1B STILLWELL DR - BUILDING INSPECTION r� The Commonwealth of Massachusetts
Board of Building Regulations and Standards REGE ED CITY OF
Massachusetts State Building Code, 780 CMR ; f PECTtOtiA "3R�vI
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Dpe�mo�(i5h��
One-or Two-Family Dwelling t�,� F..
This Section For Official Use Only
n Building Permit Number: Date Applie .
IA �e+J
Building Official(Print Name) Signature Dale
SECTION 1: SITE INFORMATION
1.1 Proper,tx.Address: N,,,. 1.2 Assessors Map& Parcel Numbers
I.In 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 ❑ — Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2 1 Owners of Recor
Name(Print) % City,State,ZIP /� 4
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other I Specify:
Brief Description of Proposed Work':
a w\-J Jy�ci +C P O C? 0 O 1 ra� L, k-)A e rs i=
tA ;)'N C\C!s"�1� T
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:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ /
4. Mechanical (HVAC) $ List: co
5. Mechanical (Fire $ _
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 31 ❑ Paid in Full ❑ Outstanding Balance Due:
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �57(D)l Qc/��
� '�l�Y, LLQ License Number
0 Expirati n Da
Name of CSL Holder
List CSL Type(sec below)
No. and Street Type Description
U Unrestricted(Buildings u to 35,000 cu. ft.)
I Y>. t y l 0� —\ �� R Restricted 1&2 Family Dwelling
City/Tok n, State,ZIP M Masonr
y
RC Roofing Covering
WS Window and Siding
, spa q-4U SF Solid Fuel Burning Appliances 6
)V-)OCRGD- I Insulation
Telephone Email address D Demolition
5y77'Registered'Home Improvement C tractor(HIC) � ��
�� � �1� HIC Registration Number Expir tion Date
C Company Name or HIC Registrant Name o l .l 7.� C O—A Y , � ®clIz-)CL)
o.and Street �/'�n �,^ G-1 Email address
lA PY\ 1 1 — \ �t'1�� � UI � l a' I 1LJ
City/Toiwri, 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 .......... No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize �(��
to act on behalf, in all matters relative to work authorized by this building permit application.
Print O ner' a (Electronic Signature) Dal
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
contain"this application is true and accurate to the best of my knowledge and understanding.
C�
Print Owner's or horized A t' ame(Electronic Signature) Dart/
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.)'I� ---,2��`i \ 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"
,< CITY OF SUM F.,N1, L L-kSSACHUSETTS
BUMMING DEPARTNMNT
• P 130 WASHLNGTON STREET, 3w FLOOR
O� 'I E1- (978) 745-9595
FA..c(978) 740-9846
Kl.,{BERt EY DRISCOLL
MAYOR T HomtAs ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BUUMr%G 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
t 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
�J(10 I�UCI�� d
(name of facility)
tXgf� 6
(address of facility)
signature of rmit appli t
/,;2,g
j L(,
date
Jcbrisa tT Jx
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
a I Congress Street, Suite 100
s�
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PlumLibs
Applicant Information Please Print L
Name (Business/Organization/individual): EB Window and Siding CO
Address: 756 Western Ave
City/State/Zip: Lynn, MA 01905 Phone M 781-592-9747
Are you an employer? Check the appropriate box: Type of project(require ):
1.❑■ I am a employer with 6 4. ❑ 1 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. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
insurance.' 9. ❑ Building addition
comp.[No workers' comp. insurance P.
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs oi additions
3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs oi additions
myself. No workers' com right of exemption per MGL
Y [ P• 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. ■❑ Other
comp. insurance required.]
*Any applicant that checks box#] must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicati such.
tConlractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities ave
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and j;b site
information.
Insurance Company Name:Berkshire Hathaway Gaurd Insurance Co
Policy# or Self-ins. Lic. #:EDWC643855 Expiration Date: 12/13/16
Job Site Address: fJ l l'AD e `� City/State/Zip: r�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirati date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pena ies 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 if
Investigations of the DIA for insurance coverage verification.
I do hereby cernf"!,til er the pains and penalties ofperjury that the information provided above is true aJcorrec
i
Signature: Date:
Phone#: 781-592- 47
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspe s or
6. Other
Contact Person: Phone#:
A41C40 R& CERTIFICATE OF LIABILITY INSURANCE °`TE'MMDDYYYY'
2/18/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: N the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. U SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsemen s).
PRODUCER CONTACT COffinercial. Lines
Admiral Insurance Agency,Inc. W�X,EU, (781)599-2000 �aG.
70 Munroe Street EMAIL
ADDRESS:
Suite D _ _. INSURER(S)AFFOROING COVERAGE _ _ NAIC#
Lynn MA 01901 INSURERA:ProV,idence Mutual 'Fire Ins Co 115040
INSURED INSURER e..,Guard Insurance
EDMUND DHA. BYRNE 6 ED 'BYRNE WINDOW COMPANY INSUAERC:
756 Western Avenue
INSURER E: �
LYNN 14A 01905 INSURER
COVERAGES CERTIFICATE NUMBER:CL1561720927 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INBRT rAODQ __.POLICY
LTR� TYPEOFINSURANCE 3 I POLICY NUMBER D k M ( LIMITS
I X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE_ _ $ S,OOO,OOtl
A CLAIMS-MADE F X OCCUR ` DAMAi;El'O"RENTFD
PREMIgE�(Ea occurtPnceL $
C SOP0063101 6/21/2015 6/21/2016 MED EXP(Any one person} �S 5 000
PERSONAL B ADV INJURY IS 1,000,000
GENL AGGREGATE LIMIT APPLIES i GENERAL AGGREGATE �$ 2,000,000
X POLICY�I EC J LOC i PRODUCTS-COMPrOP AGO�II 2,000,000
� i OTHER:
F FILL _ !$ ^50,000
AUTOMOBILE LIABILITY CO INE Si Utt LIMIT $
MANY AUTO BODILY INJURY{Per person) $
.... ALL OWNED : SCHEDULED
AUTOS AUTOS BODILY INJURY{P.,.m MI!$
NON-OWNED ---"' —"-
- HIRED AUTOS AUTOS Lsta�s p+ gncDAManE $
$
UMBRELLA LIAB OCCUR EACH OCCUR
RENCE I$
EXCESS LIAB CLAIMS�MADE AGGREGATE S
CEO RETENTION S $
B :WORKERS COMPENSATION 3 P H
1 STATUTE ER AND EMPLOYERS'LIABILITY y)N , _._ _. L
iANY PROPRIETORlRARTNERIEXECUnVE --1, MDMC643855 12/13/2015i 12/13/2016)E L EACH ACCIDENT E_ 1,ODO,000
11 OFFICEL'MEMBER EXCLUDED? 1NIA
1(MerPI.Je y in NH) -''i E.L DISEASE EA EMPLOYEF S 1 000 000
IIfw s.descnbe ondor
`DESCRIPTION OF OPERADONS behw I E L DISEASE POLICY LIMIT S 1,000.000
I
I
DESCRIPTION OF OPERATIONS)LOCATIONS/VEHICLES TAMED 101,Addilen¢I R¢mer*p Schedule,may be adaah4d it mare¢Pace is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
.f J Scholl-nlckiSRN
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025"Alan"
Office of Consumer.A ffAirs Business Reg Intiun
.n
i Vi,JHOME IMPROVEMENT CONTRACTOR
�Registratlon: 126634 _Type:
Ws r D
Expiration: 51212017 DBA
ED BYRNE WINDOW CO
EDWUND BYRNE -
756 WESTERN.AVE
LYNN, MA 07902 Undersecrctary
Massachusetts -Department of Public Safety ~
Soard of Building Reguiat3ons and Standards
t`iiciilF d (f .qy �B —
License CS.010870
EDMUND J BYRN,$
18 Woodrow TerrA" �.
Lynn MA 01- 4
l �
Expiration
Commissioner 0710912017
American Properties Team, Inc. /\
TO: 1B Stillwell Drive i
FROM: Jennifer Pappas, Property Manager
RE: Window Replacement
DATE: May 12, 2016
****�*�**r***�►*�r��**•�*s�*�:e*a*e**�*e**rarrssr*►sr**********�**+*�*a�*
Please be advised that the Board of Trustees for Pickman Park has approved replacement
windows for the above referenced unit. This approval is contingent upon-them matching the
existing windows and that they fit-in the existing opening. Installation of the windows must be
completed from the interior of the unit and they must be the same in appearance from the
exterior. Should the installation be completed from the exterior of the unit, you will be
responsible for any damage that your contractor might cause (this includes painting). The Board
will not allow windows with grids, crank outs, etc. Should you contractor find any rot or
damage during the window installation,please make sure that it is reported to my office
immediately.
We also require that permits be pulled in advance (regardless of what your contractor may tell
you), and then a copy of the final approved permit once completed must be sent to APT for the
unit file as well. We also recommend that owners obtain a certificate of insurance from the _
licensed contractor.
You will need to bring a copy of this letter to the Salem Building Department in order to receive.
your permit.
Should you have any questions or require additional information, please feel free to call me
directly at(781)569-2675.
cc: Unit File
500 WEST CUMMINGS PARK SUITE 6050• WOBURN •MA •01801.781-932-9229 •FAX 781-935-4289
E.B. Window and Siding Co. Invoice
756 Western Ave
Date Invoice#
Rt 107
Lynn MA 01905 6/4/2016 52796
Bill To
Mary Rogalski
113 Stillwell Dr
Salem.MA 01970
P.O. No. Terms Project
Quantity Description Rate Amount
7 Remove existing windows and prepare opening to accept new vinyl replacement 0.00 O.00T
windows
7 Furnish and install Mezzo replacement windows. 440.00 3,080.00T
7 Clima-techplus insulating glass including low e/Argon gas, double strength glass 0.00
7 Seal Windows in and out using Tite bond lifetime sealant 0.00
7 Take away all job related debris 0.00
7 Angies List discount 7 ey-30.00 =-210.00 -30.00 -21Q00
1 Permit Fee 50.00 50.00
0.00 0.00T
acceptance of propos
authorized signat
Sales Tax 6.25% 192.50
Sizes on file ready to order
Phone# Fax# E-mail a A e $3,112.50
781-592-9747 781-592-9746 cbwindowa ntsn.com www,cbwindow.com