9 GREENWAY RD - BUILDING INSPECTION (2) 'rP� - 1 �- 132 GK0041 :535!'
The Commonwealth of Massachusetts
�
Board of Building Regulations and Standards EIVEL�
RE AIO nESAtECS
Massachusetts State Building Code,780 CMR, 7 editio%SpECT10 RevisedJanuarK
EM
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1 VO& I '11
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/Inspector of Buildings - Date
SECTION 1:SITE INFORMATION
1 P�operty Address: �l n 1.2 Assessors Map&Parcel Numbers
l.l a Is this an accepted s et?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:.. -
Zoning District Proposed Use Lot Area(sq fl) 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of R rd: n / � �
1001,7-tL- % ���61C yy�J iV
(Print) Addres
s
S' nature TTI O Telephone
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:
Bri Descr'ption of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.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: $ l
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ b — 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5:.CONSTRUCTION.SERVICES
5.1 Licensed Construction Supervisor(CSL)
��l7l�`�t7
License Number Expilation e
ame of CSL-Holder List CSL Type(see below)
Addre Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Si nat M Masonty Only
a • Y 7 RC Residential Roofing Covering
elephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
giSV Ho Improveme tractor(HI /
ICr ompany Name or HIC Registr Name Rcgis tion N her
Ad
pira. n Date
Signature - 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 C TRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property hereby
a rize to act on my behalf,in all matters
relativ to work aut or' ed by th' ing p it application.
Sign ureof0 er Date
SECTIO b:OWNER1 ORAUTHORIZED AGENT DEC ARATION
' ,as Owner or Authorized Agent hereby declare
that the statements and informaticiK on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Prin
�gnature ogJand
rized Agent Date
Si a derenalties of er'u
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.
2. 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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
�j
I
I rk-'ers" Cotnupens2t' vlt:
t 7 u0n MSU=C�- AIDd
ADO 1-- a 2i Ta- for-nation Pieas' Print Leg:b!",
d di-
Ciry�---Le!zip:L4�M� Phone V ) ,59,2 - 57 -2(-1 -7
,re -v-1,an employer? Check the appropriate boa: 1 Type of project(required):
, 4. 7 1 am 2 zeneral contractor I
1.vp a employe;��ifz (a 6. 17, New coas7ucnon.
es(hill amdim pzz�-tinae-).' have aired the mb-conta"3cm 71 [] vernodeling
T a a I scle pnpriemr or parmcr- listed nm rbe a=cbed sheet -
Tbese sub-con-zracto-s have i S LI Demolimom
st; and have no employees
for tne in any cap -5, con=. irm-MCC.
- ' 1 9, [1 Buildir�-add�mort
71IN') wcr!= cot-m. insurance 5. F❑I We MIC 2 C0Ip0T2d0n and its om-C-11's have exercised their10.E] Electrical repairs or addirious
�
ighlofexcrnp upeTIAGL i irscraddiUons
homecAmu doims�allv;onc T, , Tio I I-El FIttrabing repair
-r,--L Rocfr I-Nowor � 14 1EI repair cc c. 152,6 1� '), and we have no 1
employees. [No Nvorkeis'
imsz:=-ce required.] ' 1 Other
-
C')TT.insurance required.]
��
'AMY a7Pq:=-Lhw chcckieex�I Imas"also 1.1 he;oven bclwx=� owrng L wrupevsa�on policY in C
'de C I=n g sac-,e ou= ommm=-,;=I zu . 1 3 re�Anda,�I"-dicatm:ic-nd, �bo jui=�jt*,his affid--�4,*indicating they,are doing ej] wCTIA-nd men hire
that cheek this hcx'huszz anached an addi6cnal sheet showine the name of the sWb-conmacto -=d:heir wo�mens'eamu.�*icv infotr Eton.
art an enpI4Zvzr that is providin.- wont,ers'compensation insurance for my employees. Belov is the polky and job size
infe r m a-r i:r" , ,�7
17 Lz a ar,C--C 0-,up a ny N11 anae: LI,112
c-Sell'ins. Lie. - /W-4436.90T Expiration Date:
Job Site wlddr
Attach a -opy of the workers compext j on policy declaration pace(showing the policy number and expiration date).
Failure a,secure coverage as required=der Section 25.E ofN-!GL c. 152 can lead to the imposition cfcTirranal penalties of a
4 "Al,,a,- .to M S1.500.00 ZZI'OTone-year ' .riscarne t.-2- as well as civil penalties in rye form of a STOP WORK ORDER and fine
Of UD to 5-150.00 a day against 6c v--ioLtc-T. Be advised that copy ofthis state-near may be ferwarded to theOffic-- Of
I as r"erctry cerTi;y under th-0,pains ardpe?;a:ies of perjury m jury rl=tke information Provided above and cor-e
I�f�-
Sim;-mmt: �,A- Date:
Phor-,
of,�4cw on,'v. Do not wr4re in this area, to be compleud by c!V or town off-icia-I
C Ferrmh:�Licllzse
�kL'Thori-,v (Circle one):
so--d cf Ee-�Itl--- 72. BuDdin" Dep:aftntent 3. Citv.�--o-wn Clerk 2. Elec-tr-r-,-' lrspeczcr 5. Plumbing-lasn-einor
WORKERS `, _.i U^ ' AND h;Pitj'CE4 Li431 i Y 'N^j.R.NC` Pn3 ',CV
A.I.M. jN-;:ORMA7!CN PAGE
Mutual Insurance Company
54 Third Avenue, Surlingion, MassaChusetts 01803.0970
(800) 875-2755 NOV NO25155
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R lstrat,dni ,a, '128634 Type.
+, Ex;piPation: SM2016 DBA
EO BYRNE WINDOW CO
EDWUND BYRNE
756 WESTERN AVE
LYNN, MA.OIS02
Undcrstcretary a
Test Method:
AAMAJWDMiNC SA 101/I.S.2/A440-08-
and CSA A44 O,1.09
Max TestSize752X96 ---- __.—_-_
Window Size:.?7.➢x52.25 _ _. . ......_ ___.._....__ -- .
PG30 -- 214-9007B7
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HI-SIDE
NFRC WNDOU COMPANY
TOEL L201 - DOUBLE HUNG
NauntngCo yia;lu CPO# HLc_q_11-059B2-00002
Rating Councile
SOLID UINYL - WELDED - DOUBLE GLZO
3/4" IG. SS LO-E. ARGON. GRIDS < I"
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EN'f PERFORMANCE RATINGS
0 30 F3ctor -- -- - ---- --
SolarHeat Gain coefficient
1 . 7® 0 . 28
(Metric/SI)
A[DDITIC�NA4. f�ER
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LMnuopulate tht f lase r3n.10,c.c.00 r,fu zpplirable NFRC Procedures for determining whole
arings are determined br a fired yet of environmental condmOns and a
SNFRCde Pei recmninend any pmdu:f and does not warrant the surability of any
pecific use.[ nsu't marmfaciure(s I Is"o fe niher product performance Informalio,.