78 FREEDOM HOLLOW - BUILDING INSPECTION The Commonwealth of Massachusetts
i R OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 780 CMR SA
Revised M Marar Z011
t Building Permit Application To Construct, Repair, Renovate Or Demolish a
U One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied:
L� Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 pertKA�res� i 1.2 Assessors Map&Parcel Numbers
l-T1n�
1.l 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'
21 OWaer' fR` ecord:iLAA � �J�l n '^ 0 ' C1 L
Name(Print) City,State,ZIP
No.and Street Telephone Emad Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other JW Specify:
Brief Description of Proposed Work'-:
u,-D�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ a — 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 S 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees: $
_
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $
a�� ❑Paid in Full ❑ Outstanding Balance Due:
MfAxt-joo tN -SPL ✓ J-2-3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) o IQT-�-YD
t
e m A Al_N\-Ij License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street r Type Description
U Unrestricted(Buildings u to 35,000 cu.ft.)
DICA R Restricted 1&2 Family Dwelling
City/To n,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
c/ _ SF Solid Fuel Burning Appliances
-j ,.���G'">(l-k� ��yL,Q()�7� �• 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Ex irat n Date
IC ompany Name or HIC egtstrant Najk _
o. and Street Email address
o 1 C1 O'- 7�1 Sq)-CE`!
Cit / own, Statc,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 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT q
1,as Owner of the subject property,hereby authorize CiIJ �
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) I Elate
SECTION 7b: OWNERS 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 application is true and accurate to the best of my knowledge and understanding.
G 5
t Owner's or n Ag am on&Signature) I Dat
NOTES:
1. An Owner who obtains a Mildnig 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
;y)y ass. og v/oca Information on the Construction Supervisor License can be found at w-wv.mass.eov/dps
2. When substantial w k is planned,provide the information below:
Total floor area(sq. ft.)� ;I5 o�C7 (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 EiNi, 2%L-kSSACHUSETTS
13CUMLNG DEPAIt"rME.NT
• 120 WASHIINGTON STREET, 3' FLOOR
TF-L. (978) 745-9595
FAx(978) 740-9846
KI,SBERL EY DRISCOLL
MAYORTHo�tAsST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BUMDNG COMWSSIONER
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:
f cLl� y t �l
(name of hauler).
The debris will be disposed of in
(name of facility)
(address of facility)
signature o permit apt 'can
date
dcbri.�ir.dm
CITY OF SM-EINA, MASSACHUSETTS
BUILDING DEPiR-r%m iT
• t 120 WASHINGTON STREET,3w FLOOR
• TEL. (978)745-9595
FAX(978)740-9846
Kl,,lBERLEY DRISCOLL
I
MAYOR �iOMAS ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BL•IIDMG CO%L`BSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information I
I ` Please Print LeRibiv
Name(Busincas:Organizationilndivitb l): Vl/
Address: S dti
City/State/Zip: IU Phone #: 1 al�
i
Are you an employer? eck the appropriate box: Type or project(required):
1. - I am a cm to er with I 4. 0 1 am a general contractor and t
P Y 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ I am a sole proprietor nr ptutner- listed on the attached sheet.+ 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. [1Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOIL I LEI Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4)s and we have no 12.❑Roof repairs
insurance required.]t cmployces. [No workers' 13 Odrer
comp.insurance required.] t
'Any applicant that checks box A I must also fill�uut the section below slowing their workets'compensation policy information.
'I hxmcowrem who submit this amdavh indicating they are doing all work and thes hire outside contractors must submit a now.affidavit indicating such
=Coters chat ch must x csk this box m anhed aq nfron additional sheet showing the name of the sub-com actors and their workers'comp.policy inf tmtation.
I am an employer that is providing workers'compensation insurance for my employees, Below is the policy and Jab site
information, //�� ( �I
Insurance Company Name: lil�.V i I 1 IMJr IA �_ X 1, Ik 0—M CJ i A",
Policy#or Self-ins.Lic.#: t'llil W��a�l M—tanlq Y l Expiration Date:
C � �
Job Site Address YYt City/State/Zi jl�-_
Attach a copy or the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required ll`nder Section 25A of MGL c. 152.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 viol&r. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of ilia DIA for insurancel coverage verification.
I do hereby certi a the aims ani{ e=erurythata information provided above Is true and correct.
I
�n t ve' Date!
OJfciai case only. no not write in t Its area,to be completed by city or town aJJiciat
City or'ruwn: Permit/License#
Issuing Aulhority(circle one):
1. Board of Health 2.Building De lartment 3.Cityrrown Clerk -4. Electrical Inspector S. Plumbing Inspector
6.Other _
Contact Person:
---.....__--_-- Phone#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800)876-2765 NCCI NO 26158
POLICY NO. AWC-400-7022109-2014A
PRIOR NO. AWC-400-7022109.2013A
ITEM
1. The Insured: Edmund Byrne
DBA: Ed Byrne Window Company
Mailing address: 756 Western Ave FEIN: "---'9236
Lynn, MA 01905-2456
Legal Entity Type: Sole Proprietor
Other workplaces not shown above: See Location
2. The policy period is from 12/13/2014 to 12/13/2015 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 item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident S 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease S 1,000,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
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 Estimated Per S100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 50459
INTER SEE CLASS CODE SCHEDULE
Minimum Premium S575 Total Estimated Annual Premium S10,152
GOV GOV Deposit Premium $10,707
STATE CLASS
MA 5651 State Assessments/Surcharges
_- $9.567.00 x 5.8000% S555
This policy,including all endorsements, is hereby countersigned by ww _Data 10/28/2014
Autnorrzatl signa
Service Office: Admiral Insurance Agency Inc
54 Third Avenue 70 Munroe Street Unit D
Burlington MA 01803 Lynn, MA 01901
WC 00 00 01 A(7.11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with Its permission.
��e�n,rnuaurrrvr�/�n�(y'�/.rrli2e�rB['//1
Office of Consumer Affairs&Business Regulation
OMEPROVEMENT CONTRACTOR
RegistraIMton: 128634 Type:
Expiration:. 52/2017 DBA
ED BYRNE WINDOW CO
EDWUND BYRNE "-
756 WESTERN AVE
LYNN, MA 01902 Undersecretary
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Con:tr-acr':.n Sarerric„r _
License: a-010870
EDMIJNDJBYRI9t
18 Woodrow TerrA a 9�"LJI G
Lynn MA 01904 7
v
Expiration
Commissioner 07/09/2017
2- oz �
E.B. Window and Siding Co. Invoice
f 756 Western Ave
5,
Rt 107 Date Invoice#
Lynn MA 01905 1HSPECT1 '1 RtJiCES
9/4/2015 51599
P I b P 12 35
Bill To
Kristen Tavano
78 Freedom Hollow
Salem. MA 01907
P.O. No. Terms Project
Description Qty Rate Amount
Windows:
Furnish and install Harvey Classic replacement windows. 5 48200 2,410.00"F
All windows to have matching grid pattern to existing 5 22.00 110.004,
Full Screen 0.00 0.004,
All windows to have Climatech Glass(Double strength glass with 0.00 0.00-1,
low c and argon gas)
Seal Windows in and out using"Fite bond lifetime sealant 0.00
All Window to carry a lifetime warrantee to the original owner 0.00 0.00
including glass failure and breakage
Take away all job related debris 0.00
Any building permit required to complete project to be added at cost 0.00 0.00
to the final payment
0.00 0.001,
acceptance of proposal
authorized signatu
4ii
We look forward to working with you!
Subtotal $2,520.00
Sales Tax $157.50
Total $2,677.50
Payments/Credits -$850.00
Balance Due $1.827.50
Phones! Fax# E-mail Web Site
781-592-9747 781-592-9746 ebwindownmsn.com www,ebwindow.com