0018 DEARBORN STREET - BPA C,l"n" Ol,
11.131 .1(: 1'ROI'I :K'1'1
DEPARTNIFN
I'_II(� V•II1119-3 -1l • Ttll ',I,.Arlt III .I . I-ill"-il
l'I I 9-3 -1; Orli � I'�\ `I'ti.-Ili oFlo
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DVVELLIM
IMPORTANT: Applicants must complete all items on this page
SITE INFORMATION
Locanon Name /8 DY_4 ✓,ab ,d Sr Building
Property Address .... ..
Loc:ued in: Conservation Area Y/N Historic district
APPLICATION DATE ` Q
Use Groups
(check one)
Group Homes 123_Ra_
Residential (3 or more Units) R2_)0
Type of improvement Residential (hotel/mo(el) RI _
(check one) Assembly(Theaters) Al —
New
l _New Building_ Assembly (restaurants &clubs) - A2r_A2ne_
Addition Assembly(churches) A I
Alteration Business B_
Rcpair/Replacement 4-10 Educational E_
Demolition Factory(moderate hazard) Fl _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard IF_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile N1_
Storage Sl _Moderate I-lazald
Storage S2_Lo,v I lazard
O\%'NFRS1IIP INFORMATION(Please Iv
pe ur Print Clearly)
OWNER Name Drg . i?orA ��Y.vcPo 465 -D
Address /,a �oers+ 5 r
Telephone 1,03 - 7�(— 7f b 4(
Si);nature
DESCRIPTION OF R'ORR"1'0 BE PERFORMED
Rz'hla
F:SI'Idl:\"1'IfU CONS'I'RL'C'HON C'U5'I' r
C>' C, a� z
1 �
CUNTK.I CT Olt INI ORNIA rWN
Name w 11 4
Address Z/ gra Re"I 3/. CA
Telephone
Construction Supervisor's Lic # b
Home Improvement Contractor # % ,013
\RCI11'I'l-C'I'/I,'NGINEr;R INFORMATION
Name
Address
Telephone
Mass. Registration #
11J.'101IT FE'E CALCULA-rION
Estimated Cost x $11/$1,000 + $5.00=
CORINIENfS
The undersigned applicant does hereby attest that all information stated above is true to he best of my knowledge
under the penalties of perjury
Signed (owner) (aecnt)
APPROVED BY :
DATE APPROVED: ( �� 6
CITY OF SALEM
1,At PUBLIC PROPRERTY
DEPARTMENT
.I\In:M:11".)Milt„I 1
\1 o,M I J:W AIL It s\;I oi,S 1 f4 LL I' # 5,\t IA.M.WNIt.I II ill IN 0197,,
Ih1.778.713-9595 OF\x 978J4il 1346
Workers' Compensation Insurance Afftdosit: Builders/Contractors/Electricians/Plumbers
\ r ilie,ant Information /. Pleas Print LeeibiY
Naim:[Ihnuletil)r;[atnntioNlndn uluul):4' 2 - 42 d/ran ry gnz '20
r. ) - 7:z --,v-
ltidr�ss:�
CitylSta[u%3-p.T`a s� Gj 1'hunr i': 7
.\re)uu an employer?Chuck the appropriate box: Type urproject(required):
��-1-�1 4. ❑ I mn a general contractor and l f3-. New construction
I. / ant a employer with ❑
/ cntplo)'ccs(full indiur part-Bute).' have hired the sub-contractors 7. ❑ Remodeling
2.❑ I aot a sole proprietor or panner- listed on the attached sheet. :
ship and have no employees These sub-contractors have K. ❑ Demolition
working for one in any capacity. \\'orkers' comp. insurance. 1). ❑ Building addition
No workers'comp. insurance 5. ❑ We are it cniparation and its 10 El Electrical repairs or additions
I required] officers have exciciscd their
r3- ht of per MGL I I.❑ Plumhing repairs or additions
3.❑ I om a homeowner doing all workexem exemption Pon P'
myself. [No workers' comp. C. 152, $1(4),and we have no 12.❑ Ruuf repairs
insurance required.] t employees. LKo workers' I).❑ Other
comp. insurance required.]
•1u}.ylpllcaa that checks box lot must:dao till out the.r'cuan lnluw showing their wutkus'cunipenaution lwlwy mtiantatiun
'I Iomm,wnera who submit this atlu
ldavit indicang they arc doing all work and Ire om
hen him coracton must.uhwmit a neatlidavil indiW mg.null.
-Contncwn that timck this box intuit auxhcd an additional altc-ei\huwmg llw name of the sub<ontrxton and their worken'txxnp.policy mfurmanun.
/am it,, eurployer that is providing rvorRers'curnpetrrnlion irtsurturce jar try eurpluyee.v. Behnv is rhe pu/icy and job site.
infurnrution.
in,oranev Company Name:
Iwlicy it or Sclf-ins. L/icc..70: ��C z2,0.2A0_rz9r aG0 __-- Expiration Date:
/ �—�--
Job Site Address: / t/ d_>'4�' j�� City+Slat 'zip:
Attack a copy of the workers' compensation policy declaration pulse(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25:\vl->IGL c. 152 can lead to the imposition of criminal penalties of a
hoc op to 51.500110 jnLVor ung-year imprisonment,as\vcll is civil penalties in the I'urm of a STOP WORK ORDER and a fine
of up to 5250.00 it day against the violamr. lic advised that a copy of ill's alinement may be lurwarded to the Oiilce of
lu\e,u,inons uf;hc UTA for utsurarce co\cr.tgc \cfiticalmn.
/du herehyecrlify under nder dre pairs a 1d r nu/ties off rjury that the information provided above
iTs/true and correct.
I'll rc +
I)/jiciul use ouly. Do not nvite in this arca,tube raupleted by city up toava a/jiria/.
('itv or fn\vn: __... _— Pcrmit)Liecnse I!,
Issuing.\uthurily (circle otic):
I. Iioafd of Ileallh 2. liuildia:; Department .1. Cil),-I'uwu Clerk 4. L•'lecarird Inspector i, Plumbing luspeetor
6. Other
Phone it:
Information and Instructions
Massadwscns General Laws chapter 152 requires all employers to provide workers' compensation for their comployees.
Punu.mt to this statute, an empfuree is defined.as"._every person in the service of another under any contract of hire,
express or unplied,oral or wrnten."
An einplupir is defined as"in individual, partnership, associatiou,corporation or other legal entity,or any two or more
a the ttregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
reCclver or nrubice or .ut nldlvlduaii,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 in employer."
MGL chapter 152, �25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of u license or permit to operate a business or to construct buildings in the commonwealth for any
applicant w bo has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally. NIGL chapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall
inter into any contract for the performance of puhlic work until acceptable evidence of cumpliance 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)nanme(s),address(es)and phone number(s)along with their certificatc(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 docs have
employees.a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confinmatiun of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he retooled to the city or town that the application for the permit or license is being requested, not the LXpartment 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 0Melals
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to till 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 pennitlliceitse 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 file 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
t i.e. it dug license or permit to bur leaves etc.)said person is NOT required to complete this affidavit
I he t)I Ilce Ut lliveltgations would like lo thank you in advance for your cooperation and Should)'tor lial'c:my questions,
please Ju not hesitate to give us a call
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
ofAce of Investicedons
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
www.mass.gov/dia
CITY OF SALEM
a �a � PUBLIC PROPRERTY
.. 1 _
�,K • DEPARTMENT
I i i 9's '4;.y;4r ♦ I \s: 1)78 '4: 0844.
Construction Debris Disposal Affidavit
(required liir all demolition and renovation work)
In accordance %k idi the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of:VIGIL c 40, S 54;
Building Permit H is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
G /� /•Qae lL
(name of halter)
The debris will be disposed of in
(name of facility)
taddress of lacdily)
tilLllalnle Ufp (nYl' .(1 )I nt
tate
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 7022109012008 —�
ITEM PRIOR NO. AWC 7022109012007
1. The Insured Edmund Byrne dba Ed Byrne Window Company
Mailing Address: 756 Western Ave
Lynn MA 01905-2456
(No. sliest
Tawn or City County
® ware Zip code
Individual ❑ Partnership [I Corporation ❑ Other FEIN 01-0449236
Other workplaces not shown above:
2 The policy period is fmm12/13/2008 to 12/13/2008
3. A Workers Compensation Insurance: Part One of the Policy applies to the•Workers Compensation Law of th01 &m.standard time at the e states listed here
MA -
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A
The limits of our lfabilityunder Part Two are: Bodily Injury by Accident$__ 100,000 eachaccident
Bodily Injury by Disease $ 500,000 policylimit
Bodily Injury by Disease $ 100,000 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,Classifications,Rates and Rating plans.
All Information required below is subject to verification and change by audit.
PCIassificaflonsPremium Basis Renes
rodeTINFOR �ON
$100 Esaated
No. rnarab- ArmumPremium
SEE EXT AGE
Minimum premium$ � -
Asindicated,interim adjustments of premium shall be made: Total Estimated MnuaI Premium - --
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly Deposit Premium
MA Assessment Chg.
$1,754.66 x 6.3000%
This policy,including all endorsements,Is hereby countersigned by
11/21/2008
GOV GOV KIND PLACING CLAIM NAME SAFETY AuthomadSignalum Data
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP
MA 5657 705 Admiral Insurance Agency Inc
POBcx71
WC 00 00 01 A(11-88) Lynn,MA 01903
Includes copyrighted matedal of the Nalional Caunal on Compansa0an Insurance.
used enln 0s pemlisslon,
I
/te .. sm
Board of Building Regulations and Standards
'}" s _ HOME IMPROVEMENT CONTRACTOR
Registration: 128634 .-
Expiration: 512/2009 Tr# 129057
Type: DBA.
ED BYRNE WINDOW CO
EDWUND BYRNE - -
756WESTERN AVE
LYNN,MA 01902 Administrator
Bn8�0 111 Illu�en�'�OIIS:I I���tall AfB"$'
_ Construction Supervisor License
License: CS 10870
4 Birthdate: 7/9/1953
Expiration:: 7/9/2009 Tr# 16721 -
1
Restriction: -60 -
EDMUND BYRNE
71 REVERE BEACH BLVD
REVERE,MA 02151` - Commissioner
l ��. Y7J►si Page No. of Pages
E.B. Window and Siding Co. 4184
E-
0� 756 Western Avenue
o® Lynn, MA 01905
�p 781.592-9747
E-mail: ebwindow@msn.tom
PROPOSAL SUBMITTED TO PHONE DATE
n d Ocf-67Y- 7 /'07 14: 9
STREET JOB NAME
> ra L /Irk 1%W;,54
CITY,STATE and ZIP CODE JOB LOCATION1 .
rIq_!a/ Y A" Aft Ti
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for
R.-M,0vc a/f Wood 61- 17r�GS GaLcP 7'�a/lr !✓19�
R-r Ilfde Avj Ro!/rd Aedl�v 7-0a2o/Zy��a�t �
ria &*,4 rl 49f re l4rile-oO /�z� �T /'f'��a1,.,e e
R=c.�s�' L°y.'aT,A� �ow.�s�oaTS/ R�t�/lase- o.vr o0ow ,o �S�oaT
Ord 6,4r1/y Hwy `31;rf,`sry '/(ldws .
To
L1om,l�.i�aT:...� /fy/O�iK/gj 6ysT/n
R*d4ri(. (,v0o� (,t HrLa'zrt cL's,Cy/Y.L (jf�i.UtYOU+ �D T�-U�N/� `if4 /L'
�o✓ 'rL �I/ ��G/ G,d� �y.ST�,� /l�L�//� /av �H/�C �!U/f�/�� U� -
Me Prop05¢ hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
/— i / ---,4Zw ro i dollars
Payment to be m de as follows:
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices.Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders,and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire,tornado and other necessary insurance. Note:This proposal nor a e
Our workersare fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted"
within / days.
Arreptatirr of Proposal —The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: Signature
tY