6 HOLLY ST - BUILDING INSPECTION (2) 12A 1
The Commonwealth of Massachusetts
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)
�o H-oiw St so-Qe,l-, MA n) a :�
No.and Street- 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 check all that apply in the two rows below
I� Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
Is an independent Structural Engineering Peer Review required? Yes ❑ No ❑
Br f Description of Proposed Work:
tU Jl� n1.lZfQ Z v tiw t fA 'L
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
Existing 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 ❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ 1-2❑ 1-3❑ I-4❑ M: Mercantile ❑ R: Residential R-111 R-2❑ R-3 ❑ R4 ❑
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 ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? 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
�1,I I `I yit Y�_( e I k)i 1 to ,«. I - c y�,
Name(Print) No.and St et City/Town Zip
Property Owner Contact Information:
IC.c: k - 0L0k_e-r Il_$IV Co A.t,4
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes �, ��,�
Name Street Addrrss'''//�� City/{Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant T lephone No. e-mail address Registration Number
1" o)q —
Street Address Cit /Town State Zip Discipline Expiration Date
10.2 General Contractor
E6 U X Ix c$t3�.1
Company Name
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Name of Person Responsi le for Construction License No. and Type if Applicable
Street Address ity/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS COMPENSATION INSURANCE 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 FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building $ 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
6.Total Cost $ a Lp LP L'jo (contact municipality)and write check number here
SECTION 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.
Please print and�O,sign nam Title , ' .A_Telephone No. ate
4SLO ` ��ti b� vt& /j I r�
Street Address Cit /Town State Zip
s
Municipal Inspector to fill out this section upon application approval:
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)
1Z,4 SqU P.*-Y\ c) )I
No. and Str t City /Town Zip Name of Bui ding (if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No Ll Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ NoU Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ NoM 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*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 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 pennit
fee.
Registered Professional Contact Information
Name(Registrant Telephone No. e-mail address Registration Numbe
Il.� o� 5 02
Street Address Ci /Town State Zip Discipline Exp ation Date
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
Discipline Expiration Date
Street Address City/Town State Zip
CITY OF S.U.F_M, iNJASSACHUSETTS
13UM301ING D£PARTSE&NT
N• 120 WA3HCVGTON STREET,3s°FLOOR
TEL. (978) 74S-959S
FAx(978)7404846
KI\IBERI EY DRISCOLi
MAYOR THoMAs ST.FhERRB
DIRECTOR OF PCBLIC PROPERTY/BCiLDLNG CO\t!%aSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information I ' / Please Print Leeibly
Namc IBusimx arganizatiorvindividual): l y^?�{J LO I�l(1P(n -)
Address.4S(.0
City/State/Zip:I " Kr) As C�IG(�S Phone #:
Are you an employer?Check the appropriate box: Type or project(required):
I am a employer with 4. 0 I am a getteml contractor and 1 6. ❑New construction
employees(full and/or part-time)-* have hired the sub-contractors
2.❑ 1 ran a sole proprietor or partner-
listed on the attached sheet. 7• 0 Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9, 0 Building addition
[No workers*camp. insurance 5. 0 We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 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.� hoof repairs
insurance required.] i employees. [No workers' 13. Other /GC
comp. insurance required.]
-Any applicant that checks box A 1 most also rill out the section below showing their workers'compensation policy infurmasion.
s I irmn:ownem who submit this affidavit indicating they are doing all work and then him outside contractors must submit a r>ew affidavit indicating such
;Conrracaon that check this box must anactted an additional sheet showing the name of the M1b eontractda and their workeW comp.policy infixmation.
l am an emplayer that is providing workers'compensation brsurance for my employees. Below is the policy end fob site
information. '/ ^ i. , 1 y}
Insurance Company Name:r.BP A 4�!`KI.A.<'lG' T�`�-Ir\,()I i fa &A
Policy#orSeif-ins.Lie. #:y hV__10 DLA Expiration Date: 1
Job Site Address: CO 4AA1SA �F+ CityiStateJZip: l ��
\tack a copy of the workers'co venation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL a 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. He 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 cerrif nder the pains and penalties of Flury that the information provided above Is true and correct.
i n t ire: Date:
Phone
Official use only. Ao not write in this area,to be completed by city or town afficial
City orTowa: Permit/I.icense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
(
CITY OF S.U.E.%i, ,LLkSSACHUSETTS
BUILDING DEPAM RTENT
1'_0 WASHNGTOIV STREET, 3" FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINIB ILF,Y DRISCOLL
,MAYOR T Ho.%As ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUMDING COSLMISSIONER
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 e 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
i 11, S 150A.
The debris will be transported by:.
(name of hauler)
The debris will be disposed of in r
(nam1eofnfacility)
p l� V nV`R
(address of facility)
signature permitap
ite�
dcbnsaff dew
BERKSHIRE HATHAWAY Worker's Compensation and Employer's Liability Policy
V UA$1D INSURANCE
COMPANIES NOrGUARO Insurance Company - A Stock Company
Policy Number EDWC643855
Renewal of NEW
NCCI No. [25844]_
Policy Information Page
[1]Named Insured and Mailing Address Agency
Edmund Byrne ADMIRAL INSURANCE AGENCY I
756 Weston Ave 70 Munroe Street
Lynn, MA 01905 Lynn, MA 01903
Agency Code: MAHARR12 F
Federal Employer's ID 20-1160335 Insured is Individual
Additional Names of Insured —
(N2) Ed Byrne Window Company
[2] Policy Period
From December 13, 2015 to December 13, 2016, 12:01 AM, standard time at the insured's mailing
address.
1 [3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in Item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $1,000,000 I
Bodily Injury by Disease - each employee $1,000,000 i
Bodily Injury by Disease - policy limit $1,000,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms M.
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates,and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 10,055
Total Surcharges/Assessments $ 545.00
Total Estimated Cost $ 10,600.00
IN1f!kNA�t2 Page- i - Information Page
MGA : EDWC643855 WC 000001A
Date : 1.1/04/2015
MANOTE
Issuing Office: F.O. Box A-H, 16 S. River Street. Wilkes-Barre, PA 18703-0020 9 www.guard.com
'I/1Y1,(/1(l.l,/(//�//II/.(� I(.lu(Ifl/iC�a
w Ot5[e of Consumer Affairs&Business Regulation
WkHOME IMPROVEMENT CONTRACTOR
19 Registration: 128&U Type:
Expiration: 5/2/2017 DBA
ED BYRNE WINDOW CO
EDWUND BYRNE
756 WESTERN AVE �a
LYNN,MA 01902 Undersecretary
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
License: CS-OIOg70
EDMUND J BYRN
18 Woodrow Terrace DLO
Lynn MA 01904 7 -
Expiration
Commissioner 07109P1017
E.B. Window and Siding Co.
- Invoice
756 Western Ave
Rt 107 Date Invoice#
Lynn MA 01905 11/19/2015 51990
Bill To
Kate Sullivan
6 Holly Street
Salem MA 01970
P.O. No. Terms Project
Description Qty Rate Amount
Vinyl Siding Installed:Coventry premium .42 siding. 1 26.900.00 26,900.00
Color:
New customer discount 1 -300.00 -300.00
Scope of Work: 0.00 0.001,
Insulate building with 38 Airlock double foil platinum insulation 0.00 0.001'
Wrap windows and fascia with custom bent aluminum 0.00 0.001
Install vinyl soffit for high wind location 0.00 O.00T
Install vinyl siding per Alside spec's 0.00 0.0o"f
Remove all job debris 0.00 O.00T
Any building permit require to comp)I e project to be added at cost 0.00 0.00
to the final payment 41) to $300
0.00 0.00"f
acceptance of osal o
authorized signat
Subtotal $26,600.00
Sales Tax $0.00
Total $26,600.00
Payments/Credits -$8,600.00
Balance Due $18,000.00
Phone# Fax# E-mail Web Site
781-592-9747 781-592-9746 ebwindowmmsn.com www.ebwindow.com