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81 FREEDOM HOLLOW - BUILDING INSPECTION 41(33k ci 52s, The Commonwealth of Massachusetts ' Board of Building Regulations and Standards IP�SRc .ET OF PECTIOd�1IVES&L )>MES Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct, Repair,Renovate Or Der?05s�p U P �r 2 One-or Two-Family Dwelling This Section For O ficial Use Only © Building Permit Number: D to Applied: Building Official(Print Name) Signature V Date I SECTION 1: SITE INFORMATION (� 1.1 Pr(o�erty Address: I 1.2 Assessors Map& Parcel Numbers t—�o '11wv 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: Public❑ Private❑ Zone: _ Outside Flood Zone'? Municipal❑ On site disposal system ❑ Chcck if yes❑ SECTION 2: PROPERTY OWNERSHIP[ 2. Owner'of Recor N (Prinr City,State,ZIP � No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other Specify: 4A1C QkJ LOi' ,4)0.10 B!rDescription of Proposed Work'': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1. Building $ D 1 — I. Building Permit Fee: $ Indicate how fee is determined: Lo ❑ Standard City/Town Application Fee 2.Electrical $ ❑ Total Project Cost' (Item 6)x multiplier x 3. Plumbing S 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Su ression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ EI Paid in Full 11 Outstanding Balance Due: M1a%k--1 n 10 s•n •s•t t2.1 N SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) cs- / IQ ( d 111 UNLd f�k ,' J f" License Number Exp alio Date Name of CSL Holder '"t-' �p List CSL Type(see below) '�,)1 f. 1. )Q .� 12Wy P ,Vu-Ls, No.and Street Type Description I�� ) _ �� U Unrestricted(Buildings u to 35,000 cu. ft.) W R Restricted 1&2 Family Dwelling City/T wn, State,ZIP M Masonry RC Roofing Covering WS Window and Siding ��QQ fbSF Solid Fuel Burning Appliances �C Q�'��(,) l ( �YVI�S��. 1 Insulation Telephone Email aa-dress D Demolition 5.2 Registered Home Improvement ContractorU IC) HIC Registration Number pir wn Date Compa y ame or Hl== nt ame P7( L)ClCf7C) lc YhS� No.and Street Email address Ci 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 .......... No ........... ❑ SECTION 7a: OWNE AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR �APgPLIES FOR BUILDING PERMITnn 1,as Owner of the subject property,hereby authorize 2t). to act on my behalf, in all matters relative to work authorized by this building permit application. V \I )cin I Print er's Name(Stec me Signature) Da e 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 contained i his application is true and accurate to the best of my knowledge and understanding. � / not wner s or e Auth Agent' e(Electronic Signature) Dat 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.cov/dps 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" CITY OF SM EM T%LkSSACHUSETTS BUUMLNG DEPART%MNT 120 WASIFINGTON STREET, 3"O FLOOR a� TEL,. (978) 745-9595 FAX(978)740-9846 KIN fBERLF-Y DRISCOLL MAYOR T Hor*LAsST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BL'II.DrNG coNMIISSIONER 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 ; c (name of facility) (address of facility) signahue permit ant l/ I 'ZVdatf7A i JsbrisutT.Jix CITY OF S�U.Ebt, MASSACHUSETTS BUMDING DEPARTNMNT 130 WASHINIGTON STREET, 3'o FLOOR TEL (978) 745-9595 FAX(978)740-9846 IU,,iBERLF-Y DRISCOLL MAYORTrtoMAsST.P[ERRi3 DIRECTOR OF puBLIC PROPERTY/Bua.DLNG CoNL\BSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Q Please Print Lettibly Name(Busimxs OrganizatioNlnd \�ividmi): �'d J. i X d (( f� ,L Address:_ q S(D W P [1 Pmt n-`. } 1 Le—yk-� City/State/Zip: Vw` C)\—q C)\-qPhone#: C�%\' S �l � 'q�� Are you an employer?Check the appropriate bolt: Type of project j (required): 1.;9 1 am a employer with� 4• 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet 7• ❑Remodeling ship and have no employees These sub-contractors have V. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y9. 0 building addition req workers'comp. insurance 5.. ❑ We are a corhave exercised and its 10.0 Electrical repairs or additions required.} officers have exercised Their 3.0 1 am a homeowner doing all work right of exemption per MGL ILEI Plumbing repairs or additions myself.f No workers'comp. c. 152,§1(4),and we have no 12.n Roof repairs insurance required.)t employees.[No workers' . comp. insurance required.] 13.M rA Other,Other, •Any applicant that chocks box#t must also fill out the section below stowing thea wo(ked'compensation policy inlemtanon. 'I hurauwtted who submit this affidavit indicating they ad doing nil work and then hire outside contractors must submit a new aftidavit indicating such. 'Cunlra Cosa that chuck this bot must anached an additional sheet showing the name of dte sub.eoatmctors and their worked'comp.policy in fotmadon. I am an employer that is providing workers'compensadon insurance for my employem Below is the policy and Job site information //�' �(�� I - (� .Insurance Company Namc:l /l1 In r i U�--1.1,__'x"!i1 A' ,V -/V..4 )-4.4 � a� �o ' z Policy#or Self-ins.Lic.#: ( l`1�-�.�a��-� —��q I (Expiration Date. I)- tk J....1 �v Job Site Address: 0 [ G-1, ACTYv- .�t7)`� City/State/Zip: YA �,�.i'Yi� I� Y 1/61;- Attach a copy of theworkers'compensation policy deelaretlon 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 impositionofcriminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to 5250.00 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 regi .0 tde the alas nd naId afperjury.that the information provided abovels.true Rd correct: t ire Date: � S P o #: Oficial use only. Donot write in this area,to he completed by city or town official City or Town: Permit/License Issuing.Authority(circle one): 1.Board of Health 2.Building Department 3.Citylrown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Ot her Contact Person: Phone#: 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 NO 26156 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 front 12/13!2014 to 12113/20I 5 12,01 a.m. standard time at the irisumd'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,& The limits of liability tinder Part Two are: Bodily Injury by Accident $ 1.000,000 each accident Bodily Injury by Disease $ 1,666,066 policy limit Bodily Injury by Disease S 1,000,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 8 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, Eslimated Per Sloe Estimated No. Total Annual Of Annual Remuneration Hemuneration Prefrium INTRA 50459 INTER SEE CLASS CODE SCHEDULE Minimurn Premium $575 Total Estimated Annual Premium $10,152 GOV GOV Deposit Premium 510,707 STATE CLASS MA ms I State $9,567,00 x 5-8000% This policy, including all endorsements, is hereby countersigned by 10/2812014 Aulhlwe5n,"tuln Dale Service Office: AdiTilral Insurance Agency Inc 54 Third Avenue 70 Munroe Street Unit 0 Burlington MA 01803 Lynn,MA 01901 WC 00 00 01 A(7-11) Includoi copyrighted truafteritO of the National Council on Comporeintion Intruronce, used with its feennihilon. ��r Yinvu urnruruvrl/�n�C'l�.rralar./rtrX'Ikr 54... Office of Consumer Affairs&Busmess Regulation O ,,t=ROVEMENT CONTRACTOR Registration: 128634 Type: xplratlon: 5!2!2017 DBA ED BYRNE WINDOW CO EDWUND BYRNE 756 WESTERN AVE LYNN,MA 01902 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Crncisucifnn Sonars i.;,rEmu= License: C3-010870 EDMUNDJBYWO �Ci+� r f8 Woodrow Terrlce l4{"1 ff t Lynn MA 01904 %r. . .-�$- Expiration Commissioner 07/09/2017 E.B. Window and Siding Co. M O� I 756 Western Ave — Proposal, Ea Rt 107 Date Estimate No. _�-,..� Lynn MA 01905 ®v 1/6/201 1 55 43833 Name/Address John Wagner 81 Freedom Hollow Salem, MA 01970 Project Description Qty Rate Total Furnish and install Harvey Classic Replacement 4 482.00 v� 1,928.00 Window C Matching grid pattern to existing 4 22.00 88.00 Full screen upcharge 4 0.00 0.OOT All windows are to have Low E glass, Argon Gas and I 0.00 0.OOT carry an Energy Star rating Seal Windows in and out using Tite bond lifetime I 0.00 i sealant Take away all job related debris 0.00 I r Note: all sizes on file ready to order i ! j Any building permit required to complete project to be ; 0.00 0.00 added at cost to the final payment I � E I 0.00 0.OOT acceptance of proposal authorized signatur j Sales Tax 6.25% 0.00 I I o I Thank you for your business. Total $2,016.00 Phone# Fax# E-mail Web Site 781-592-9747 781-592-9746 ebwindow(�msnxom www.ebsvindow.com