The URL can be used to link to this page

32 OSBORNE HILL DR - BUILDING INSPECTION o� y� The Commonwealth of Massachusetts ' Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 ` Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only 7 Building Permit Number: - Date Applied: C.T' yy Building Official(Print Name) Signature I9ate 2 lL SECTION 1:SITE INFORMATION 1.1 Property Addres`s•, 1.2 Assessors Map&Parcel Numbers O - 3� C9S�arfJ2 �t\11 per_ 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Ln Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided G9 1 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public d Private ElZone: if yes❑ Municipal eon site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: X04 � I✓� ►Nt�4 . Name(Print) City,S ate,ZIP No.and Street ' Telephone Email Addre s SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction<Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altemtion(s) Cl Addition ❑ Demolition ❑ 1 AccessoryBldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': /, 4>?& bi B/I Af AitC> W I TLA F:c-- � . SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building 17C;pL, $ aQ QCT O L Building Permit Fee: $ Indicate how fee is determined: 2.Electrical g 9� E�0 ❑ Standard City/Town Application Fee _ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 'j d 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ r6. Total oppression Total All Fees: $ Check No. Check Amount: Cash Amount: Project Cost 00 ❑Paid in Full � ❑Outstanding Balance Due: CA-L--L- L-► sa q__ LI ' '5-ay 39 -6 h-1 Ctku P.o SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 115'57 2-9 -.w(& y— { r L Mk 14L HIC Registration Number Expiry ion Date H Company Name or IC Re Lstrant Name T (�vMn� �� - - ca"M .caM No.and StreetEmail address V-x� c MAl o an 9 4c� 1 Ci /Town, State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit 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. Signed Affidavit Attached? Yes ..........W No...........❑ _ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize TPL MA �N L lam 11112,--PAMD to act on my behalf,in all matters relative to work authorized by this building permit application. CA 01A4 rini Owner's Name(Electronic gnature) Date SECTION 7b OWNEW OR AUTHORIZED AGENT DECLARATION 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 ace to to the best of my knowledge and understanding. n Iu Print Owne 's or Authorized Agent's N (Electronic Signature) Date NOTES: 1. An Owner who ob-ta-in-s-a-bTritifing permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at www.mass. o1+ v/oca Information on the Construction Supervisor License can be found at www.mass. oe v/dua 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost' k Office of Consumer Affairs and Business Regulation • 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvemei f'Contractor Registration Type: Corporation TPC MA Inc , 1 1' ,I" Registration: 185728 PO Box 893 - ;iw1, Expiration: 08/01/2018 � � ,r A Essex, MA 01929 -> t SCA 1 O 20M-05111 Update Address and return card. Mark reason for change. ❑ Address ❑ Renewal ❑ Employment ❑Lost Card � C�/�e��rnionearra�en�l�o�G��aa1n��Fr.Je�r Office of Consumer Affairs a Business Regulation (3 HOME IMPROVEMENT CONTRACTOR License or registration valid for Individual use only Type: Corporation before the expiration date. If found return to: tkistratlon Expiration Office of Consumer Affairs and Business Regulation =185728 08/01/2078 10 Park Plaza-Suite 5170 TPC MA Inc Boston,MA o211f / Michael Byrne F 315 Bridge Street �. S.Hamilton,MA 01982 Undersecretary Not valid without signature r€ A .. •l,yjn a, m I yq 1 � y� S3'4•¢{ - - TEL:978.468.9793•MOBILE:978.423.4388•mibyme@comcast.net - PO Box 893,Essex,MA 01929 • A Hunter Lane LLCCompany y 7 i \P i y (3 F1195- �? �na�o� band ��oo� D��oQ�a�oa9 Joao Professional land Surveyors & Civil Engineers ESSEX SURVEY SERVICE 1958- 1986 OSBORN PALMER 1911 - 1970 BRADFORD 8 WEED 1885 - 1972 PLAT PLAN OF LAND LOCATED IN 5'i9LEhl MASS. 51r'iAk't 54-1-le&Al OIlm S2.au L�s�d L, fj -I Z,4� o �0 j Gt rp(i i 65&9W; ff/LL pkz/!/E° �N OF kA��%G,'a o CHRISTOPHER Z R. YEUD F •p Ho.31317 O .U,• / ,,, 6ATE: Jork 29 7G REFERENCE: ®� ix !U2 PG Z? topher E. Mello PLS 31317 104 LOWELL STREET PEABODY.MASS.01960 (978)531-8121 GGY-/0791 SM-S09ff - The Commonwealth of Massachusetts Department of lndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 of www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Ai nlicant Information Please Print Legibly Name (Business/Orgalnimtion/Individual): -A Q L Address: CL, CAI),-cI L G n—k-- City/State/Zip: `SS ev YY\A� Phone #: q)r %Qt— Q 7 Q ?j Are you n employer?Check the appropriate box: Type of project(required): La employer with 1( ))�employees(full and/or part-time)." 7. [JNew construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling any capacity.[No workers'comp. insurance required.] IF-11 am a homeowner doing all work myself[No workers'comp.insurance required.]' 9. El Demolition R 10 ❑ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. twill ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.[ o p 6.❑Weare a corporation and its officers have exercised their right of exemption per MGL c. 14. [her r, G 152,§1(4),and we have no employees. [No workers'camp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. [Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'camp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name: ''`` -Ey-S 2 o Policy#or Self-ins.Lic.#:u p I Pr �C7 6q I� ( Expiration Date: CPII ��)) Job Site Address: 31 0� Q1 /U ```t L I \-(�� City/State/Zip: G(5j ?t/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veriftc0ion. I do hereby�ce�t under thepains an penalties of perjury that the information provided above . t ue`and correct. SignaturelV<r� .f/.(_ Date: S_ Jlb Phone#: �/��— �f(a� - 9? ! Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Client#: 16242 TPCMAI ACORD. CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 8/09/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER -NAME,CONTACT jmurrey@rrsins.com Richards Robinson Sheppard Ins Pa"c°Nq Ea,:617 2845267 F 152 Conant Street E-MAIL A C,No); 6I7-654-9044 ADDRESS: certificates@rrsinS.COm Suite 304 INSURER(S)AFFORDING COVERAGE NAIC# Beverly, MA 01915 INSURER A:Travelers Indemnity Co of Anted 25666 INSURED INSURER B:Travelers Indemnity Company 25658 TPC MA, Inc.d/b/a The Patio Company INSURER C:Travelers Casualty Ins Co of Am 19046 P. O. Box 893 Essex, MA 01929 INSURER D: INSURER E: INSURER F; COVERAGES CERTIFICATE NUMBER: 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 OF ANY CONTRACTOR 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRR TYPE OF INSURANCE INSRL WVD POLICY NUMBER MM/LDDY/YYYFY MM/DDIIYYYYYY LIMITS A GENERAL LIABILITY 6801 H885447 D610112016 06/0112017 EACH OCCURRENCE $1,00 '000 X COMMERCIAL GENERAL LIABILITY DA A E O RENTED PR MI E Ea acwnence $300,000 CLAIMSAMADE 7XI OCCUR MED EXP(Any one person) $5,000 PERSONAL B ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $2,000,000 POLICY PRO- LOC $ JECT C AUTOMOBILE LIABIDTY BAl HB85816 0711112016 07/11/2017 EOMBINEED,SINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per eaident $ B X UMBRELLA LUSX OCCUR CUP001H887465 6/01/2016 06/01/201 EACH OCCURRENCE $2 000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE $2 000 000 DED I X RETENTION$10,000 $ B WORKERS COMPENSATION UBIH887096 6/01/2016 06/01/201 WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ANY PROPRIETORIPARTNEWEXECUTNEMA E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N NIA (Mandatory in NH) E L.DISEASE-EA EMPLOYEEI$500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$500,000 FT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION The Commonwealth of SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. Board of Building Regulations and Standards City of Salem AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S323149/M322937 JNM