2 SEEMORE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7"edition R O ed rLEM
uary
Building Permit Application To Construct, ir, Renovate Or Demolish a t,2008
One-or Two-Fa 'y Dw Iling
This Sectio or Offt al Use Onl
Building Permit Number: J I Dat A pli
Signature:
Building Commissioner/Inspect of Buildin Date
SECTION : INFORMATION
1.1pe Address: ` ' 1.2 Assessors Map&Parcel Numbers
�ff mUR—� S� ,SAIL" /"I
Lla Is this an accepted street?yesp�t no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
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 R ord:
N riot) Address for Service:
G-J `7� I Y�0
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ I Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WorkZ: �I
/,t 2lify c/ ,k,2S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
1.Building $ /0 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ r ❑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: $ y� Ov 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) C) G -7 Q -7 / l�' �� 11
License Number Expiration Date
Name of CSL-Holder
7 k"�LkLA e-46&1-eh J�/vo List CSL Type(see below)
Address AI-M T U Description
Unrestricted to 35,000 Cu.Ft.
�T' Z r•O , �� R Restricted 1&2 Family Dwelling
'
7e) �9�//� /� M Maso Ont
`f RC Residential Roofi Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5. Registered JHome A 01 egt Contractor(HIC)
HIC my N�(Ir WCReg�nCtNcapte Registration
Norther
Addrz D� QV24 �V
'eK Expiration Date/
SignaqFff or Telephone 7
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..........Jy No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r � � �
-.I, ioj )11 ad �z`!\ as Owner of the subject property hereby
authorize �� iS t� G tJF /�/aj Lvi �d uJ ('p to act on my behalf,in all matters
relative o authorized by this building permit application.
I ////,f/-eg
Si -re of owner Dates
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I> /.,dM 6 wJ 2-7,2 as Owner or Authorized Agent hereby declare
that the statements and infirt ation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print
Signature of Owner or VV Agent Date�—
(Si ed under the and nalfies ofr'u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.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"maybe substituted for"Total Project Cost"
t
e— J��,�
.Roar �ef:�°��'g.��8'AHBStendaras '
H6ME1MPROVEMENT'CONTRA6TOR
. Rea stration 128634,. . , .
�E�q;Uation 5/2f2oi1l. TNI -t}2f38i!
Type DBA
r.,
• ED BYR ,g WINDC)W CO
EDWUND�"L'Y2NE',.
- 756 WESTERN'pVL -
" LYNN,MA.C1902
Administrator -
+} Massachusetts- Depiu'tment of Public Safet,N
WS Boarll of Building Re_ulatiuns and Styttl.dards
'a Construction Supervisor License
License: CS. 10870
Restricted to: 00';
EDMUND J BYRNE }
t71 REVERE BEACH BLVD
REVERE A 02151
r 1'Me'.
3,. e
ExpudUon 7/9/20#M• .
18258
PD�JDrNI Page No. of Pages
E.B. Window and Siding Co.
C-)Qoocn,
756 Westem Avenue 4342
Lynn, MA 01905
781-592.9747 Fax 781.592-9746
E-mail: aWndow@msn.eom
PROPOSAL SUBMITTED TO PHONE DATE
� /� Zf /d
STREET JOB NAME
r lel- -a
CITY,STATE and ZIP CODE JOB LOCATION
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
FaK if awc/ jiusril // /4/s-'1s- G�1sr� wT sry'ov_S
�OW f'v fX 4"4 Af TOI+vS=
/ 5rx, fir 09179 fug 41Nw/ C�//st' Pg4f!/ /�L,r
3 Sro-;£s 09,7,2 /C4/f6L-,-
d1 &,i ICS Of 71
c9.'%1rf
p( 6,2,,C S 05/4-/ lir lar w;'-w UUZ�vv�D ul
14);Wdlo, S C oe7 A f'E-r r rT<!�t
04."11 oiev IJ/ w40vv3
Mr PLOP SP hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
d
Payment to be made as follows: dollars($ .. 0� ).
'9V
'25'F F y o ol.L //>r
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized /^ l
manner according to standard practices.Any alteration or deviation from above specifications
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 may be
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days.
Acceptance 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
1
r
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
54 Third Avenue, Burlington,Massachusetts 01803
(800)876-7765 NCCI NO 26158
POtkCY NO. I AWC 7022109012010
PRIOR NO I AWC 7022109012009
ITEM
1. The insured Edmund Byrne dba Ed Byrne Window Company
Mail Address: 756 Western Ave Lynn MA 01905-2456
Street No. Town or City County State Zip Code
FEIN 01-0449236
®Individual ❑Partnership ❑Corporation []JointVenture []Association ❑Other
Other workplaces not shown above:
2. The policy period is from 1211312010 to 12/13/2011 12:01 a.m. standard time at the insured'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 dem 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident S 100.000 each accident
Bodily Injury by Disease S 500.000 policy limit
Bodily Injury by Disease S 100.000 each employee
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.
Classifications Premium Basis Rates
Code Estimateo Per$100 Estimated
No. Total Annual Or Annual
Remuneration Remuneatlon Premium
INTRA 050459
SEE (TENSION OF INFORMATIC N PAGE
Minimum premium$ 500.00 Total Estimated Annual Premium $ 6,555.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 6,976.00
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly
MA Assessment Chg.
$6,186.40x 6.8000% nn $421.00
This policy,including all endorsements,is hereby countersigned by 12102/2010
Authorized Signature Date
GOV I GOV I KIND PLACING CLAIM NAME SAFETY Admiral Insurance Agency Inc
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP P O Box 71
MA 1 5651 2 705 Lynn,MA 01903
WC 00 00 01 A(11-88)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
Page 1 of 1
file://C:\Users\Ed\AppData\Local\Temp\Low\67N7D4FY.htm 12/9/2010
b CITY OF S'U.E.NVI, NL-uSACHUSETTS
BU DLNG DEPART ONT
120 W.A.SHL%IGTON STRM. 3i'FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KI\tBE uEY DRISCOLL
I
'AAYOR }iO.HAs ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO\DIISSIONER
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 1 l 1.5
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
I 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
�oo)G S 7-z
. (name of facility)
r ✓ r rl C—
(address of facility)
71 signature of p n a cant
AI
IC
Icbn�lf�R