
C�
7D,UG 2
_ m
LA
c
0
�
P ,
C5 �o2ti1" l//LL VelVC
I hereby certify to the
Building Inspector that the pro-
ZONE: l LOT AREA: LOT FRONTAGE: �7�� posed construction shown conforms
// to the dimensional zoning of
FRONT YARD: 151-7 SIDE YARD: MA7 REAR YARD: 3ef-, S4LL-mil Mass.
SCALE: ` 4✓
DATE: A PiZZ G
REFERENCE: ( L BK QGZ PC 7l Christopher R. Mello PES-31317
104 LOWELL STREET
PEABODY, MASS. 01960
(978) 531-8121
FAX: (978) 531-5920
Professional Land Surveyors 8• Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1 885 - 1972
PLAT PLAN OF LAND
LOCATED IN
SILL M MASS.
m
��rSG c
ra ��
�-
ti 14, Okt1C�h6 " s
/49,4 z
(5 �o2ti1" I/iLL G7G1iV
I hereby certify to the `iAL&iE'1
Building Inspector that the pro-
ZONE: 1 LOT AREA: /<(u%' LOT FRONTAGE: ��� -'" posed construction shown conforms
to the dimensional zoning of
FRONT YARD: 151-7 SIDE YARD: /G r`'7 REAR YARD: 30Pr S9LL- Mass.
SCALE:
DATE: A P✓ L C r`Jl
REFERENCE: NL BK 4GZ PG 7�i Christopher R. Me110 PLS- 31317
104 LOWELL STREET
PEABODY, MASS. 01960
(978) 531-8121
- FAX: (978) 531-5920
�4 /o /_ 3�
- I5- -7
CITY OF SALEM
ROUTING SLIP
.New Construction
Certificate of Occupancy
LOCATION2r] DATE
ASSESSORS DATE 7' )S" '
93 Washington St.
pIT1G t k IG A ray A s au t`
n §t. na uu .�. s...� - ,y�• a:;i4
PUBLIC SERVICES DATE
120 Washington St. r
WATER DATE
120 Washington St.
CROSS CONNECTION DATE N (✓v
5 Jefferson Ave
PLANNING DATE 1
120 Washington St.
CONSERVATION � 77 c0�
120 Washington St.
FIRE PREVENTION -DATE ��rfif
29 Fort Avenue
M E�sLT�H 3,x4�ca#i1F� A E { '
20 Rai I igton�St
BUILDING INSPECTOR DATE
120 Washington St.
I�
77
4.
- Pro`essional Land Surveyors B Civil Engineers"
ESSEX SURVEY SERVICE; 1958 -.1988
OSBORN PALMER 191't - 1970
BRADFORD R WEED . 1885 - 1972 "
PLOT PLAN OF LAND
LOCATED IN
`TA/,QF-/t? MASS.
LC
A -
7U.UG 2
L�rSG c
0
`vlq Okturh� �' s
/49,�z'
6
,/! GJGlitlr .S�o2ti2 / LL
L�Z sT�vC
I" hereby cert fY'to the z6w
n Building Inspector that the "pro
ZONE: is LOT AREA: &1)S LOT FRONTAGE: Idz posed construction. shown conforms
to the.' dimensional zoning of
FRONT YARD:. /5r-1 SIDE YARD: • `ij Al REAR YARD: 3Ofc, SALL�R Mass.,
SCALE:
DATE: .A Pp,/L z 0
J K. �
REFERENCE: pG BK qGZ PG 7�/ Christopher R Mello .No 3133f 31d
104 LOWELL STREET -�
PEABODY, MASS. 01960
'`5 SU11'1'.
(978) 531-8121 -
FAX;(978) 531-6920