17 AMANDA WAY - BPA-12-646 NEW, SINGLE FAMILY HOME 6p4�/U l
The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 20]]
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Dat A�ppplli,ed'::
Building Official(Print Name). Signature D t
SECTION 1:SITE INFORMATION
1.2 A�' Nm _ssQrs Map&Pa el er 3�
Lla Is this an accepted street?
Vyles K no Map Number Parcel Number
1.3 ing Information'oinali I 1..4 Property Dimensions: I
n
Zoning District , Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
5 d5 ' 1U iLe IDU bc)
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Fl qd Zone? Municipal kOOn site disposal system 13.
Check if e
SECTION 2: PROPERTY
,T/Y�yO�W�NERSHIP''
wner'ofRe r I TAS+ LI n 1LlX�CL 1 y I I 1 r)lqqo
Name(Print) City,'State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Altemtion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Workz:
l f ti Yf ld P �nH
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor ang Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
DOTJ ❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost?(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (UVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
a�ooa�i;
SECTION 5: CONSTRUCTION SERVICES
5.1 Construe ton Sunperv/i�sor License(CSL) �S --L , I C.
f pa" J`IXVI License Number `i Expiration Date
Name of CSL Holder
I, I I 1 U r^ 1 1 5�_l�I�fyV —l6O List CSL Type(see below) 1�
No.and Street(Y V�1'il u/� Type Description
Crl U Unrestricted(Buildings u to 35,000 cu.ft.
� i t tl t R Restricted 1&2 Family Dwelling
Gown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidiniz
1 ii SF Solid Fuel Burning Appliances
0' N [D iffy II L a dibtoy.,�I I ) ys .L,-Yi I IInsulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant N< e
is
No.and Street - 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..........)il No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING,P{}E�RMIT
I,as Own a subject property,hereby authorize�� ��� - I row cr�,
to act m eh elf in al atte alive to work authorized by this building permit application.
,Yfint Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By enterin my name below,I hereby attest under the pains and penalties of perjury that all of the information
conta' this ap lic< ion is t
and accurst the best owledge and understanding. G�
C/
t Owner's or uthorized 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.sov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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.)_rQ Habitable room count �
Number of fireplaces I Number of bedrooms 3
Number of bathrooms ] Number of half/baths 1
Type of heating system L l,t.�, Number of decks/porches
Type of cooling system c Q Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
01/31/2012 10:12 FAX 617 527 4078 Eastern Ins Newton 1gf0U01/0001
INSURER'S AFFIDAVIT AS TO WORKERS' COMPENSATION INSURANCE
I, Robert A Hertericb,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)t
3f❑ 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)t
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 41orkghways and Bridges of the Highway Division of
the Massachusetts Department of Transportation
Vice President
COMMONWEALTH OF MASSACHUSETfS
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 thful and accurate to
the best of thew knowledge and belief. 3wa4//
SaAA R P. SC AFAN Notary
Nouar PL—K
�+ °F c Samuel Sclafani
" A producer is an insurance company that provides insurance policies directly,not an insurance agent.
r 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 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 offices)of the Prime or the Sub-
Contractor.
�l:��15061C1S �L.7LI3� �Q� v�� �C.1GJO��t;9170C1a �LL.f�o
Professional Land Surveyors & Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSBORN PALMER. 1911 - 1970
BRADFORD & WEED 1885 - 1972
PLOT PLAN OF LAND
LOCATED IN
Sf�LEM MASS.
So T
82.�0
wi 39
Uy I so & Loi 3�
1).Z9
f� I hereby certify to the
ZONE: `S LOT AREA: /UD/�C LOT FRONTAGE: �Cc Building Inspector that the pro-
posed construction shown conforms
FRONT YARD: /,6fr SIDE YARD: /OF/ REAR YARD: to the dimensional zoning of
3�>c� Mass.
SCALE:
DATE:
J4ti 26) 2& l2 ACHNI�IOPH&tREFERENCE: YL BK �u Chri pher R
. MellZ PG 179 l
� 31 � 't� ,pNo.„3„ o �
104 LOWELL STREET ` c
PEABODY, MASS. 01960
•a;;v
(978) 531-8121
_.. FAX: (978) 531-5920
CITY OF SM.&M L WS.XCHL'SETTS
BumDING DEPAR"111ENT
\ AEC130 WASHINGTON STREET, 3' FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KINiBERLEY DRISCOLL
MAYOR T Homs ST.PtERRE
DIRECTOR OF PIBuc PROPERTY/lBUMDING cow%ass10,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:
\L(Ddh-s wie
(name of hauler) �—
The debris will be disposed of in
t�.Y1 5 I n C ( TU
(name of facility)
(address of facility)
signature of permit applicant O`�
date
dcbriulT.du:
ENERGY STAR VERSION 2 HOME VERIFICATION SUMMARY
Date: January 31,2012 Rating No.:
Building Name: Essex 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: Essex Modetblg Rating Date: 1/2 312 01 2
Building Information
Conditioned Area(sq ft): 2138 Housing Type: Single-family detached
Conditioned Volume(cubic ft): 18362 Foundation Type: More than one type
Insulated Shell Area(sq ft): 5130 HERS Index: 69
Number of Bedrooms: 3
Building Shell
Ceiling w/Attic: R37,CE10",8.16 U=0.029 Window/Wall Ratio: 0.14
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(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 kBtuh,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 dominantvalue 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 warrantyof energy cost orsavings.
0 1985-2012 Architectural Energy Corporation,Boulder,Colorado.
mop 09 - O 3z7
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION
ASSESSORS DATE Z df/2 -
93 Washington St. .
C&VtL,ERK : ,* x'.'t' 4 DATE
93 Washington St.
PUBLIC SERVICES I6k!A�5ATE
120 Washington St.
1VATE �/� DATE i
120 Washington St. �� q
CROSS CONNECTION DATE
5 Jefferson Ave / 2
PLANNING , Uo ]1,1As DATE 2 �� ( !�
120 Washington St. ^^ p I Q
CONSERVATION
TE_
120 Washington St.
ELECTRICAL : ., ;." DATE',"::,
48 Lafayette St.
FIRE PREVENTIO DATE__
29 Fort Avenue
H,EALTH�-*-» � s r- •-. w v,>t' DA'TEv -' ,a, ' `..-; `'
120 Washington St:
BUILDING INSPECTOR DATE
120 Washington St.