13 AMANDA WAY - BPA-12-683 NEW, SINGLE FAMILY HOME if
.ILI The Com onwealth of Massachusetts
W
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 Demobs
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A plied:
Building Official(Print Name) Signature tl
SECTION 1:SITE INFORMATION
1.1 Pro r Address: 1.2 Assessors Ma &Parcel be
i�
G�i Cl I � CA P t-P13�5
L l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: L�PtioReAly Dimensions. I
nCill
Zoning District posed se :, y Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required F77Provided Required Provided Required Provided
1 ,51 IU ' ID1. 1 11' 30 ' 50' -1'
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood one?
Publicl� Private❑ Check if ye' Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
wnerrofR d S Re
n L . I��1 i jn acigo
�- -nd-�� fly �� ]a n��_�
Name(Print) CityRtate,ZZIP
L-�DX -1bQ 7 Antahm hugs
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Constructio xisting Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWor z
j�1P\n 1 n 1 �(i ►yil IAGi t)e 1 , l
SECTION 4: ESTIMATED CONSTRUCTION COSTS r'`
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ A/
Suppression) �V Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due:
W 00d-LL
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C S a-1 1 `t—1 I ' z
�PCAUS� D 1 b`C VV License Number Expiration Date
Name of CSL Holder
` List CSL Type(see below) LI
1�1q �o"A 54 - �x lbw
No.and Street( Type Description
I , 1 r n h, p c � C) �j(�(� U Unrestricted(Buildings u to 35,000 cu.ft.
✓`'� I `I I ,ZIP
V 6 t R Restricted 1&.2 FamilyDwelling
Gown,State,Z1P M Masonry
RC Roofing Covering
WS Window and Siding
-�' I nn IInn `,��/��, h SF Solid Fuel Burning Appliances
M�' V tJ� � '_)Itt.21._J YJ( S.LLY)l I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC
HIC Registration Number Expiration Date
R�e i st �me
No.and Street F
Email address
City/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 .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR
/B�U,IIL,D-ING PERMIT
I,as Own e he subject property,hereby authorize 1�� 5`C (
t7acin al atte lative to work authorized by this building permit application
t Owner's Name(Elecuomc ignature) I Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering name below,I hereby attest under the pains and penalties of perjury that all of the information
contain n is ap licati is d accu a to the best of my knowledge and understanding.
Owner's or uth a lectronic S' ) Daze
NO S:
1. An Owner who obtains a building 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.eov/oca Information on the Construction Supervisor License can be found at www.mass. ovE /dus
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 g
Number of fireplaces Number of bedrooms _'"S
Number of bathrooms Number of half/baths
Type of heating system - 1 Vl Number of decks/porches 1
Type of cooling system "(, Enclosed Open �-
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
r
Z,01*1411
CITY OF SM.E:tit, NWSACHUSE—M
BUMDING DEP s.RI\MNT
i 120 WASHINGTON STREET, 3' FL.00R
T L (978) 745-9595
FAX(978) 740-9846
KIJiBF.RLEY DRISCOLL
MAYOR II omAs ST.PmRRa
DIRECCOR OF PLBuc PROPERTY/IlUnDING cow\tlsslO iER
Construction Debris Disposal 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 c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
Lb4hSicie
(name of hauler)
The debris will be disposed of in :
In C C761 )
(name of facility)
I�UP r
(address of facility)
signature of permit applicant 0 . f
date!!!
dcbriuffduc
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POOL
Professional Land Surveyors 8 Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1885 - 1972
PLOT PLAN OF, LAND
LOCATED IN
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I hereby certify to the 5XZZ- �
�f Building Inspector that the pro-
ZONE: LOT AREA: LOT FRONTAGE: &o1.71L posed construction shown conforms
f to dimensional zoning of
FRONT YARD: Ilk. SIDE YARD: ldvt REAR YARD: J)A Mass.
SCALE: F
DATE: J AN 15 70/Z
I P y
- aeuo
REFERENCE: L Bx �oZ PG 7� Christo er R. Me11o�PLSra31:317
104 LOWELL STREET Fors, e .`obi
PEABODY, MASS. 01960
(978)531-8121
FAX:(978)531-5920
01./31/2012 10:12 FAX 617 527 4078 Eastern Ins Newton s 4 0Ua1/U
�l�1
INSURER'S AFFIDAVIT AS TO WORKERS' COMPENSATION INSURANCE
I, Robert A Herterich,Vice Presdent-Eastern Insurance Group LLC 130 Rumford Avenue,Newton,MA
02466 am:
❑ an authorized representative of Insurance Company
(a producer'in the voluntary market)'
X❑ an authorized agent of Acadia Insurance Company(an agent in the voluntary market,
authorized to sign on behalf of a producer)'
❑ an authorized signatory of the the Prime Contractor
(an insured of a producer in the voluntary market pool)'
❑ an authorized signatory of ,the Sub-Contractor(an
insured of a producer in the involuntary market pool,group, or otherwise insured)'
and do hereby aver that effective Feburary 23, 2011,DiBiase Corporation is insured for Workers'
Compensation insurance with Acadia Insurance Company under Policy WCA0286788-12,pursuant to the
attached Certificate of Insurance, and in accordance with Massachusetts General Laws,Chapter 152 and
Subsection 7.05A of the Standard Specifications for 'ghways and Bridges of the Highway Division of
the Massachusetts Department of Transportation.
Sign
Vice President
COMMONWEALTH OF MASSACHUSETTS
On this 31'day of January,31, 2012,before me,the undersigned notary public,personally
appeared Robert A Herterich,proved to me through satisfactory evidence of identification,which
was/were MA Driver's License,to be the person who signed the preceding or attached document in my
Presence,and who swore or affirmed to me that the contents of the document are tKuthfal and accurate to
the best of their knowledge and belief.
p SAMOR P. SCLWAN c ry `L/ L4
Notary
CWnwMeabb�ft
MY Cmm
9 MAMU Samuel Sclafani
DYakee .2%0
' A producer is an insurance company that provides insurance policies directly,not an insurance agent.
' For Prime or SulrContractor companies insured through the voluntary market,this Affidavit must be completed by
the insurer or an authorized agent of the insurer.
t If the Prime of Sub-Contractor is insured through the involuntary insurance market,a pool,such as the Worker's
Compensation Inspection and Rating Bureau,or is otherwise insured they may provide a Certificate of Insurance
and this Affidavit which may be signed by an authorized signatory(company officer)of the Prime or the Sub-
Contractor.
ENERGY STAR VERSION 2 HOME VERIFICATION SUMMARY
Date: January 31,2012 Rating No.:
Building Name: Derby Model Rating Org.: Conservation Services Group
Owner's Name: Osborne Hills Realty Trust Phone No.: 508.836.9500
Property: P.O. Box 780 Rater's Name: Nicholas Abreu
Address: Lynnfield, MA 01940 Rater's No.: 8368122
Builder's Name: Paul Dibiase
Weather Site: Boston, MA Rating Type: Projected Rating
File Name: Derby Model.blg Rating Date: 1/2312012
Building Information
Conditioned Area(sq ft): 2092 Housing Type: Single-family detached
Conditioned Volume(cubic ft): 17788 Foundation Type: More than one type
Insulated Shell Area(sq ft): 4684 HERS Index: 69
Number of Bedrooms: 3
Building Shell
Ceiling w/Attic: R37,CE10",8-16 U=0.029 Window/Wall Ratio: 0.13
Vaulted Ceiling: None Window Type: U:0.30,SHGC:0.35
Above Grade Walls: R21,FG1,6-16U=0.058 WindowU-Value: 0.300
Found.Walls(Cord): None Window SHGC: 0.350
Found. Walls(Uncond): Uninsulated Infiltration: Htg:5.00 Clg:5.00 ACH50
Frame Floors: R30,FG2,X-16 U=0.040 Duct Leakage to Outside: 100.00 CFM @ 25 Pascals
Slab Floors: None Total Duct Leakage: 100.00 CFM @ 25 Pascals
Mechanical Systems
Heating: Fuel-fired air distribution, 100.0 kBtuh, 95.0 AFUE.
Cooling: Air conditioner, 36.0 kBtuh, 13.0 SEER.
Water Heating: Conventional,Gas,0.58 EF.
Programmable Thermostat: Heat=Yes;Ccol=Yes
Note:Where feature level varies in home,the dominant value is shown.
r-- This home MEETS OR EXCEEDS the EPA's requirements for an ENERGY STAR Home.
REM/Rate-Residential Energy Analysis and Rating Software 0297
This infomtation does not constitute any warranty of energy cost orsavings.
@ 1985-2012 Architectural Energy Corporation,Boulder,Colorado.
CITY OF SALEM
ROUTING SLIP
Neiv Construction
Certificate of Occupancy
LOCATIONVK
ATE a
ASSESSORS DATE Z /Z
93 Washington St.
CITY CLERK' `�; a<44 E DAT3 Washing ,ton St.
.,_ � ,..
PUBLIC SERVICESDATE
120 Washi on St.
WATE DATE
120 Washington St.
j
CROSS CONNECTION E
5 Jefferson Ave
PLANNINC��:-_._0110nc �Qf D:1TE ll li
120 Washington St.
CONSERVATION
120 Washington St.
ELECTRICAL s y: y DATE.. :
48 Lafayette St.`"
FIRE PREVENTIOC _® DA'fE
29 Fort Avenue
LIE >LTFIm-^z-°aa-+� x. . '*rDATE" t ,r
120 Washington St:"'
BUILDING INSPECTOR DATE
120 Washington St.