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8 OSBORNE ST - BUILDING INSPECTION (3) r _ Zoz �% �, � �.�o �' .,� T6e Comi onwealth of Massacl�usetts ,: r°e i�s Board of Buildi��g,Regidations and Stvidards CITY oP I �\�Jy� h4assachusetts StAte Ruilcliii�Code,780 C1�4R SALEM ,.;: •;��.�; Rerised eNor 70/[ -- Siiilding Peilnit Ap�lication To Consf29ict,Repair,,Renovate Or Demolisli a Orre-or T�ro-Fmuily Ihrelli�lg � � - � �� � � � Tltis Section For Official Use Only � � � Buildine Peiniit ri�iwiber. � � Date Applied: � � . � � � Budcfine Officiai(Print Namc) . .— -- Siguahve . � � � ����al�-- �I � ' � SECTfON 1:Sl"fF.INFORVIATIU\ � - � � � 1.1 P�n erty Address� 1_2 Assescnrs Mnp&parcel\'umbers i�h��e� z7 �3rd� l.la ls tl�is az�accepted sh'eet?yes^ uo Map�umbn� Pnrcel Nmuber � 1.3 Zoui�Infoemallou: 1.4 PropeA�h_-ryDimensiovs: I �— `t� a� 7_oning Distnct Pro�sed Use Lot Area(eq h) LroNa_e($j 1.5 Bnildiug Sefbacks(ft) irnnt Yard Side Yards Rcar Yatd Required Provided Required Prot'ided Reqiured Prot'ided 1.6 Wfltet�Sappl�:(D1.G.L c.40,§54) i.� FIoQd�one Informntion: 1.8 Sen•n�e Disposnl System: I ���,� Zene: � Outside Flood 7_oue^ � Prn�ate❑ n4iwcipnl On site disposal system ❑ � C�ItC�]f VifiO . . �$ECTION 2e�PROPERl'Y 0�4'\�ERSHIP� � � 21 O�cnet} f R co•d•_ � sco�►--� (��/��ie r �l�lP�d�.r (�v�.e S'a.P�vn , M� O 1�D7 Name(Avit) �^ City,Stetc,ZIP �_OSho�- c�-. (�1 2�0- 2`�`f i.,�bv @C�s e�u jRv� , No.aud Street Telephoiie inail Ad��ess � SECIION 3:DESCItIPTION DF PROPOSED WORK''(eheck all thatappl��) NeN�Constnution❑ Exisline Building❑ Owner-Ocwpicd ❑ Repairs(s) ❑ Alterztion(s) Addition �I Demolirion ❑ t\ccessory Rlde.❑ Number�of�ti7n�—its ' Other 0 Specify: Arie([yDesu'iplionofProposedWo�r�k�:�—��i(y�p�y.pX Lo.R�n��}{,�� � Y1Rl.(L � -'-l�O0 tr1���-Oa f'-�x`e�r---ev_v_a�(-e �5�-----5,1 -----—-- �� � �- SECII01 4:�ESTII'I�1'IED CONSTRUCI70�COSTS � �� . - Item FsY,im�reJ Costs : pfflcia►Use Onl�� (Labor aiid Matetlals) � 1.Building S (�' ��� l. Buildine PcnnifGee $ - � �� .Indtcatc how fee is deternuned:. 2.!_ledrical S ❑Stfu�dard City�To}vu Applicatiou Fee � �a ❑Total Peojec[Cost3(Ifem 6}x mul�iplie� x 3.Phunbing S ?j �g QD o. Other Fees: $ : �. � � 4.Meclianical (HVAC) $ I List � � - 5.btechuiical (Fu�e � . . �. Su ression) 5 � Total Al]Fees:S -.�. � .. Check�o.� CheckAmounT.�� CashAmomit:_;�I 6.Total P�'Oject CosC S 2� (� Q� O Paid in Fu(l �� ❑Outstandin2 Bala��cz Due: � �(ic�c,�... J� �'U �'�-�lc'= �v L ` sECTYoNs: co�s•reocT[o�'stxv[cEs 5.1. .�onshiiccion ape�vism•].i .ense(CSL) CS-„`�}p�•2�0 �5 ��� � „ � (TIlL7-i License\wnber L•xpiranonDate N�ne of CSL���IIIppqIder � ,/,2 ��� rT rj List CSL Type(see belo«) (� No.aud Str5etr /' �3 t� . - Descriytion �. . M��,,L,I���� ��r-J �� O I Q�e — Unreshicted(Buildmgs u to 35.000 cu.fl. ��� %,��,r��=/ �—��' Restnctedlfi_'Famil D�i�elhne CiTylIon�n.State,Z[P �4 Masanry RC ReoCv�e Covavig 7�r A'S l��iudow•audSiciii� � SF Solid Fuel Bnruino p,pp�auccs 6 9 m 5'f �Ccc,fQ�ca Cm �vm < <„���ia,�o„ - Tdc�Lone Email address D Demolition �.�re ome I�upro �eme t Coulc�c[or(HIC) � � C'D 12�� �il�o �s I HIG egistration\vmber Expiraqrn�I)aCc ��ompp}�7�'ame o � , e2istr Na�vd � � ,/ � C�,� � �qev�Sr _ tir 2 �Sl a z�/1�'� �u�,�lp/: __ N 1/il. Q� l /n� /p�_ .-i/'19 Email nddress �K�Gtw /,•l r`r �.d- ��trr�-J-r�1 City/To��n.State,ZIP Telephone �, SECTION G:WORK"ERS'GOMPENSATION L�'StiRA\�CE.AFEIDAVIT(_VI.G.L.c.152.§ 2gC(6)) I Workers Compensation Insm�u�ce affidacit nmst be completed and suUnilried tiith tlds Tpplication. Faiture ro pro4�ide I tlus affidavit�eill result vi ilie deuial of tliz Issuanc f tlie bvild'vie pemiit. ! Si�ned Affida��it Attaclied^ Yes .......... No...,,,....,❑ _.�_ _ _ � ��. . �� .-� �SECIlOV�7a:OWIVER�AUTHORI2:ATI0\�TO-BE�C0�3PLETED WHEP' � � � - ���� � OW'NER'S�AGE�'POR�COI�TRAC APPLIES ORBUII.DL�GPERVIIT I.as O��mer of Hie suUject propeny,hereby auH3orize �(�-� to act.on m��behalf. in all m Iters relative to Hrork aullwrized by thfs buitdiii� er��it application. 1�2na.� �:�rGQ ��/��j �f 301�'� Print O��n �'s Nam ' tun�oiuc Signnmrc Datc � � � SECTION�76;��0�'VI�ER��ORAL:THORIZED�AGENTDECLAR4TION 13y emering my name below,I hereby a est w er tlae p�iau and penalties of perjury IhAt all of Ihe information co/�med in tlii applicatioi�is ve an accura �a to 1 est iny latowledge and utidersta�id'u�e. I"�Q !��//�-- Aiut Onmer's or And xi ed Ae<nTs N ne(Elcetroi 'i u � Dnre . �. .. �� . , OTES: . � . . . . 1.. An Owner wl��obtains z buildiun pennit co do liie/l�er o�i'n�vork,or an owner U�ho 6ires an�mregistewd contracror (not regis�cred in the Fiome lmprovement Cnntractor(}IIC)Prograui)>w211�ro[have acccss to�he arbi�ration proeram or euaranty fi�nd undar M.G,L.c. 142A-Otlier impo�]ant inCmzneGon on the I-ItC Proeram can be{outtd at www.mass. ov/oca Lxfonn�tiort o��t6e Co�istmction Supeivisor License can be fo�md at www.mass. oR v/dqs 2. When substantial work is planued,providz the infarmation bclow': lbtal Aoor arca(sq. ft.)_ fiududing earagc,fnished basetucnt�atficx,decl�s oi'po7ch) Gross li��ine arca(sq.ft.) Habitable room count � __ \'umber oE lireplaces Number of bedrooms Number oEbathrooms Number of half/baths Type oFhealing system \untbcr of decks/porches Type of cooling cystem Enclosed (fien 3. "Total Project Sqiiare Footage"may be substih�ted for"'CofaL Project Coaf ,< CIT'Y OF S.1.I..E�i, l�'L'�SS.'�CHUSETTS BI:ILD4�IG DEP�R7?1�..`T , ` �i��• � 1�O W.j3H4�IGTON STREET,3'�F1.00R TEL (978) 7�5-9595 F.�c(978) 740-98�16 (V�{g�.EY DRISCOIl. ;�UYOR THoaus ST.P�as DIREC'COA OF PtiSLIC PAOPER7Y/BL'II.DL�JG CO�L�(iSS[ONER Workers' Compensation Insurance Aftidavit: Quilders/Contraciors/Electricixns/Plum6ers :1 i licant Information Plcase Print Le �bt V�i1101UusincsvOrganizatiaNlndividuaq: � 0 Address: �� �� � C� 2 Cify/Statc/Zip: /'blef�__�__�''�A- °f�'� �`��: `?81-G�9C��5'-Fv� Are y an employer?Check fhe appropda[e box: Type uP project(nyuired): L � I am�emptoyer wieh ��' 4. Q I em a�mRal contrdetor and 1 6. Q Ne ionawcdon employees(full andlor part-ume}.� have hircS the sub-contracmrs 2.Q I am o wle pmprietor or p:utner- lis�ed on the attached shecc� �� amodeling SI�Ip JIItI IIJVC IlU CIfIPIO�/CCs These sub-cOntrOctors have $. �Demulition working for mc in any capaciry, workers'comp.insurance. q, �puilding Uddition (No workers'cmnp. insurance 5. [] We are a corpotation and irs rcquimd.] oKeers have exerciud their ���0 tilec�ricai repairs or additions 3.� I am a homcowner doing all work right of exemption per MGL 11.[] Plumbing repairs or aclditions myulf.[\o workera' comp, c. 152, §I(4),and we have no �Z,� aaof mpairs insurancNreyuired�t tmployeos. �Tdoworkers' l3.QOUut camQ.inxurance mquired.J Mny opplic:uit iha[�fceka box al muct alw 6i1 w�the seaion below shoreing their wmke�a'wmpenaariun policY informuion. �I h+mcuw�nae whu submit tAis affidavi�i�dicazing they a�c doiny alt wmk and�hrn hirc otnside cnmracio�s mwt submit a xv afflJavil indieting wel� =C.�mr.r•�on�M�cMck ihis Wtt munt onxhed an aJdi�iwul nha�aAuwiny iM:namr o(IM aub�cumracbra and theit wuhera'comp,poliry infotinatien, /am an ewpioyer fhaf u yrovirIInR xrorkers'compensarioa insurance jnr my emptuyees. Eelyw is the potfey ond Jab stta injormu�inm _��_ � __�c3�L � i Insurance Company Vame: f✓� ✓/5!/�(211 y((��, , �;_ry�yj�� Palicy N or Self-ins.Lic.p: �C �� L'Z� L� Eacpiration Date: ��. �� � lob Site AdJr�cs: �O OS�O✓)'�Q. (7�� CirylStam2ip:JC�%P�1'l ,� '7/T G�{� ,\ttach a copy oP lhe Morkera'compensatioo poliay declaratlon pn{,re(ahowin�the pollcy number and etpirntloe date). Faifure io x:cum mvemge as required under Saciion 25A of JQGL e. I 52 can lead to the imposition of criminaf penaltiea of a finc up to SI.S00.00 anNor ont-year imprisonmen4 us weI!;�civi!penulties in thc torm uCu STOp W 02K OItDER unQ a fine of up ia S250A0 a day a�• 'nst tha violamt. 11e advi+ed that o copy u(this statement muy!xx furwurdcd io Ihe 017ice of 1m�estigaiiu�Gi nl'Ihe D A f insuranee cov•r�ge veriticutian. /do/rcrcby rc +rQcr d p .r un e ul�les perJu thal the lujormydan provided ubwr is Irue und corrret "mature- �r I)ate: t/lv l �"T— c Phun �: '� O�cia!uxe m+ly. Du�mt write in 1Gis urru,m ba eu�eplrted by city w�awn i�J]iciuf CiYy or 7'uwn: __ Permidl.ttense# [ssuing Awhurily(circic oncJ• ^~ � I.ISua�d of Ilealih 2. 9uildtng Depvrtmcnt 3.City/(nwn Cierk a. Elertrical Lispector 5.Plumbing 6iapectur b.O�her Cunlect Pcrson: ._ P�one#: d . . . . .w_ . . . . _ . ___"_____— I �` ' ! ��� 3�" � r'{�i 0"- 23" � - r �74 -- - . 9 I � 11 � ' 322" � 0" , � � ; 33" 1 .� 0�� � 23„ 2�„ � ' 644„ 284, ; � „ 28 , � 5�� j . 7" 3 " 11 " � � 11 " 14" 33" �=�--�-j- �:� � + �. -� a ,: � - �" .�Ga.,z �' � ' '�`-] � \ � � - / �_ - ` ( ' - N i , .\\ � / � e.,cr::� � t A..: ish � q. A :3 �T \ . .; _ . .,�. .�� t�a� i� � �'�,\ F 30 W3330 pW3�Q424L � i i _-p `- ��. W331524 F . _ W � ; W � _ :,.� TEP2 , 41/�/D�S - � � � w .Ga � �w x = W � V.��,' ,'�' 1� A � I . .O I —�' � � -� _ ^' � _ - _ I �L� M j � W ,�''s� �I� (j7 �j � �.j _ = — � � � `Y,� - W � I � -I : o .� � o w � .'' = ,iw � e - _ �, -T, .' " . � s . m w � . . ;. � � BT R 3DB30 30 ;RANG 3`s BG48L �G � p�= � ,' : ; , � o � � � � - � _ � ; = F 301530R W2730 W3012 W2430 30 N '` z = A x s K �.�i}F';��� .l Fy '.� ..:. �u ���F�?a� n.;1.'b � a`�'�.,i'a�k'-tz`�`3.-•� 4 w_f�` °L F- 3�'�-'-'�-. k --y.'.= � Y�NG' �.�,t'� _ I .& ,"��.,,,.,� _. �r ,-.x_, .� -cn—i,..� ,�. �,.z F,�.S`"_ . 7.. �...1'k.. . '�-:t..v� � am-'x��"y.a�,..,.^i1 � 18�� � 2�� 30�� 3 �� �� ; . � , � � 76" 63 Z" 19" 15" 27" 30" 24" „ 24" � 2 139 Z" I All dimensions _size designations ��� �'�t fi����, Tl�is is an original design and must Designed: 1/28/2014 given are subject to verification on recHr�o�ocies �"r�� not be released or copied unless Printed: 1/28/2014 ..�L _"i' '"' � _ �' ��. �.-_ t_._ . _i_ . .....«.1:....l.l'.� �F.. t�.... L.00.� r��ii-1 ��- i�l� . .