19-21 FOREST AVE - BUILDING INSPECTION d 'T
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PUBLIC 7 OPE.R.,IA DEPARTMENT
KINMERWY Um5C01j,
MAYOR
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APPLICATION FOR PLAN EXAMINATION AND BUILDING PEKMIT
ALL STRUCTURES EXCEPT I AND 2 FAMILYDWELLINC.S
IMI'OR'S1\T:Applicants must complete all items on this page
SITE INFORMATION
Location Name Building'
Property Add / ,f-ovrsT A-gu-L
Map#
Located in: Conservation Area YRd Historic district Y/N
Use Groups
(check one)
Residential(3 or more Units) R2
Type of improvement Residential(hotel/motel RI _
(check one) Assembly(churches) Al _
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(mslaments,recreation) A3__
Alteration Business B_
Repair/Replacement_\.1 Educational E_
Demolition— Factory(moderate hazard) FI_
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard 11_
Accessory Building_ Institutional(residential care) It _ y�
Other(describe) Institutional(incapacitated) 12_ v
Institutional(restrained) 13
Mercantile Itil
Storage(moderate hazard) S l _
Storage(low hazard) S2
�.
OWNERSt1tY INFORMATION(Please type or Print Clearly)
OWNER Name
/ 9—2/ Address_
Telephone 9,7:p
DESCRIF
�aO W012K TO BE I'ERFORRIF�U
'42/uee�w r.+ r WS
hJsoc Aa/"d r o
6�
ESI'LVLITED CONSTRUCTION COST OD
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CONTRACTOR INFORMATION
Name �t3 LoI ry Q CD .
Address� S (. wESt£2N YYll1 Di4oS�
Telephone-281 —
Construction Supervisor's Lic# I r)
Home Improvement Contractor# —f'it l a 4 DS'7
ARCHITECT/ENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Re i st. cost x $7/$1,000 + $5.00 =
Commercial t. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signed/ `i_
Date fir
u� Bo�id-ot�uil'dtrig R`egulauoes 8ud`Siandard`s
Construction Supervisor License
License: CS 10970
Birttida0e: 7/9/1953
-Expiration:_7/9/2009 Tr# 16721
ResMetion: 00
EDMUND J BYRNE
71 REVERE BEACH SLVD
REVERE,MA 02161 --- Comoriaiener
Board of BmMingReSoiatiees and Standards
HOME IMPROVEMENT CONTRACTOR
Regisiration::-12B634
_ ExpiraBorl;-5/1JaW Tr# 129W
ED BYRNE WINDOW=CO =
EDWUND BYRNE ..
756 WESTERN AVE
- LYNN,MA 01902 - Adwhgs!mwr
CER77[F+'i AT E O SIIRANC� _ ISSUE DATE 0112212008
PRODUCER -
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Admiral Insurance Agency Inc CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
P O Box 71 , DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
Lynn,MA 01903-
COMPANIES AFFORDING COVERAGE
INSURED
Edmund Byrne -
dba Ed Byrne Window Company COMPANY A A.I.M.Mutual Insurance Co
756 Western Ave LETTER
Lynn,MA 01905-2456
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RAYS BEEN ISSUED 7'O THE
PERIOD OQ.ISURED NAMED ABOVE FOR 77-IE POLICY
__.... NOIEA-TEW NOTWITHSTA'NDWG ANY REQUHUM ENT.TERM OR CONDMON OF ANY CONTRACTOR OTHER DOCUMFN'T WITH RESPECT'TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL THE TERMS,EXCLUSIONS AND CONDMONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF mSURMVa: MUCYIQIAOpt M'IYO(Mlaercv) MTY FA/RAi1G1Y LIAO>S Msmorcr)
GF]VRRAI.WAUIIJiY GPNERAI,AGGREGATE S
Q COMMFRCRAt.GFNEIRAL LIAEOltY PROeVnS.COp(P/OP wG4 F
0 QCLAa1S AtAOEQORVR PE0.5pNALQADV.INIIMV
EACH OCCURRENCE
QOmJEUSRC)HIMCDRS PROi: .-
_
M EIPPNSE(Mymcpv,®)
.AVrOMOBOA:L1wa1LRY - -. -
comomeeswou
AW AUTO
ALLOW AVIOG BODLLY RUURY
SCHEOUL®AUf0.5 (Pepmov)
HMEDAUfOR
NON-0R'G LIA AUTOS BODU.Y R11NtY
ARAGE LNBUltY (PesWmO
PRWEIRYDAMAGe
EXC64 GIAa14TY
LMOREL aFORM eACa Occuaj NCE
AGGREGATE
011O2TUM!MUMM IAFORM _
WORKERS COMPENSATION AND ATUTORY LIvI7S -
EMPLOYERS LUBH.rrY
X
A FFICIERSAM EL EACH ACCIDENT 100,000
MCL ®exC. 7022109012007 12/13/2007 12/13/2008 Ec D sF SE POLICY LIMIT I 500,000
FEL D1. YEE-FAcH 100,000
COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS:
EDMUND BYRNE IS NOT COVERED BY THE WORIMR.4'COMPENSATION POLICY.
WORKERS'COMPENSATION COVERAGE APPLIES TO MASSACHUSETIS EMPLOYEES ONLY -
PROOF OF COVERAGE. OIl[DF.ANY
BE CAN CELLED
THE ISSUING COMPANYANY WILL E HOEACVVOR MCI, WRBEFORErnEN THE EX AT70N DATE
OLDER NAMED TO THE LEFL BUT FAILURE 7'O MAIL SUCH NOTICE SHALL SHE CERTTFICA
R LIABILITY OF Amy KIND UPON THE COMPANY,tTs I�IPOSENOOBLIGATION
r SAy'gGENMOR�R7EPREMffATraM .. ...._ ..
UTHORIZED REPRESENTATTYE l
rDDStt� Page No. of Pages
EME.B. Window and Siding Co.
756 Western AvenueLynn, MA 01905
781.592-9747q 7(�E-mail: ebwindow@msn.eom
PROPOSAL SUBMITTED TO PHONE DATE (�
r , /; r r/�
STREET JOB NAME
--OrrK 7-
CITY,STATE and ZIP CODE JOB LOCATION
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for
—
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Rip propoS¢ hereby to furnish material and labor— complete in accordance with above specifications, for the sum of:
zzl�& All, v - - --- dollars($
Payment to a made as follows:
� L
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 roposa may be
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if n6t accepted within days.
r�CCF1 g
}tfF[IlCP ofproposal —The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature vvU L " tl
///
to do the work as specified. Payment will be made as outlined above. t,j
Date of Acceptance: Signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n / Please Print Leeibly
Naive (Business/Orgarvzation/lndividual): L� [7 1d;j0dQW aye-0
Address' 1lXL1 ��� �z 2S, 42"
City/State/Zip: tt-) Phone.#: 17
Are you an employer? Check the app opriate box: Type of project(required):
. general contractor and I
1.�am a employer with 4 ❑ I am a 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp.insurance comp. insurance.#
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4), and we have no 13.0 Other
employees. [No workers'
comp. insurance required]
•Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
information.
hnsurance Company Name:: r. rw A
Policy#or Self-ins.Lic.#: Expiration Date: z /3 U l5
Job Site Address: �� �r t6/� y ,L City/State,/Zip: �,r�t y
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. 152 can lead to the imposition of criminal penalties of a
fine up to$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. 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 certify under the pains and pen 'es ofperjury t t the information provided above is true and co rect
Signature: Date: 6 _
Phone#: 7
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, , ,
express or implied, oral or written."
An employer is defined as "an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,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 an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for,the performance of public work untilacceptable evidence of compliance 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-contiactor(s)name(s), address(es)and phone number(s) along with their certificate(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 does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department 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 Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill 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 permit/license 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 the 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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
+ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
- Tel.# 617-727-4400 east 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.govtdia