46 1-2 ESSEX ST - BUILDING INSPECTION 2 -s!
The Commonwealth of Massachusetts " PE " /v
Board of Building Regulations and Standards $ R CITY OF
� V/�EM
T Massachusetts State Building Code, 780 CP�T�t
b,MA �/� Revised Mar 2011
S Building Permit Application To Construct, Repair, Renovate Or DemollYh A 0 03
NOne-or Two-Family Dwelling
This Section For Official Use Only
.Building Permit Number: "- Date Ap ied:
3 3)
Building Official(Print Name)= Signature Date
1 , SECTION 1:SITE INFORMATION
,�(� 1.1 Property ddress: 1.2 Assessors Map& Parcel Numbers
�1-
1.la 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 8) Frontage(R)
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 ifyes❑
SECTION 2: :PROPERTV OWNERSHIP'
1 Owner,of cord\ �'-
Name(Print) V City,Stale,ZIP
�1, 12 2s�,C-Y �1 > i t��cr 1 catl.a u ct
No,and Street Telephone —Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brie I
Description of Proposed,Work':
( M tQ &Jj \Jt n aA Aram s2 �� _n D ID�GtFnnt �� f u �ivcQuwn.
A&A QC_-)n C
SECTION 4:ESTIMATED CONSTRUCTION COSTS '
Estimated Costs:
Item Official Use Only
Labor and Materials
1. Building $ a �U— 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:$ °
6.Total Project Cost: $ 3 a Check No. Check Amount: Cash Amount:
s \�U ❑Paid in Full ❑Outstanding Balance Due: _.
hA Pi.I l✓G:v V N 13 1
SECTION S:`CONSTRUCTION SERVICES
5.1 Const
ruction Supervisor License(CSL)
t s j � �.� y`R N License Number E�xpurat n D to
'�p��.p�g
•-�-alm-e of CSL Holder Ii List CSL Type(see below) lJ
". - "�`� l`� Type- Description
No.and Street
q U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/T wn,State, IP M Masonry
RC Roofing Covering-
WS Window and Siding
G� 6 SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
k it 1 4 HIC Registration Number Ex vati Date
HIC Company Name or HIC Registrant Name
jJo.and Street q Email address
Y,AVk- O
City/Town,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 7w OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�
I,as Owner of the subject property,hereby authorize_ C �A
to act on my behalf,in all matters relative to work authorized by this building permit application.
t'Aiz''k �S,\ Vim\U
Print Owner's Name(Electronic Signature) Date
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 in-t is application is true and accurate to the best of my knowledge and understanding.
- Print Owner's or Auth ed Agent' e(Electronic Signature) Dae
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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) 3a9w — (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"
`fir 7 ti/U t ?F�r drrrfrcfc/_...
Z i , Office of Consumer 4tfrirs&Business Regulation
a ZOME IMPROVEMENT CONTRACTOR
egistration 12853C Type:
Expiration 5,1=017. DBA
ED BYRNE WINDOW CO ;r
i F '
EOWUND BYRNE
756 WESTERN AVE"
n
LYNN,MA 07902
Underaerretary
Massachusefts .Department of Public Safety
Board Of Building Regulations and Stan
dards
f`nE7d£�utCioi>'�Ernr,-viviar . , �I
License: CS.-010870
EDMUNDJBVRN,$
£8 Woodrow TerrSOe t -
Lym MA 01904 7
l
Expiration
commissioner 077091Y017
CITY OF SiUZIM, MASSACHL'SETTS
• BUILDING DEPARTsCENT
120 WASHIINGTON STREET, r FLOOR
TEL (978)745-9595
FAX(978)740-9846
KI-,(BERLF-Y DRISCOLL
MAYOR THOMAs ST.PIExim
DIRECTOR OF PUBLIC PROPERTY/BUnDLNG cow%assIONER
Workers' Compensation Insurance Affidavit: Buildens/Contractors/Electriciano/Plumbers
Applicant information Please Erin Lei l
Name(Busim%&organintiontindividuai):
Address:
City/State/Zip: U Phone #: l _,�)q a
Are you an employer?Check the appropriate box: Type of project(required):
1.P 1 am a employer with ( 6 4. ❑ 1 am a general contractor and l 6. ❑New constructioneinptoyocs(full and/or pastime).° have hired the sub-contractors;2.❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance.
9. El Building addition
[No workers'comp. insurance 5. El We am a corporation and its I
required.] officers have exercised their 10.❑ Electrical repairs or additii us
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additii ns
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13 ❑Other
comp. insurance required.) I
-Any applicant that checks box#1 must also fill gut the ashen below showina their workers'cmnpentuuion paucy infomtotion.
'I hwneawnen who submit this affidavit indicating they sae doing old work and then hire'Contractors oa181de contractors muss submit a new.andavil it diwtina such,
'Contractorsrhnt check this ttax moral anached an additional sheet showing am name of Poe sub mmcton and their workers'oomp.policy information.
/am an employer that is providing workers'compensation insaraneejor my employees, Below is the polity and site
ifi ormardoe.
Insurance Company Name:
Policy #ar Self-ins./+Lie.#; Il\ IA �� n �j_� Expiration Date:I� 14�
Job Site Address' 4 [ 2 � City/Staw/Zip: �G� �6 V `J
Attach a copy of the workers'commons an poBey declaration page(showing the policy number and eaplradon date:
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition oferiminal penalties of?i
tine 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 I me
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the flice of �I
investigations of the DIA for insurance coverage verification.
/do hereby cerli rfndgr the palm and Penaldes ojperfary that the injarutafion provided above Is true and ci rrecR
Jat
Phone#. �� _
01TIciai use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/1.Icense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/rownClerk 4. Electrical Inspector 5.Plumbin
6.Other g Inspector
Contact Person: _.__,...._ Phone#:
A CITY OF smzm NLkSSACHUSETTS
BUILDWG DEPAR11LENT
130 WASHNGTON STREET, 3'a FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLBY DRISCOLL
MAYOR T tioNw ST.PmRRE.
DIRECTOR OF PUBLIC PROPERTY/BUTLDFNG CONMOSSIONEB
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 111.1
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debt is resultinlI from
this work shall be disposed of in a properly licensed waste disposal facility as defined b GL c
111, S 150A. y M,I
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
I ySL
(name of facility).
(address of fa i ht
Y)
7-4 signature. permit ant
dat
dcbriwlY.dm
E.B.Window and SidingCo.
. InVOIC@
756 Western Ave
LynnOMA 01905 ' Date; Invoke# '7 ,
3/30/2016 52481 w
Bill To
Robert DiFazio
46.5 Essex st
Salem Ma 01907
� '`�°"' g T$rmS E i'k �s�"�'.F[i .,tDUe DateK y /�CCOUnt#: {"1in Pro�ect `�u- ,i`,,
P O No «v
.. ,....
3/30/2016
d + P'� "to- 'M x .� ch
i ew3;i ,'� DBSCrlptl4n F v'+�;mis 1a (r '' � `�q` Qty ,} x�, R .,.,� s Ratet .- � y Amount
,. ... : .r. . .E � v, a ., ,. s .. z
Vinyl Siding Installed: Coventry .42 by Alside. Color: 1 20,500.00 20,500.00
Harbor Blue
Contractor DISCOUNT (19600 final price) 1 -900.00 -900.00
Strip existing siding, dispose 1 1,000.00 1,000.00
Strip wood siding (may not be advisable) OPTIONAL 0 1,000.00 0.00
Heavy gauge seamless gutters, formed on site, 1 0.00 O.00T
installed
Fusion replacement windows by Alside. Add exterior 23 400.00 9,200.00
casing to back two windows.
Contractor DISCOUNT (9100 final price) 1 -500.00 -500.00
Front door unit delivered and installed, six panel 1 1,650.00 1,650.00
fiberglass with half lite side lites
Property owner 1 -100.00 -100.00
Back door unit delivered and installed, primed white, 1 1,100.00 1,100.00
six panel fiberglass
Property owner 1 -100.00 -100.00
Deck door delivered and installed, full lite, primed white 1 1,150.00 1,150.00
fiberglass
Property owner 1 -100.00 -100.00
Scope of work: 0.00 O.00T
Remove and dispose existing siding 0.00 O.00T
Insulated building with .38 airlock insulation 0.00 O.00T
Thank you for your business. Total
Payments/Credits
Balance Due
Phone# Fax# E-mail Web Site
781-592-9747 781-592-9746 ebwindow@msn.com www.ebwindow.com