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5 OCEAN AVE - BUILDING INSPECTION t The Commonwealth of Massachusetts ' Board of Building Regulations and Standa gEAVED CITY OF Massachusetts State Building Cod g {dA� $ERVIGE' SALEM 10 Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Detp12Iis.ht a' One-or Two-Family Dwe'1in —E1 1' 1L This Section For Official Use Only Building Permit Number: Date pplied: -ti `7 , l� Building Official(Print Name) Signature Date �J SECTION 1:SITE INFORMATION I 1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers �� CEO L 1 a is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 1 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 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner Record: I L// �, ��. Q'�', oiq Name(Print) City,State,ZIP No.and Street Telephone Email Addrds SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other Cf Sp,cify,aaaaaafta&J LJ.O Beef'Description of Proposed Work': SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost?(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ n Check No, Check Amount Cash Amount: 6.Total Project Cost: $ `1 ❑Paid in Full ❑Outstanding Balance Due: 5W0 Tp OPF►C15S. W GA.T W K . Se'D -r l � g 115 SECTION 5: CONSTRUCTION SERVICES 5.1 ConstructionSupervi or License(CSL) License Number Expir tion Jate Name of CSL Holder I��)O /J��' \ � _ _ List CSL Type(see below) No.and Street �(/ // /CJ Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City own,State,ZIP M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances )iA nm Sty 1 Insulation Telephone Email address D Demolition 5 Registered Home Improveeme Contractor(HIC) /� f/ �r / / / A—& HIC Registration Number F/piration Date mpany Name or Registrant N e o.an Street Email SN• �Y � u� b 1 �7 VJ �y Email a ess Cit own,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 ...........x No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize F,6 -/ CJ/ t,) to on ny behal ,i all mars relative to work authorized by this building permit application. P ' caner s Name(Electronic Signature) Oate 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 contamt;coq this application is true and accurate to the best of my knowledge and understanding. � C Q � . riot Owner's or Au rized Age s Na (Electronic Signature) Date 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. ovg /oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss 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" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 4f-6J 61a:yt�Oj� -It- ��`L� !) r Address: :�—,, ` l P d p—p /yv Q yl.� City/State/Zip: UAWALL Phone #: D%k• Sq A e _� Are you an employer?Check the appropriate box: Type of project(required): 1.3& I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' 13jelfF�%)L Other ElZ T comp. insurance required.] uJt 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. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �\�` Policy#or Self-ins. Lic. #: &OC- �`Y 00 — D a "1 DL 1 _ CJ� I�Expiration Date: �� p Job Site Address: � o— City/State/Zip: Q�7 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde the pains and enalties ofperjury that the information provided above is true and correct. Si nature: Date: Phone#: F use only. Do not write in this area,to be completed by city or town official own: Permit/Licenseuthority(circle one): of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitnicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a.home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.# 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803.0970 (900) 876-2765 NCCI NO 26158 POLICY NO. AWC-400-7022109-201_..-.0_. _4A'. PRIOR NO. AWC-400-7022109-2013AI ITEM 1. The Insured: Edmund Byme DBA: Ed Byrne Window Company Mailing address: 756 Western Ave FEIN:**--9236 Lynn, MA 01905.2456 Legal Entity Type: Sole Proprietor Other workplaces not shown above: See Location 2. The policy period is from 12Ii3/2014 to 12113/2015 12:01 a.m.standard time at the insured's mailing address. 3. A, Workers Compensation insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ i,000.000 policy limit Bodily Injury by Disease $ �1,000,OQO each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. _ _ .. — Giassifications.„ Premium Basis - - Rates Code Estimated Per S100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 50459 - i i INTER SEE?CLASS CODE SCHEDULE Minimum Premium $575 Total Estimated Annual Premium $10,152 ...._GOV ._.G.....___OV._. Deposit Premium $10,707 ', STATE,CLASSL MA 5 --- 65 1-- State Assessments/Surcharges ................__. _..... . ... ....; $9,567.00 x 5.8000% $555 r This policy,including all endorsements,is hereby countersigned by "" Q -'n 10/28 2014 . awlhonzad Signature Dala Service Office: Admiral Insurance Agency Inc 54 Third Avenue 70 Munroe Street Unit D Burlington MA 01803 Lynn,MA 01901 WC 00 00 01 A(7.11) Include%copyrighted material of the National Council on Compensation Insurance, used with its permission. is woodiv t a at L6 ,l 4 r r rro� CYTPfi�f21�'45 r� +�nnet�sxs�e4��cvfusrdl� Oflict of Coljft tr Aftin&'Uoirieas Aegui fio�c Exp ME IMPROVEMENT CONTRAcTQR gestratiow 12W34 TyPi:iration: '602015 DBA ED BYRNE WINDOW CO EDWUND BYRNE ' 766 WESTERN AVE LYNN, MA 01.902 _ t i i I I 1 I FBC#v8134.3 Test eclod: AAMAPNDMFUCSA1101A.S.2/A440 ,. Max Test SIZe:48X78 Wincow Size:30.25n58 211 Illilllllll PG40 RLSIOE JNRC WIN00W COMPRNY ' MODEL W1 - OULE HUNG Natcna Fenesta on CRO# RLS-R-18-00063-00004 Ra[inE,CourN SOLID UINYL - MECH./UELGEE. - DOUBLE GLZD u � 13/16 IS. OS LO-E, ARGON. SST GRIDS < 1' mCI1�N � ENERGY PERFORMANCE RATINGS U-Factor Solar Heat Gain Coefficient 0 . 90 1 . 70 0 . 27 (Us.il-P) (MetridSp ADDITIONAL PERFORMANCE RATINGS Visible Transmittance � . 49 Martlfadrip,vlipflFafasthatthis ratings[ontorm6tapDlieableNFRCp:o!curesfordelemir�ing�hole pmJecr Ve iur�r.:nce.NFRC re+inps are denolinad for a fixed set oI environmental conditions and a specif is product sure.NfRS does not recommend any product and Do's Wei aEnani':he suitability of any prC(I'ldfo aii spvclfio u;i COMA rnanufactulnv sireorgre for ether pall - performance Information. - E.B. Window and Siding Co. Proposal 756 Western Ave. (Rt 107) Lynn MA 01905 Date Estimate No. 11/22/2014 42758 Name/Address Jill Pabich 5 Ocean 43t-A NC Salem MA Project Description Qty Rate Total Remove existing windows and prepare opening to 21 O.00T accept new vinyl replacement windows Insulate weight pockets 21 0.00 Install Windows 21 0.00 Seal Windows in and out using Tite bond lifetime 21 0.00 sealant Clima-techplus insulating glass including low e/Argon 21 0.00 gas, double strength glass All Window to carry a lifetime warrantee to the original 0.00 owner including glass failure and breakage Take away all job related debris 0.00 Mezzo window 21 380.00 7,980.00T Tempered safety glass bathroom 1 75.00 75.00T obscure glass bathroom 1 40.00 40.00T All sizes on file ready to der 0.00 O.00T acceptance of proposa Y or authorized signat e Sales Tax 6.25% 505.94 Hope to be working with you soon Total $8,600.94 Phone# Fax# E-mail Web Site 781-592-9747 781-592-9746 ebwindow@msn.com www.ebwindow.com