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16 AMANDA WAY - BPA 17-261 NEW HOME The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Building Permit Application To Construct, Repair, Renovate Or Demolish a RevisedMar2011 One-or Two-Family Dwelling This Section For Oflici -Use Only Building Permit Number: Date pplied: Building Official(Print Name) / ignature Date SECTION l: SITE INFORMATION L1 PropRrtyAddressssss• a / � 0 r�1 '�/ 1 1.2 Asses ors Map& Parcel Numbers I.la Is this an accepted sire-et?yes.& no / ) Map umber Pare:el Number 1-3 ZoningInformation: �/ IA Prop Dimensions:c,milL .-7 ZodinglDistrict Proposed-use / / Lot ea(sq R) Frontage(it) 1.5 Building Setbacks(ft) Rear Yard Front Yard Side Yards Required Provided Required 9 Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: �( 1.8 Sewage Disposal System: Public V_- Private❑ Zone: _ Outside Flood Zone? Check ifyes Municipal�flOn site disposal system ❑ 21 Owner of Re d• SECTION 2: PROPERTY OWNERSHIP' � t�°(Ii►SR�I� fl T1 ,�t sir 06 Name Prm[ City, LIP No. md T 2 "�t3f7 7tSL �11�1 Ezra C StrePetxk �'LD f'l a(y )t rvl (7n)S .c Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units f _ Other ❑ Specify: Brief Description of Proposed Work: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ �D,6 ❑Standard City/Town Application Fee 3. Plumbing ❑Total Project Cost'(Item 6)x multiplier x /9�U 2. Other Fees: $ 4. Mechanical (FIVAC) $ l 00 List: 5. Mechanical (Fire ,y Su ression $ // `Dotal All Fees: $ 6. Total Project Cost $ 2�/` legll Check No. Check Amount: Cash Amount: tv 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C`.S 2-1 W1 N II 11ot`CSL Ho0I 1a 1d`� be _ License Numr Expiry ion Date 71'- q L UN Q 11 5F— r cp1 - 150 List CSL Type(see below) No.and Street Type Description 1�� I a ,► 4 D l 5 LJG U Unrestricted(Buildings u to 35,000 cu. ft.) City/f r State,LIP R Restricted I&2 F;unil Uwellin M Maso RC Rootin Coverin WS Window and Sidin SF Solid Fuel Bumin Appliances ��1'�SZn I t7�< Ibl([S' � YIYt;S t g PPl ' Telephone �- Insulation Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1-IIC Company Name or I11C Registr t lam HIC Registration Number Expiration Date No.mud Street Email address City/Town, State,ZIP Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.14 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 711: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Own of the subject property,hereby authorized I�I � ,( , �� 'fi M,L, [o act beh , in m relative to wor uthonzed by this building permit pplication./ int Owner's Name(Electronic Signature) �" 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 contain u this a plicat' n is and accurate to the bestof my knowledge and understanding. !O 7 1 Owner's or Authorized Agent's Name(Electronic Signature) [ate NOTES: 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.,,ov/Oca Information on the Construction Supervisor License can be found at WWw.mass.gov/dps [Type When substantial work is planned, provide the information below: al floor area(sq. ft.) (including garage, finished basement/attic decks or porch) ss living area(sq. ft.)_ Habitable room count mber of fireplaces Number of bedrooms ber of bathrooms .� Number of half/baths of heating system D /L Number of decks/porches e of cooling system �$."y/e �'pc Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ��l� � M1 a 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: 1/23/2012 Building Information Conditioned Area(sq it): 2092 Housing Type: Single-family detached Conditioned Volume(cubic it): 17788 Foundation Type: More than one type Insulated Shell Area(sq it): 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 WindowT YPe: U:0.30, SHGC:0.35 Above Grade Walls: R21,FG 1,6-16 U=0.058 WindowU-Value: 0.300 Found. Walls(Cond): None WindowSHGC: 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 k8tuh, 95.0 AFUE. Cooling: Air conditioner, 36.0 kBtuh, 13.0 SEER. Water Heating: Conventional, Gas, 0.58 EF. Programmable Thermostat: Heat=Yes;Cool=Yes Note:Where feature level varies in home, the dominant value is shown. This home MEETS OR EXCEEDS the EPA's requirements for an ENERGY STAR Home. REM/Rate-Residential Energy Analysis and Rating Software v12.97 This information does not constitute any warranty of energy cost orsavings. ©1985-2012 Architectural Energy Corporation, Boulder,Colorado. CITY OF &U E.NI, , L-kSS.A cHUSETTS BUU-DLNG DEPARTMENT \ �a f 130 WASHLYGTON STREET, 3'n FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KI\iBE.RLSY DRISCOI.I. MAYOR THO&w ST.PIEma DIRECTOR OF PIBLIC PROPERTY/BUIIDLNG CONWISSIO,ER 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: �IV� i-h5 � cie C'Gr�, ��i I,nc (name of hauler) The debris will be disposed of in (name of facility) 2 a �add I r�1�vP r (add ��ress of facility) signaturo of permit applicant dace t./2U 12 IA: 12 FAX UL7 527 4078 Enstern Los Newton ' lgf UUU1./UUUI. INSURER'S AFFIDAVIT AS TO WORKERS' COMPENSATION INSURANCE I, Robert A Ilerterieh, Vice Presdent—Eastern Insurance Group LLC 130 Rumford Avenue,Newton, ivlA 02466 am: ❑ an authorized representative of Insurance Company (a producer* in the voluntary market)[ Y❑ an authorized agent of Acadia Insurance Company(an agent in the voluntary market, authorized to sign on behalf of a producer)t ❑ 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 I 'ghways and Bridges of the Highway Division of the Massachusetts Department of Transportation4sign Vice President COMMONWEALTII 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 attirmed to me that thIZ ents of the document are fitful and accurate to the best of their knowledge and belief, q l r r� R t AN . Notary fCW M-5-d—ftSamuel Selafaai iA producer is an insurance company that provides insurance policies directly,not an insurance agent. For Prime or Sub-Contractor companies insured through the voluntary market, this Affidavit must be completed by the insurer or an authorized agent of the insurer. t If the Prune of Sub-Connector 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. Irvpv/WIJ�emnr�t^-' �_._ urm,�a,uLLmuXu®QYmlllvwueYNC.16Jari.1c (�f/Z Professional Land Surveyors & Civil Engineers ESSEX SURVEY SERVICE. 1958 - 1986 OSBORN PALMER 1911 - 1970 BRADFORD 8 WEED 1885 - 1972 PLOT PLAN OF LAND LOCATED IN S/�L�7vJ MASS. DOE�G Sl>/ACC G / /�1�1f1/�l)A Why 1, I hereby certify to the ZONE: �I LOT AREA: /Go�GC LOT FRONTAGE:, /BULL Building Inspector that the pro- FRONT YARD: I y��j SIDE YARD: '1Q/7 REAR YARD: 3G'j'/ to the dimensional zoning of SCALE: Mass. DATE: �Gi//(z�// 21 Zo l2 ya: RIST xOPHErt � .; REFERENCE: UL BK "t6(L PG /1/ Chr stopher R. MekId PIS N41A No.31317 O 15 104 LOWELL STREET PEABODY, MASS. 01960 (508) 531-8121 FAX:(508) 531-5920 CITY OF SALEM ROUTING SLIP A� New Construction Certificate of'Occupanc� LOCATION v UGC E rnI ASSESSORS /� DA"I'E 2 93 Washington St. CIT_`VCLERK: - . -i. _ DATE 93 Washington St. PUBLIC SERVICES DATE 1 �� 120 Washington St. WATER DATE avi �► �� 120 Washington St. A / CROSS CONNECTION DATE D 4 t�(4-- / 5 Jefferson Ave / PLANNINGI` &O'A ]" 4DATE_ vvv 120 Washington St. ✓CONSERVATION , -TE_ 120 Washington St. _ELECTRICAL . DATE , rs �1R`Lal'ayette St. FIRE PREVENTION DATE S �Z 29 Fort Avenue HEALTH- f ,. - DATE 120 Washington St. BUILDING INSPECTOR; DiLTE (o 16 120 Washington St.