19 AMANDA WAY - BUILDING INSPECTION (3) l
The Commonwealth of Massachusetts CITY OF
° Board of Building Regulations and Standards
I Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One- or 71vo-Family Dwelling
This Section For Offici - se Only
Building Permit Number: Date; pplied:
owl
Building Official(Print Name) Silmature. Date
SECTION 1: SITE INFORMATION
L1 Property Address: /4-9 I 1.2 Asses ors Map&Parcel Numbers
Lck
L to Is this an accepted street?yes no Map umber - Parcel Number
1.3RRZoning Information: 'yY 1.4 Property Dimensions:
Z.E,,Disnict Propose C se / Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required 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 Flod Zone? Municipal On site disposal system ❑
Check if y
SECTION 2: PROPERTY O WNERSHiP`
2 1 Owner of Re
°��ll� SIG 40
Natne(Print) city, date,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED,WORIe(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg. [] Ntunber of Units Other ❑ Specify:
Brief Description of Proposed Work2:
SECTION 4:ESTIMATED CONSTRUCTION:COSTS
Item Estimated Costs: Official use Only
Labor and Materials
1. Building $ 1. Building:PemtitFee:$ Indicate how fee is determined:
2. Electrical $ _ ❑-Standard City/TownApplication Fee
❑Total:Project.Cos?(Item 6)x multiplier x
3. Plumbing $ - - . 2. Other Fees: S
4. Mechanical (HVAC) $ 5 _ List:
5.Mechanical (Fire ,/ �}
Su ression $ � // Total All Fees:$ .
Check No. Check Amount Cash Amount:
6. Total Project Cost: $ Q� ❑Paid in Full ❑Outstanding Balance Due:
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) r'C 2--1 I�1 -1
7Ps1 1� �\ 1- 1( t✓ License Number Y Expva
Name of CSL Hol&r
�,19 ' �w e l I 5L, �� -1 50 List CSL Type(see below)
No.aandvSltreeettih\ 1 V Type Description
' f 1 3 I v�n/1 D l 67 LI O U Unrestricted(Buildings u to 35,000 cu. ft.
LLvdl-w t � Y'1 R Restricted 1&2 FamilyDwelling
City/C o,State,ZIP M Maso
iry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning� Appliances
_�r I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Regist [i�am HIC Registration Number Expiration Date
No.and Street
Email address
City/Town, State ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MLGAL 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 AGENTOR CONTRACTOR.APPLI;(ESFOR BUILDING PERMIT
1,as Own e a subject property,hereby authorize U �. Ci(ff'`� �,L b��
to act y b alf, 'n al, after alive to work authorized by this building permit applicatio
wner's Name ectronic Signature) Date
SECTION 7b:OWNER'ORAUTHOP"FRAGENT'DECLARATION
i
By enteri nrqname below, I hereby attest under the pains and penalties of perjury that all of the information
contai is�apl 's tr d accurate to best of my knowledge and understanding.
fnt Owner's or Authorized AgenPs Name(Electronic Signet Date
NOTES:
I. 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.aov/oc Information on the Construction Supervisor License can be found at www.mass.gov/d s
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.) j SLR Habitable room count Z`J
Number of fireplaces 1 Number of bedrooms
Number of bathrooms __ -s- Number of half/baths
Type of heating system r Number of decks/porches
Type of cooling system Enclosed Open k
3. 'Total Project Square Footage"maybe substituted for"Total Project Cost"
C-71��Qo� brand �3nBoo� o�aoc��n�o�� ���a
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
MASS
DO�� SP�G
G Zac
try
3,0
ZtT3q ! t4737
2 fi
I bereby certify to the 'ghZS- i
ZONE: el LOT AREA:/t l&/ - LOT Building Inspector that the pro-
posed construction shown conforms
FRONT YARD: /S/� SIDE YARD: 1l)`T REAR YARD: 34f-' to the dimensional zoning of
5/j1 L Hasa.
SCALE:
DATE: Al2el-7' 27 2a/2
nn
REFERENCE: PZ BK 4//Z PC pher R. 1
e ME a)
31317
104 LOWELL STREET E
PEABODY,MASS.01960 N� 5gR
(508)531.8121
FAX:(508)531-5920
T•1 TTTMe O�TniT:ni niaF.C-TIC-RJF,-L J. 1W1S ONH1 M831SU3:WOa3 £2:2T 2T02-b-NAf
-� CITY' OF SiU.F`I, 1�I.1SS.�CHLTSETTS
BUILDLNG DEPARTNELNT
120 WASHiNGTON STREET, 3'°FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
KWBERLEY DRISCOLL.
MAYOR THomAs ST.PmRRs
DIRECTOR OF PUBLIC PROPERTY/BUUMING CONMSSIONER
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:
(name of hauler
The debris will be disposed of in :
pds Inc C761
(name of facility)
(address of facility)
signature of permit applicant
bate
Jc6riu11.Jrw
4
tiy� xr
roohn
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 DiUase
Weather Site: Boston, MA Rating Type: Projected Rating
File Name: Derby Model.blg Rating Date: 1/23r2012
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,CE1U',8-16 U=0.029 Window/Wall Ratio: 0.13
Vaulted Ceiling: None WirldowType: U:0.30, SHGC:0.35
Above Grade Walls: R21,FG1,6-16U=0.058 WindowU-Value: 0.300
Found. Walls(Cond): 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 airdistribution, 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 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 v1297
This information does not constitute any warranty of energy cost orsavings.
0 1985-2012 Architectural Energy Corporation,Boulder,Colorado.
0li3U'2012 10:12 VAX 617 527 4075 Eastern ins Newton 1gj00011UUU1
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)[
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 I 'ghways and Bridges of the Highway Division of
the Massachusetts Department of Transportation.
Sign
Vice President
COMMONWEALTH OF MASSACHUSETTS
On this 3 1° 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
waslwtm 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 sruthful and accurate to
the best of their knowledge and belief.
rJ SMeM P. SCLAFAN Notary
i1W cep" Samuel Sclafani
�.wer 9.70t6
° A producer is an insurance company that provides insurance policies directly,not an insurance agent.
t 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 officer)of the Prime or the Sub-
Contractor.
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p� - 0-3z� - D
CITY OF SALEM
ROUTING SLIP
New C•onstructlon_�
Certificate of//Occupancy
L OCATIO:VGD
ASSESSORS64W I/DA"f E 6 $ a o 12
93 Washington St.
CITY CLERK DATE
93 Washington St. /
�/PUBLIC SERVICES� � DATE
120 Washington St
V, DATE
VVVVV 120 Washington St.
CROSS on Ave TION�j��
/5 Jefferson Ave
r/ PLANNING An -�w`x. 4, ,DATE 6I/�I_ ———
1l/ 120 Washington St.
CONSERVATION DATE 120 Washington St.
ELECTRICAL DATE
a�N Lafayette St.
�//PI4
KE PREVENTION D:vT"E
29 Fort :venue
HEALTH- DATE
120 Washington St.
BUILDING INSPECTOR DATE
120 Washington St.