390 HIGHLAND AVE - BUILDING INSPECTION tt� 103, aoa �- o
�1 The Commonwealth of Massachusetts
tr
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
Aac Q,5se/rm Am
No.and StWet City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑ or chuck a[I that apply in the two rows below
Existing Building 1�0 Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No AD
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 1212
Brief Description of Proposed Work: —_
Y_��� � d.L--s--c'll� [/iS lJ �/IZt 62(Y�i111 6 . 7
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA _
lxisting Proposed
No.of Floors/Stories (include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5 ❑ 1 B: Business's E: Educational ❑
F: Factor F-1 ❑ F2❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
Ii Institutional I-1 ❑ 1-2❑ 1-3❑ I-4❑ M: Mercantile ❑ R: Re:idantial R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use ❑ and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Situ
Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be P
required ❑ or trench
Private❑ or indentify Zone: or on site system El required
is enclosed ❑
Railroad tight-of-way: Hazardsrea?ds to Air Navigation: 61A Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach a Is their review completed?
or Consent to Build enclosed ❑ Yes ❑ or No❑ Yes ❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
G� #tna g1 T., MVP l/J". x't �i.at G lJ�q)19
Name(Print) No..6 d Street City/Town Zip
Property Owner Contact Information:
Ow W r r -.M L7,3
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes x 1,3
Name Street Address Ci /Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor c n Z
Company Name
Name of Person Respons&le for Construction License No. and Type if Applicable.
Zo 42--xTrr ,J ,1OA'u.r Ali9 O 9
Street Address Ci /Town State Zip
7- ---110A(I u. W 10
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCL-AFFIDAVIT(M.G.L.c.152.§ 25C(6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT E
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
1..Building $ Ao 416 0 Building Permit Fee=Total Construction Cost x (insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to Aa���
6.Total Cost $ Q (contact municipality)and write check number here
SECTIO 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.at
Please print and sign name Title Telephone No. Date
LO>,57-e so Arz d
Street Address C' /Town Stat Zi
Municipal Inspector to fill out this section upon application approval: Ij
Name Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block # and Lot # for locations for which a street address is not
available)
No. and Street City /Town Zip Nanie of Rnildinp, (it applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No V Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No Ej4 Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ NoV Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
M ark "x"where a licable
No. Item Submitted Incomplete Not Required
I Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investi ation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction. Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State 1p
Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zip
&MfTaReord,I,c 1-000,2WAM arwww nabs cona
PRODUCT 118
Proposal Page No. Of Pages
E.B. Window and Siding Co.
756 western Avenue 4458
Lynn, W 01905
Eg 781-592-9747 Fax 781-592-9746
E-not ebw1ndow@n=A*m
PROPOSAL SUBMITTED To ^ONE DATE
4LIT .4 14,10 -U 417V _
Ste/STREE: /3
L JOB NAME
4/ a )�V Z- — --- x
,,
CITY,STATE and ZIP CODE JOB LOCATION
ARCHffECf DATE OF PLANS
JOB PHONE
We hereby submit specifications and estimates for:
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4
All .......r
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propUSt hereby to furnish material and labor complete in accordance with above specifications, for the sum of:
dollars($ Ze
Payment to be In us as f V
Avu , u)
All material is guaranteed to be as specified. AI work to be completed In a workmanlike
manner according to standard practices.Any alteration or deviation from above specifications Authorized 1�11�1
specifications
extra Signature
involving�kctra 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 i. Not Osal m6b,
Our workers are fully covered by Workman's Compensation Insurance. Insurance. withdrawn ndrawn by o ccepted within
Aruptance-of propusil —The above prices, specifications
if.
If fit or, d Sign time
ra�nd c�o!mlifi!Ts am satisfactory and are hereby accepted. You am authorized Signatifins,
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803
(800)876-2765 NCCI NO 26158
POLICY NO. I AWC 70221 D9012011
PRIOR NO. I AWC7022t09012010
ITEM
1. The insured Edmund Byrne dba Ed Byrne Window Company
Mail Address: 756 Western Ave Lynn MA 01905-2456
Street No. Town or City County State Zip Code
FEIN x)o=9236
®Individual []Partnership []Corporation ❑Joint Venture ❑Association pother
Other workplaces not shown above:
2. The policy period is from 12/13/2011 to 12/13/2012 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 our liability under Part Two are: Bodily Injury by Accident$ 100.000 each accident
Bodily Injury by Disease $ 500.000 policy limit
Bodily Injury by Disease $ - -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 Rules,Classifications,Rates and Rating plans.
AU information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Cade 6Gmaled Par$100 Eswmated
No. Total Annual Or Annual
Remuneration Remuneration Premium
INTRA 050459
SEE TNSION OF INFORNATIC.N PAGE
Minimum premium$ 500.00 Total Estimated Annual Premium $ 7,382.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 7,796.00
® Annually ❑ Semi Annually D Quarterly ❑ Monthly
MA Assessment Chg.
$7,009.58 x 5.90000A $414.00
This policy,including all endorsements.is hereby ceuntersigned by 11/28/2011
Authw and Sianaeae Oats
su
GOV GOV I KIND PLACING CLAIM NAME -S-A—FE--TY-1 Admiral Insurance Agency Inc
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP PO Box 71
MA 15651 12 705 - - - -� Lynn,MA 01903
WC 00 00 Ot A(7_11).
hxhxl a myrditd material of dte NatinrW Council on Conperuation btvwarce.
ased wit Fs Pem�bn
Massachusetts - Department of Public SafetN
Board of Buildin- Re-ulations and Standards
Construction Supervisor License
License: CS 10870
EDMUND J BYRNE F
jz:�
71 REVERE BEACH BLVD
REVERE, MA 02151 r
Expiration: 7/9/2013
Commissioner Tr#: 17669
�oaru r A
Office of consumer A airs &c ti�in� egu aht
!PHOME IMPROVEMENT CONTRACTOR
Registration: *128634 Type:
Expiration: 5/2/2013 DBA
dF!E WINDOW Cd?F;-_
EDWLIND BYRNE_
756 WESTERN AVE'
LYNN, MA 01902 :.`n r Undersecretary