10 VICTORY RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR,7`"edition OF SALEM
'It Revised January
U Building Permit Application To Construct,Repair, Renovate O Demolish a 1, 2008
One-or Two-Family Dwelling
AA, This Secti For Official Use O
l Building Perm I NL er: Da lied
d') Signature:. ��./Jr/ 09
AlyBuilding Commissioner/.nspector ofBui tgs 1 Date
SECTIO E JNFORMATION
1.1 Prope/r[ Agr2s �U D 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes a no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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
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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2:.PROPERTY OWNERSHIP'
2.1 Owner'of Record:
m
e(Print) Address for Service:
�fo
Sign ture ITelephone
SECTION 3:.DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 'Accessory Bldg.❑ Number of Units Oth ❑ Specify:
Brief Descrfion of Proposed Work2:
SECTION-4:'ESTIMATED CONSTRUCTION COSTS
Item i Estimated Costs:
Labor and Materials Official Use Only
1.Building 0 $ 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:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 6�s (�. ❑Paid in Full ❑Outstanding Balance Due:
i
r SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction SuIp lJ
rvisor(CSL) L /� � �O//
((
� ("�d � 1'�A)v License'Number Expiration Date
List CSL Type(see below)
Address- Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
'M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Reg] er
i3 eduJ Hoiti me Improvement Cont actor(HIC)
�fDli ) � /� -
y
HIC Com any 'lameFRICRegistramName' �I Registration_Number
-
Address
J—/j/ Expiration Dar
Signature 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
1, b &M e� rn r» 6-171 as Owner of the subject property hereby
authorize to act on my behalf, in all matters
rela ive to work authorized by this building permit application.
�a / 6 G/
a ore ot'Owner g-�� Date f //�
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing.,lCSL)can be found in 780 CMR Regulations I10.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 bfMassachusetts
i Department oflndustrialAccidents
_ t �•
E ` Office of Investigations
- - ---- --- 600 Washington Street
t-i
Boston,MA 0211.1
www.massgov/dia
Workers' Compensation Insurance Affidavit:
Alit:ant Information Builders/Contractors/Electricians/plumbers
Please Print Le 'bl Name(Busin_Worgaoi.60111lndividualy .
Address: _���
City/State/Zip:_ Ph
one#: /
[2.0
a y�ou—an�employer?Check the appropriate box:
I 1 am a employer with 4• Type of project(required):
employees I am a general contractor and I
(fun and/orpart-time).• have hired the sub-contractors 6. ❑New construction
I am a sole proprietor or partner- listed on the attached sheet.t 7.ship and have no employees These sub-contractors have Remodeling
working for me i workers'n any capacity. g• El Demolition
rs' comp
•insurance.=[Notazwodrkers'comp,insurance 5. El are a corporation and its 9. Building addition
q ] officers have exercised their 10.❑Electrical
_3_❑ I am a hnr„ er�nin repairs or additions
myself, g �.orl�----- rightof-of - ---11--ETVlumbin .
Ys [No workers'comp. C. 152,§1(4),and we have no b UR ' ---
insuraucerequired]t employees. [No work 12•�Roof repairs
ers'
*Any applicant that checks comp,insurance required.] 13.(]Other
box#I must also ""out the section below showing then workers•compensation Policy t Homeowners who submit this affidavit indic""o
toontracton thatch g they are doing all work and then Po ey information. .
eck this box must attached an additional sheet showinghum outside contractors must submit i new affidavit indicating such,
the name of the subcontractors and the-aworkers•comp,polity information,
lam a a employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: &2(2. ;?o 2, Z
� Z Expiration Date: -
Job Site Address:1/� /�j(��� ���,.p/A`
Attach acopy of the workers'compensation policy declaration page(showingthe policCitylstate/Zy:
Failure to secure coverage as required under Section 25A ofMGL C. 152 can lead to theoimpoginumber
obof ancximinalmation date). r
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil n e to$250.00 a day a penalties in the form of a STOP WORK ORDER p and of fine
Y against the violator. Be advised that a copy.of this statement may forwarded to the.Offi a
Investigations of the DIA-for insurance coverage verification
I do hereby certify under thepains andpenalties o/perjury fltat the informationprovidedabo
Signature: ve is[rue acid correct
�i�
Phone# // 2 Date-
0
fficial use only. Do not write in this area,to be completed by city or o
Jficiaf
City or Town: �.
Issuing Authori PermitUcense#
ty(circle one): --------------
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PlumbiJInspector
6.Other
Contact Person:
Phone#:
E.B. Window and Siding Co.., Invoice
756 Western Ave. 3
Lynn, MA 01905 c Date Invoice#
_ " - 10/7/2009 46895
Bill To Simmons Antoinette .-
10 Victory Rd _ - -
Salem Ma 01970 -
P.O. No. Terms Project
Quantity Description
Rate Amount
12 Famish and install Harvey Replacement windows.All windows to have climatech
glass and half screens.30 382.00 4,584.00
3 Furnish and install hopper basement windows
1 Furnish and install Masorete Style A-70 Fiberglass entry door with hardware 220.00 660.00
850.00 850.00
t
Hope t be woftgps4h you s on Fax#
781-592-9747 781-592-9746 otal $6,094.00
AAA
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual insurance Company
Burlington,Massachusetts
(800)876-2765 NCCI NO 26158
POLICY NO. AWC 70221 99 01 20 0 8
fTEM PRIOR NO. AWL;7022109012007 --
1. The Insured _ Edmund Byme dba Ed ByrneWindow Company
Malting Address 756 Westem Ave Lynn MA 01905-2456
iNo- Suet Town w Cdy camry Stem Zlp Cotle
® Individual- . ❑ Partnership 0 Corporation 0 Otter FEIN o1-0449236
Otherworkplaces not shown above:
2 The policy period Is troml2/13/2008 to 12/13120o9 1201 a.m.standard time at the Inured'mallfng address.
3. A. Workers Compensation Insurance: Part Oneof the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the poky applies to work in each state listed in item 3.6.
ThellmitsofourllabilityunderPanTwoare: BorIDylnjurybirAccident$ 3.00,000 eachaccident
BodilyinjmybyDieessl $ 500,000 poficyllmit
BodlyInjurybyDisease $ 100,00O eachemployee
C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A
D. This policy Includes these endorsements and schedules SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classlficaftons,Rates and Rating plans.
All information required below is subject to verification and change by audit
Classifications Premium Basis Rates
owe Esymated Pers700 Estlmoled
_ Tmel Anal of Annual
NO, Remmmrallm Remtmere0mr Prmnlum
INTRA 050459
SEE EXr NSION OF INFORI LATION PAGE
Minimum premium$ Totei Estimated AMtrel Premium _AS Indicated,Interim adjustments of premium shall be made: - Deposit Premium - -
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly - -
MA Assessment Chg.
$1,750.85 x 6.e000%
Tilts policy,Including ail endorsements,Is hereby countersigned by �p QD 1 1/2 112 0 0 8
to glum onto
GOV GOV KIND PLACING CAM
NAME SAFETY
STATE CIAS_S AUDIT OFFICE OFFICE CHECK GROUP Admiral7asumaceAgencyInc
MA 15012 1705 1 P011oa71
WC 00 00 01 A(11-88) Lynn,MA 01903
Includes coWal edmaledalof 0e Nmmnal Counc2 on Cvmpenae0on bmmr %
used WE;asP&misslan.
' `±i Road of lZu�il�ain a�uieal�, o�i��.aaac�n�elle ' -
�� g egulahon and Standards
-HOME IMPROVEMENT CONTRAOTOR
UP
Registration: 128634.
- Expiration: 5/2l2011 Tr# 82880
Type: DBA`
ED BYRNk`11VINOQW CO
EDWUND-8'kRNE'= - -
756 WESTE.tjNAVE , ,�,,,,`
LYNN,MA 01902 Administrntor
+=- Massachusetts- Department of Public S:d-etc
9 Board of Building Regulations and Standards
Construction Supervisor License
License: CS 10870
Restricted to: 00
EDMUNDJ BYRNEy(
71 REVERE BEACH BLVD 'r
REVERE, MA 02151
Expiration: 7/912011
("„inmissinncr Tr'i. : 18258