13 FORT AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
f� Board of Building Regulations and Standards CITY
pp Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
1\\ •y. _ Revised January - — —
' \ Building Permit Application To Construct, Repair, Renovate r Demolish a 1, 2008
One-or Two-Fa 'ly Dwelli
This Sectio For ffici O
Building Permit Number: /f Da I t /
Signature: /q (0 -
Building Commissioner/Inspector uildings ate
SECTION 1:SITE N ORMATION
1.1 Pro ertyp dress: Tn VX 1.2 sessors Map&Parcel Numbers
7
l.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 11) 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 yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) dress for Service:
fir, 4,,,aZ - 3c e—
Sfgnature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : E
Aoru S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how feeds 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: $ ^�
B Check No. Check Amount:. Cash Amount:
6.Total Project Cost: $ /.�
e t/lJ ❑Paid in Full ' ❑Outstanding Balance Due:
A t
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 10970
q
� I /
�M 4 4 a d (a A);__ License Number Ex mti Date
Name ofCSL-H [der
661D ` List CSL Type(see below)
� V '— /Y T Description _
Address - --
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling - y
Signature — Z(� M MasonryOnly
Iki RC Residential Roofing Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Be istered Home Improvement CouIaor(HIC) / �j/
C o pany Nam r C egtstrant Name 42egistrat��ion�Nuym/lj r / )
Address
(iC/ ��y.'; �y� r�, 1�� V l
2i q 7 y- Expiration Date
Signature �r� 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:OWNER AUTHORIZATION TO BE COMPLETED WHEN -
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, j as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
(
Signature of� ,
Dale
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of e
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.
27 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"may be substituted for"Total Project Cost"
E.B�Window and Siding Co. invoice
756 Y-estem Ave.
L .1n, MA 01905 Date Invoice#
10/21/2009 46922
Y
Bill TO
Diane Lima -
13 Fort Ave
Salem MA.01970,MA 01970 - -
P.O. No. TermSE'
ject
Item Description Est Amt Prior Amt Prior% Qty Rate Curr% Total% Amount
rw Furnish and install Harvey 2,700.00 9 300.00 100.00% 100.00% 2,700.00
Classics Replacement windows.
All windows to have"Double
insulated Low E and Argon Gas
and half screens.30 matching
grid main house
Note to change from Excalibur
to Harvey Classic.30 add 82.00
per window See line below for
additional chrg for upgrade.
mic Furnish and install Geneva 1,750.00 7 250.00 100.00% 100.00% 1,750.00
Replacement windows.All i
windows to have climatech
glass and half screens.30
matching grid rear porch
rw Furnish and install I Picture 1,080.00 1 1,080-00 100.00% 100.00% 1,080.00
window with 2 operating
casements one on each side.30
no grids
Hope to be workine with you soon
— Subtotal
Sales Tax (6.25%)
Total
Payments/Credits
Balance Due
Page 1
E.B. *indowand Siding Co. Invoice
756 ?Vestern Ave.
Lj MA 01905 Date Invoice#
10/21/2009 46922
Bill To
Diane Lima
13 Fort Ave
Salem MA.01970,MA 01970
P.O. No. Terms Project
Item Description Est Amt Prior Amt Prior% Qty Rate Curr% Total% Amount
mic Upgrade to Harvey Windows 738.00 9 82.00 100.00% 100.00% 738.00
i
r
Hope to be working with you soon
Subtotal $6,268.00
Sales Tax (6.25%) $0.00
Total $6,268.00
Payments/Credits $0.00
Balance Due $6,268.00
Page 2
Roa d�of 13�in in�g ifcgola[oniand Standards rJ
HOME IMPROVEMENT CONTRACTOR
Registration: 12W'4
Expiration:, 5/2/20tt TrN 82880
!3. - Type: DBA
ED BYRNE`WINDQW CO
EDWUND LYgNE`
- 756 WESTE!-iNAVEY`a""Q"4"'"'�
LYNN,MA 01902 Ad:ainistrAtor -
>iassacbusctts- t Cj)!1'insrn! of Public tiafc!N
9M - Board of BuildingRc!gulatiuns anti Standards
Construction. Supervisor License
License: CS 10870
Restricted to: 00 1
I
EDMUND J BYRNE ( "
71 REVERE BEACH BLVD
REVERE, MA 02151
Expiration:" 7/9/2011
('nnuu!.<im:rr - Irv: 18258
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
Burlington, Massachusetts
(800)876-2765 NCCI NO 26158
POLICY NO. IAWC7OP210901200ii
ffEM PRI A NO. I AM;7022100012007 --
1.- The Insured _ Edmund Byrne dba Ed Byrne Window Company --
Mailing Address: 756 Westem Ave Lynn MA 01905-2456
No. shoat Town or Cay Counq, stele zip cooe
® Individual- . ❑ Partnership ❑ Corporation ❑ Other FEIN 01-04g9236
Other workplaces not shown above:
2. The policy period is fromli /13/2008 to 12/13/2009 12:07 e.rm,standard lime at the insured's mailing address.
3. A Workws Compensation Insurance, Part One-of the policy applies in,the Workers CompensetlOn Law of the sfafas listed here;
MA
B. Employers UabNty Insurance: Part Two of the Iles policy app to work in each state listed in item 3.A.
The limits of our liabGilyunderPartTwoare: BodllylnjurybyAccident$ 3.00,000 eachaccident
Bodilylnjuryby0lsease $ 500,000 poGcylimit
BodGylnjurybyDisease $_ 100,000 each employee
C. Other States insurance:Coverage Replaced By Endorsement WC 20 03 06A
D_ This policy Includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rufes,Classifications,Rates and Rating plans_
All information required below is subject to verification and change by audlL
Classifications Premium Basis Rates
EsWRtoe Par$i00
No, TOW TOW Aatuef of Nmueltl
Remtmemtfon aemmeralbn Prtmium
INTRA 050459
SEE SION OF INFOR ON PAGE
Minimum premium$ - Total Estimated Annual Premium
As Indicated,Interim adjustments of premium shall be made. Deposit Premium -
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monimy
MA Assessment Chg.
S1,754-65x 6S000%////���J
This policy,Including all endorsements,Is hereby countersigned by l_p QD 11/21/2008
GOV GOV KIND PLACING CLAIM NAME SAFELY auuhofid ftm Mrs 0e10
STATE CLASS AUDIT OFRCE OFRCE CHECK GROUP Admired Insurance Agency Inc
IAA 15651 12 1705 1 POBox71 -
WC 00 00 01 A(11-88) -Lynn,MA 01903
httltrdee oopyrWdld mmerW or"NnWnal Counular compermaon hmrarrm,
urodWar W Pmmraloa
The Commonwealth of Massachusetts
u Department oflndustrial Accidents
I
Office Of Investigations
pia 600 Washington Street
Boston,AKA 02111
t1 www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
A lieant Information
Please Print Le ' I
Name(Business/orgazuzation/Individual): �� b'
, <�
Address: ra C
City/State/Zip: —7
Phone#:_
Arree you an employer?Check the appropriate box:
L8 I am a employer with 4. ❑ I am a general contractor and I ' Type of project(required):
2.Qemployees(full and/or part-time).* have hired the sub contractors 6. ❑New construction
I am a sole proprietor or partner- listed on the attached sheet= 7•
ship and have no employees ❑Remodeling
These sub-contractors have 8. Q Demolition
working-forme in any capacity. workers' comp,insurance.
.[No workers'comp:insurance 5. Q We are a corporation and its 9. Q Building addition
required.] officers have exercised their 10.❑Electrical
-- _3._Q I am a hom�nwner_d ain repairs or additions
myself exemption per MGL— --11 Q Plumbin ---
Y [No workers'comp. c. 152,§1(4),and we have noor a o
insurance re uired .t 12.Q Roof repairs
q ) employees. (No workers'
comp,insurance required•] 13.Q Other
•Any applicant that cheeks box Yin ust also fill out the section below showing their workers,compensation policy infomtation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating sock
tConhactors that check this box must attached an additional sheet showing the name of the sub-Contractors and their workers'comp,policy information.
ram an employer that is providing
information. workers'cpmpensation insurance for my employees. Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#: 2 Z .2 0
Expiration Date:
Job Site Address.—/- t) "r
Attach a copy of the workers'compensation policy declarationCg the policy number and
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of expiration date). (�
Sue up to$1,500.00 and/or one-year imprisonment as well as civil penalties in the form off as STOP WORK ORDER ER and a�e
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the-Office of
Investigations of the DIkfor insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Signature:
Date:
Phone#:
F
only. Do not write in this area,to be completed by city or.town ojjicial.
n:
Permit/License#
ority(circle one):
Health.2.Building Department 3.City/i own Clerk 4.Electrical Inspector 5.Pltrmbin g Inspector
on:
Phone#: