29 PICKMAN RD - BUILDING INSPECTION rr 9� 3 3q t2xz`o c z-11
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
(— Building Permit Application To Construct, Repair, Renovate Or Demolish a
60 One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date App 'ed:
LP Building Official(Print Name) signature Date
I SECTION 1: SITE INFORMATION
1 Prope Address: 1.2 Assessors Map&Parcel Numbers
)24
1.1 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 ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
1 Owner'of Record
4 / f Q Prl, .
Name(P,r City—,State,ZIP
CAU
lc�hren n(RObme,54- ne
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) u
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other P Specify: f ,' J
Brief Description of P(�roposed Work':
I A 7( PI
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 Costa(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: $ 1n
�c7 Iq 11Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5A Construction Supervisor License(CSL) a-wa
License Number Expirat on D to
Name of CSL Holder J
U���1� �" TT\YL List CSL Type(see below)
��l D
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
Cityff wn,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
\ SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Jprr ion Date
HIC Company Name or He Registrant ,ame
No.and Street Email address
1 ttiv. . JV�F� ol�c�s �glS2ci��l�
Ci own,State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 ........../UlNo ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject pr hereby authorize fi
act n m behalf, in a _,*,relative to work authorized by this building permit application.
in O ne s Name ie tropic Signam ) Date
SECTION 7b• WNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
containe this application is true and accurate to the best of my knowledge and understanding.
/ -";) /
riot Owner's ororize A ame(Electronic Signature) Date
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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial `r is tanned,provide the information below:
Total floor area(sq. ft. I C( (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 S�U.EN1, AXSSACHUSETTS
• BUILDING DEPARTMENT
130 WASHINGTON STREET,3'0 FLOOR
TEL (978)745-9595
FAX(971)740-9846
(U`CBFaf FY DRISCOLL
MAYORT1�ioMas ST.PtERRI3
DIRECTOR OF PuBL[C PROPERTY/BUILDING CONMUSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information L Please Priinnt'Lettibly
Name(Busimx &OrganimtioNlndividu"A) y/�n J l�t �J k,,P t S, �J
Address: �S� �P Udo )Llti U'� A 4
Ciry/StatelZip.- >� D� Phoned: Hyl Sim L
Are you an employer?Check the appropriate box. Type of project(required):
I� 1 am a.employer with _ 4. 0 I am a general contractor and 1 6. [1 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• 0 Remodeling
ship and have no employees These sub-contractors have V. 0 Demolition
workingfor in an capacity. workers'comp.insurance.
Y9. Building addition
[No workers'comp. insurance S. El We are a corporation and its IO 0 Electrical repairs or additions
required.) officer have exercised their
3.0 1 ama homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.4tu Odter
comp. insurance required.)- .,
'Any applirnd thu chucks brat pl must also fill out the section below stowing th*'tr workers'compensation policy infuimuiom
'I liimeuwttrrs who submit Mia aflidavh indicating they am doing all work and then him outside comrulors most submit a new affidavit ind�ting such.
=Conimctors that check this box must attached an atditional sheet showing the nam*of me akdi onlmcwm and their wodmro'tamp.policy information.
I am an employer that is providing workers'compensation Insurancejor my emplayem Below Is the paticy and Jab site
insurance C. � `
Insurance Company Name: P�`Y.A��/C.�t `n 1��,Q��^11:U.'YA_x a �.An 1{y���_� ,
Policy#or Self-.ins.Lic.#: t�-�I ,�.D`-c� t)� _1 Expiration Date:—1
Job Site Address: I — C{/2 ��� City/StaudZip:c "
Attach 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 c, 1$2 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$250.00 a day against the violator. Bc advised that a.copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I da hereby cert' de hepafn ai+d alfa ojpe rh6r the information provided above is.true and correct.
'n attire
G Date:
Phone
f
Oficial use only. Do.not write is this area,to be completed by city or Iowa officiat
City or Town: _ Permit/License# _
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3,CityffownClerk 4,Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#t
CITY OF SM.EM, i LkSSACHUSETTS
BI;ILDWG DEPARTMENT
f 120 WASI-INGTON STREET, 3A0 FLOOR
TSL. (978) 745-9595
FAX(978) 740-..9846
KI-,tBERI.EY DRISCOLL
MAYOR- TkomAs ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CONDASSIONER
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 facility)
��
(address of facility)
signatur of t scant
I0�b
date
JcbriufT:dix
BERKSHIRE HATHAWAY Worker's Compensation and Employer's Liability Policy
1111142
GUARDINSURANCE NorGUARO Insurance Company - A Stock Company
COMPANIES Policy Number EDWC643855
Renewal of NEW
NCCI No. [25844].
Policy Information Page
[1]Named Insured and Mailing Address Agency �I
Edmund Byrne ADMIRAL INSURANCE AGENCY
756 Weston Ave 70 Munroe Street
Lynn, MA 01905 Lynn, MA 01903 I
Agency Code: MAHARRI2
Federal Employer's ID 20-1160335 Insured is Individual
Additional Names of Insured
(N2) Ed Byrne Window Company O
[2] Policy Period
From December 13, 2015 to December 13, 2016,. 12:01 AM, standard time at the insured's mailing
address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts I
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. "rhe limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $1,000,000 {
Bodily Injury by Disease- each employee $1,000,000
Bodily Injury by Disease - policy limit $1,000,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
[4] Premium
i The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 10,055
Total Surcharges/Assessments $ 545.00
Total Estimated Cost $ 10,600.00
(NIERNAL USE L9 Page - 1 - Information Page
MGA : EDWC643855 WC 000001A
Date : 11/04/2015
MANOTE
Issuing Office: P.O. Box A-H, 16 S. River Street. Wilkes-Barre, PA 18703-0020 • www.guard.com
���/ `Ir:iRlUr.igPrryl���(�.�f[/LWrINIIJf�� A
��. Office of Consumer Affairs&Business Regulation
G'.
)HOME IMPROVEMENT CONTRACTOR
Registration: 128634 Type:
Expiration: 5212017 DBA
"'&&&,ria
ED BYRNE WINDOW CO
EDWUND BYRNE
756 WESTERN AVE \A
LYNN,MA 01902 undersecretary
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
f'..nkttru.n..n Sunken i...r 0,'�,
License:CS-010870
EDMUNDJ BYRA%
is Wesdraw Terciim '.1.7P.•.�
Lyes MA 01904 =
Cod�r
CommExpirationissioner 0710912017
E.B. Window and Siding Co. Invoice nvolce
dE J
756 Western Ave
Rt 107 Date Invoice#
Lynn MA 01905 11/9/2015 51941
Bill To
Megan Rimerez
29 Pickman Rd
Salem MA 01970
P.O. No. Terms Project
Description Qty Rate Amount
Remove existing windows and prepare opening to accept new vinyl 0.00 0.00
replacement windows
Furnish and install Fusion 2 Light sliding Replacement Window 4 0.00 0.00
with glass upgrade
Furnish an install 2 light sliding basement window 4 0.00 0.00
All unites to have a.30 U Value" Energy Star rated
includes All required carpentry 0.00 0.00
Painting of wood framing and finish not included 0.00 1.00
All windows are to have Low E glass,Argon Gas and carry an 0.00 0.00
Energy Star rating
Seal Windows in and out using Tite bond lifetime sealant 0.00
Take away all job related debris 0.00
Total Project 5,219.00 5,219.00
r
e
0.00 0.001'
acceptance of propos--
authorized
roposauthorized signat
Thank you for your business.
Subtotal $5,219.00
Sales Tax $000
Total $5,219.00
Payments/Credits -$1,700.00
Balance Due $3,519.00
Phone# Fax# E-mail Web Site
781-592-9747 781-592-9746 ebwindowCamsn.com www.ebwindow.com