66 ORNE ST - BUILDING INSPECTION (3) 15 -7 G-t
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
RECEI ED sA
Massachusetts State Building Code, 780 CMR c
IidSPECTIDIdA �k zolr
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling niS 171 1 h A S 9
This Section For Official Use Only
Building Permit Number: D e Applied:
Building Official(Print Name) Signature Date
\� SECTION 1: SITE INFORMATION
1.1 Propert�y'�\ddress: _�- 1.2 Assessors Map&Parcel Numbers
l.l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
Ow rerl of Record- - `
n r. 6� r
Name(Print) Ciry,State,'ZIP
No.and Stre Telephone Email dress
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other f8' Specify:
Brrtef Description of Proposed Work':
t)yA,t .tea .t,l_ Q ,rt_� Lnn.a ��$ �tif7 CL,A a_rnas'I� u�t�ti/J cOt
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ i D g(_02_— 1. Building Permit Fee: $ 9 a Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier 1000 x1. a6
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical .(Fire $
Suppression) Total All Fees: $ - V
c C eck No. Check Amount: Cash Amount:
6. Total Project Cost: $ 1�t O�Da _ aid in Full ❑Outstanding Balance Due:
y SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �I pg.}_0 , S
I'vL",l"LA I/fie_ License Number Expua on ate
Name of CSL Holder Ids
���A�D� List CSL Type(see below)—S
Y"\ - Lle wt_,L- � Type Description
No.and Street
�/� U Unrestricted(Buildings u to 35,000 cu.ft.)
t/�--Vl Y l� ( �, 1 R Restricted 1&2 Family Dwelling
City/T vn,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
q L(� ( n. f Insulation
Telephone Emaill ad address D Demolition
5.2 Registered Home Improvemet(J��Contractor(HIC/)' �jLP 3 L/
A�)�� lf U �{ 7S Contractor
HIC Registration Number Ex rati Date
HIC C�ompany Name or HIC Registrant Namg�
I� U ) .d fir in a -u-__ p�LUl1L.1'>Lr/�)J/tS('l -CJ
No. and Street Email address
'71N ( Scl a9 u-i
Cit 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 ........../kQNo ...........❑
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 e6 - (�Jl4/L-10 d'1� QL— �
to act on my behalf, in all matters relative to work authorized by this building permit application.
w A A Q t L l G ��12J� Z ,•,-
u Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
coot ed in this application is true and accurate to the best of my knowledge and understanding.
/�/"—�—. 02 t
Pont Owner's or Authorized Agent's Na e(Electronic Signature) 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.gov/oca Information on the Construction Supervisor License can be foundat www.mass.eov/dos
2. When substantial work is plannIed-,provide the information below:
Total floor area(sq. ft.) O , a (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"
v a E.B. Window and Siding Co. Proposal
756 Western Ave --
Rt 107 Date Estimate No.
Lynn MA 01905 —
9/11/2015 43619
l
Name/Address
Barbara and Eric Wyse
66 Orne Street
Salem, MA 01907
Project
Description Qty Rate ( Total j
Remove existing windows and prepare opening to 23 0 0.00
accept new vinyl replacement windows
Insulate weight pockets 1 23 0.00
Furnish and install Mezzo Replacement windows 23 0.00 0.00
Top grid to match existing 231. 0.00 0.00
Insulated hopper basement windows 5 0.00 0.00
i Cover exterior blind stop and sills 28 0.00 0.00
Clima-techplus insulating glass including low e/Argon 28 0.00
gas, double strength glass
Seal Windows in and out using Tite bond lifetime 28 0.00
sealant
All Window to carry a lifetime warrantee to the original 28 0.00 0.00
owner including glass failure and breakage
i
Take away all job related debris 0.00
Any building permit required to complete project to be 0.00 0.00
added at cost to the final payment
Angies list discount on installation 23 @ 40.00= 920 23 -40.00 -920.00
Total Project 1 11,782.00 11,782.00 1
Note : All sizes on*rerdero0.00 O.00T
acceptance of pro I
authorized signat
Sales Tax 6.25% 0.00
Thank you for your business. Total $10,862.00
Phone# Fax# E-mail Web Site
781-592-9747 781-592-9746 ebwindow@msn.com www.ebwindow.com
CITY OF S U.EN1, \'[1SSACHLSETI S
BUILDINIG DEPARThMNT
tr• 120 WASHLNGTON STREET, Sm FLOOR
TEL. (978)745-9595
PAX(978)740-9846
Kl,,tgFRi EY DRISCOLL
MAYORTrIOMAS ST.PiERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information OPlease Print Legiibiv
Name iBusiness�OrganizatioNlndividual): �'�r / ��(--��.)U >V `(- L .L/�--� (L ¢J
Address:-aEn t L/�nQ �1�A.+2S1 Yt 1�1L
City/Statc/Zip: f l 1` 11l�O�Phone N: ��[ I - SC!a 'q :) - a
Are you an employer?Check the appropriate box: Type of project(required):
I T 1 am a employer with 4. ❑ I am x general contractor and t 6. ❑New construction
employees(full and/or part-time)." have hired the subcontractors
2.E] 1 am a sole proprietor or partner-
listed on the attached sheet 7• ❑Remodeling
ship and have no employees These sub-contractors have S. [] Demolition
working forme in any capacity. workers'comp.insurance. 9, 0 Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised:their 10.❑ Electrical repairs or additions
3.❑ t am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself.[No workers'comp. c..152,'§1(4),and we have no. 12.Q,Roof repairs
insurance required.]t employees. [No workers' _
comp. insurance required.] 13 Wther
•Any applicant that chocks box 01 most also fin out the section below showing their workets'cotttpensuion policy information.
'1 tmmmeuwnrn:who submit this affidavit indicating they art doing an work and then him outside c,aMbom must submit a new affidavit indicating such.
=(wmua ion,that check this box must attached an additional sheet showing the name of the sub-eontro Mm and their wort m comp,policy infomm mo.
I am an employer that is providing workers'compensation fnsurancejor my employees. Below/s the policy and job site
information. /\ n ��
Insurance Company Name: /b 'nX, �y�/ ! 1 � I k l A�J�/ly/�'�[" ,{p1�1.f L�l
Policy#or Self-ins.Lic. M �JAy -q��-_)-]_Q� .(�'�/ lExpiration Date:
Job Site Address: L, CPD \ �p. ��- City/Statel2iP:
,littach 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 e. 152.can lead to the imposition of criminal penalties of a
fine up to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may toe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cenij er the pains and penaI I erjurythat the information provided above .true ad correct
i m-i ure' Date,
Phan X:
Ofricial use only. Do/lot write in this urea,to be completed by city or town of tclaL
City or Town: _ Permitif.lcense# _
Issultir Aulhority(circle one):
1. Board of Health 2.Building Department 3.Cityf fawn Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other_.__
Contact Person: ^__„_........_.___.__ Phone#:
1
CITY OF S.az: -M, TUNSSACHUSETTS
BUILDING DEPARTMENT
130 WASHNGTON STREET,3m FZOOR
a TEL. (978) 74579595
FA..c(978) 740-9846
KI`fBERL F-Y DRISCOLL
MAYOR THotms ST.PiF.RRE
DIRECTOR OF PUBLIC PROPERTY/BUILD of SG COSLNUSSFONER
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
(name of facitity)0
(address of facility)
si ature p crag+ r
/a i a is
date
debrisa lT.doe
1
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO26158
POLICY NO. AWC-400-7022109-2014A
PRIOR NO. AWC-400-7022109-2013A
ITEM
1, The Insured: Edmund Byrne
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 1 2/1 3120 1 4 to 12113/2015 12:01 a.m. standard lime 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 $ 1,000,000 policy limit
Bodily Injury by Disease S 1,000,000 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.
Classifications Premium Basis Rates _
Code Estfmzted Per S100 Estimated
No. Total Arnvral Of Annual
Hemmteratlon Hemuneratlon Premium
INTRA 50459
INTER SEE CLASS CODE SCHEDULE
Minimum Premium $575 Total Estimated Annual Premium 510,152
GOV GOV Deposit Premium S10,707
_STATE _CLASS
MA 565t State Assessments/Surcharges
$9,567,00 x 5.8000% $555
(__rY L1 f
This policy, including all endorsements,is hereby countersigned by °L '10/28/2014
A'sttxxizod Slgnatu�a bale
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)
Includes copyrighted material of the National Council on Compensation insurance,
used with im permission.
(l�r�ournrauaCa�/�o C-l��cuaC�CaC(/d
Office of Consumer Affairs&Business Regulation
OME Registration:
EMENT CONTRACTOR
Registration: 'j26634 Type:
Expiration:_ 5/2/2017 DBA
.'.�: - r
ED BYRNE WINDOW CO
EDWUND BYRNE ',;
756 WESTERN AVE
LYNN,MA 01902 Undersecretary
e
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
' Crustructian Super,i,o,
License: CS.0 J,:r I
I EDMUND J BYRro
18 Woodrow Terrice
1 Lynn MA 01904 7 ♦ >.
Expiration
i Commissioner 07/OM117