86 FREEDOM HOLLOW - BUILDING INSPECTION The Commonwealth of Massachusetts
OF
C Board of Building Regulations and Standards CITY SALEM
Massachusetts State Building Code, 780 CMR dMar
r•,� Revised Mar 1011
( Building Permit Application To Construct, Repair, Renovate Or Demolish a
(� One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Appl' d: p
! r� �J
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
Pro Address: 1.2 Assessors Ma & Parcel Numbers
Lla 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'
2. Ow r'of Recur
ame(Print) I I City,State,ZIP
�llQ � PpC��
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: t---)1
Brief Desc Psed Work`:
�n J _
3 7 o J2ICt01 r" 4n
l � iE)a-P PQLj7t0 Ue2OA
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 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: 1
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 3S�9` 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.J, nC/onstruction Supervisor License(CSL) �010%��
KiJ wA A/Ln pal' _ ,t n nA�— License Number Expirati n D tc
Name of CSL Holder � 1
W� ����p \�t},�.-� List CSL Type(see below) �l
'b'y—� '�}� �� Type Description
No.and Street
U Unrestricted(Buildings up to 35,000 cu.ft.)
M U NM , Y V\ L) 9-c�7 R Restricted I&2 Family Dwelling
City/To , State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
q SF Solid Fuel Burning Appliances
' I� ` (�, I Insulation
Telephone Email address D Demolition
/5'.}2 Registered Home Improv\emeJ`�t\Contractor(H(jOC)� / �U
LAD u7t Ll ���1 `t 2Sl�l V�i�S�' HIC Registration Nui/nber pira n Da e
HIC Com an Name or Tagistrant ame /
rkipyll
No.and Street Email address
CitCit / ate,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: OWNE AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Print Owner's Name*(Electrmic Signature) Date
SECTION 7b: OWN ' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contain a ican isJRe accur the best of my knowledge and understanding.
r caner s Aut mdffge ie(Electronic Signature) D to
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.eov/dps
2. When substantial work is planned,provide the information below:
Total floor 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 halfibaths
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 SM EM, iNLkSSACHUSETrS
BUILDLNG DEPART%MNT
A f 120 WASHINGTON STREET, 3iO FLOOR
o� TEL. (978) 745-9595
FA.r(978) 740-9846
KimBERLEY DRISCOLL
MAYOR T'HOh4iS ST.F'tBRRB
DIRECTOR OF PUBLIC PROPERLY/BUiIMING COMMISSIONER
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:.
(name of hauler)
The debris will be disposed of in
9 (name of facility)
1;7V,O,r.P-I 1 f=�
(ad —1—
dltess of facility)
signature.or Mir appil t
ate �
debn,aff doc
CITY OF S. .&M, tiLXSSACHLSETTS
BUILDING DEPARTIIENT
130 WASHINGTON STREET, 3w FLOOR
TFL (978)745-9595
FAX(978) 740-9W
IIyIBERLEY DRISCOLI
i�1t1YOR THOMAS ST.PtEaRE
DIRECTOR OF PUBLIC PROPERTY/BL•ILDIING COt[SBSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information Q 1 `- � Please Print Leeibiv
Name(Busim.�ssOrganizatioNindividuall): ) 1) t�1 U'^,'1
Address:---�-7!�(l D A o /1
City/State/Zip: l O, Phone#:
Are you as employer?Chec the appropriate box: Type of project(required):
1.m I am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction
l employees full and/or part-time),* have hired the sub-contractors
(
2.0 I am asole proprietor or partner- listed on the attached shcet. Z ❑Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9, 0 Building addition
(No workers*comp.insurance 5. 0 We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs L 1
insurance required.)t employees. (No workers' 13.f O her,
comp. insurance required.I /
'Any applicant that chests box B 1 most also rill out the section below stowing their worker'compensation policy infuntuadon.
t I rmn wwnets who submit this affidavit indicating they are doing all work and then hire outside cummenes most submit a new affidavit indicating such.
=Conimctons that chuck this box most attached an additional sheet showing the nomc of tho suMeontrctar and(heir worker'corp.policy information.
l am an employer that if providing workers'compensation Insurance for my employees. Below is fhe policy and job sire
information.
insurance Company Name:
Policy#orSelf--ins.Lic.#:�"(Q,y •'q 0��\ �—�\�y`Expiration Date:_1_a'
Job Site Address:� " Ciry/State/Zip: XT�
Attach copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 2SA 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 S250.00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of
Investigations of the DIA for insurance coverage.verification.
I do hereby cerdiViador the pains and penalties of perjury that the information provided abov is true and correct
i nTur
^� Dote:
Po d- Zi • � d- • -
OJIcial use only. Donor write in this area,to be completed by city or town official
City or Town: PermittLicense#
Issuing Authority(circle one):
t.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:
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 NO26158
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 1 2/1 312 01 4 to 12/13/2015 12:01 a.m.standard lime 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 S 1.6 ,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$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 50459
INTER SEE CLASS CODE SCHEDULE
Minimum Premium $575 Total Estimated Annual Premium $10.152
GOV GOV Deposit Premium S10,707
STATE CLASS
MA 5651 State Assessments/Surcharges
_ $9,567.00 x 5.8000% $555
This policy,including all endorsements, is hereby countersigned by _-'�...�,u_ �.`-'¢"— _ 10/28/2014
Aulharaod Signatwe Date
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 or the National council on Compensation Insurance,
used with Its permission.
CCl/re Ifrsuu..nmtrxv.�/�OfGylWEO
fiLoc.nlel/1
`� ORce of Coasomer AB'airs&Baseness Regulation
ff E IMPROVEMENT CONTRACTOR
Reglstra0on: '128634 Type.
xpiration: 502017 DBA
ED BYRNE WINDOW CO
1
EDWUND BYRNE
756 WESTERN AVE
LYNN,MA 01902 Undersecretary
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
C..nurn.tiun Sunersic.:r
License: CS-010870 RE
EDMUNDJBYRiO y
18 Woodrow Tercli e A f
Lynn MA 01904 % ,(T^J 1
" Y1Vi5/
y 1 r
Expiration
Commissioner 07/09/2017
- — 2,5 0c- t'75 -C44IoZ 4,(
E.B. Window and Siding Co. Invoice
756 Western Ave RECEIVED
Rt 107 Z✓1G $ Date Invoice#
Lynn MA 01905 INSPECTION E $E 8/13/2015 51485
1015 SEP 1 b P 12' 3
Bill To
Michael Steinberg
86 Freedom Hollow
Salem. MA
P.O. No. Terms Project
Description Oty Rate Amount
Replacement Window
Furnish and install Harvey Classic Replacement Window (Kitchen 3 0.00 0.00
Bay Window)
All windows to have matching grid patterns to existing 3 0.00 0.00
Full Screens 3 0.00 0.001f
All windows are to have Low E glass,Argon Gas and carry an 0.00 O.00T
Energy Star rating
Seal Windows in and out using Tite bond lifetime sealant 0.00
"fake away all job related debris 0.00
Patio Door
Famish and install Harvey patio door 1 0.00 O.00T
Any building permit required to complete project to be added at cost 0.00 0.00
to the final payment
Total project 3,529.00 3,529.00
We look forward to working with you!
Subtotal
Sales Tax
Total
Payments/Credits
Balance Due
Phone# Fax# E-mail Web Site
781-592-9747 781-592-9746 ebwindowoamsn.conr www.ebwindow.com