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323R LAFAYETTE ST - BUILDING INSPECTION 1 0 C,�: I C��✓03 The Commonwealth of Massachusetts,,�w � tr ° * VjITY OF 11 e Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 C '%b JUL 19 P J Rajed Mar 2011 (1 Building Permit Application To Construct, Repair, Renovate Or Demolish a LO One- or Two-Family Dwelling This Section For Official Use Only ' Building Permit Number: Date plied: 11 Building Official(Print Name) Signature Date 1 SECTION 1: SITE INFORMATION 1.1 Prop rrty ddre s: 1 ' 1.2 Assessors Map& Parcel Numbers 1.la Is this an accepte street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(R) 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: Zone: Outside Flood Zone'? Public ❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑ IV 1 P�1 ECTION 2: PROPERTY OWNERSHIP' Owner' ecor 0 / Name(Pn ) �0 City, State,ZIP SV. olin Uh�IGk� n C411Gi1 No.and Street U'- Telephone J Email AcTd ess �— SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: ! dkio Br of Description of Propo ed Work'-: 1 ,m l I�-9� _A P A V �a E�alsl� , o 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: $ 4. Mechanical (HVAC) S List: 5. Mechanical (Fire $ Suppression) Total All Fees: S Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ — ❑ Paid in Full ❑ Outstanding Balance Due: M C�1 l.- -\C) c©Iv\ A g- I srA-sue -11 Z) SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) N_\p_)� License Number Expi tion Date Name of CSL Herder � List CSL Type(see below) o�t Q�y� rep Noo.. and Street Type Description U Unrestricted(Buildings tip to 35,000 cu. ft.) Vnn v-Y\,A n\c\-C�� R Restricted 1&2Famil Dwelling City/T wn, State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1e6�•� \a '-1�'1� QJ��.l7\P�l._(Se,��mgr,. CS`ev` I Insulation Telephone Email address D Demolition 5..22 �Registerred-Home Improvement Contractor(HIC) L 9 A ) - I "-) ±`;^+Ly_t ysa 2 HIC Registration Number xpa ion Date HIC Compa—ny Narne or HIC Registr`a�INTame �^�, D($;I e k k -k p Q r� V — P la t h[��t 1t�WYYkS 17 • GC�f I No.and Street Email address Cit /Town, State,ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFH)AVIT(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 1,as Owner of the subject property, hereby authorize ��l.J • Lo y�l �- A % 0/ ,-R, 2a to my beha , r all matters relative to work authorized by this building permit application. Print Owner's ame(Etc> ric Signature) I Dale ECTION 7b: OWNEW 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 in this application is true and accurate to the best of my knowledge and understanding. Ig 1 Print Owner's uthorize is Name(Electronic Signature) D to 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 can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial yvprk i- llaanned,provide the information below: Total floor area(sq. ft. l �lj� (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" The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations I-Congress Street, Suite 100 s Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plu rs Applicant Information Please Print L l ibl Name (Business/Organization/Individual): EB Window and Siding CO Address: 756 Western Ave City/State/Zip: Lynn, MA 01905 Phone #: 781-592-9747 Are you an employer? Check the appropriate box: Type of project (require ): I.❑■ I am a employer with 6 4. ❑ I am a general contractor and I employees (full and/or part-time)."` have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs o;l dditions 3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs o' dditions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑■ Other comp. insurance required.] WS Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. +Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicati uch. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities h e employees. If the sub-contractors have employees, they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and j ! site information. Insurance Company Name:Berkshire Hathaway Gaurd Insurance Co Policy#or Self-ins. Lic. #:EDtW�C643855 c Expiration Date: 12/13/16 Job Site Address: 23 c�� Y— c 11.y 2 C� ' City/State/Zip: Attach a copy of the workers' compensation— policy page(showing the policy number and expirati i date). Failure to secure coverage as required under Section 25A o£MGL c. 152 can lead to the imposition of criminal pena 'es of a fine tip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER d a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and ena[t' of perjury that the information provided above is true and corre Si nature: Date: Phone #: 781-592-9747 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspe': r 6. Other Contact Person: Phone#: r�r fran.r<a c frl,-pCl/r 'rfJrl!)OFYi °ate... Office of Consumer Affairs 8 Rusiness Regulation I IIOME IMPROVEMENT CONTRACTOR "Registration: 128634 Type: kwExplredow 51212017 DBA e y. ED BYRNE WINDOW CO EDWUND BYRNE 756 WESTERN AVE LYNN, MA 01902 Undersecretnrg }fir Massachusetts-Department of public Safety &oard 0"Building Reguiafians and Standaris ••urea; ; x �0.� .. License CS-010870 " �t T EDMU"j BYRNE 18 Woodrow TerrAce Lunn MA 0141i4 7 G"' Jr i4t id Exg3ration Commisswner 07IM2017 q���® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/°°YYYY) 7/7/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Commercial Lines NAME: Admiral Insurance Agency,Inc. PHONE (781)599-2000 Fac xo:/tIC Np,_Extt. 70 Munroe Street %—AIL ADDRESS: Suite D INSURERS AFFORDING COVERAGE NAIC# Lynn MA 01901 INSURER A:Providence Mutual Fire Ins Co 15040 INSURED INSURERB:Guard Insurance _ ED14UND DBA BYRNE 6 ED BYRNE WINDOW COMPANY INSURERC: 766 WESTERN AVENUE INSURER D: INSURER E: LYNN MA 01905 INSURERF: COVERAGES CERTIFICATE NUMBER-CLI631522634 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LICY EXP LTR TYPE OF INSURANCE INSO WVD SUER POLICY NUMBER MM/DDNYYY MM/DD/YYYY LIMITS TR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGETORENTEID 1,000,000 A _ CLAIMS-MADE X OCCUR PREMISES 1Ea mcunence $ BOP0063101 6/21/2016 6/21/2017 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY[] PRO ❑ 2,000,000 JECT LOC PRODUCTS-COMP/OP AGO $ OTHER' FILL $ 50,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ _ HIRED AUTOS AUTOS Peraccitlent $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION STATUTE RH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EDW+C643855 12/31/15 12/21/16 EI.EACH ACCIDENT $ 11000,000 B OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 11 yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS[VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE J S Scholnick/MPB ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I149025 nnlnml E.B.Window and Siding Co. Invoice 756 Western Ave Date Invoice# Rt107E Lynn MA 01905 7/15/2016 53021 Rep Bill To Charles Connelly 323 R Laffayette st Salem Ma 01970 P.O. No. Terms . Due Date Account# Project 7/15/2016 Description Qty Rate Amount Furnish and install Mezzo replacement Slider windows, 2 1,450.00 2,900.00 large, three lite, white low-E Package/Climatech Glass 2 0.00 0.00 Installation 2 0.00 0.00 Furnish and install Two Lite Casemnet replacement 4 1,150.00 4,600.00 windows Low-E Package/Climatech Glass 4 34.00 136.00 Installation 4 150.00 600.00 Furnish and install One Lite Casemnet replacement 2 790.00 1,580.00 windows Low-E Package/Climatech Glass 2 0.00 0.00 Installation 2 0.00 0.00 Remove existing windows and prepare opening to 0.00 O.00T accept new vinyl replacement windows Install Windows 0.00 Seal Windows in and out using Tite bond lifetime 0.00 sealant Take away all job rel d de ris 0.00 acceptance of propo 0.00 O.00T authorized signatur Sales Tax y 6.25% 0.00 Total $9,816.00 Payments/Credits -$1,500.00 Balance Due $8,316.00 Phone# Fax# E-mail Web Site 781-592-9747 781-592-9746 ebwindowa msn.com www.ebwindow.com Lesley Management July 18, 2016 Re: Lafayette Street Condominium Trust, 323 Lafayette Street Salem, MA 01970 To Whom It May Concern, Please allow this letter to confirm Lafayette Street Condominium Trust, is aware and approves of the window replacement project of Charles Connelly, 323R Lafayette Street, Salem, MA 01945 by E.B.Window and Siding Company. Please do not hesitate to contact our office with any questions. Sincerely, Kivn�ly Lord Kimberly Lord P.O. Box 946 Marblehead Massachusetts 01945 Telephone (781)639-0534 Facsimile (978)374-4852 Lesleymanagement@comcast.net