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12 OAK ST - BUILDING INSPECTION (2) ;► ' The Commonwealth of Massachusetts . I Department of Public Safety -.-..f \lass.achu,ells State Building Code(780 C�IR)Seventh Edition City of Salem Building Permit Application for any Building other than a 1- or 2-Family Dwelling (This Section For Official Use Onlv) Building Permit Number: Date Applied: Building Inspector: SECTION l: LOCATION (Please indi a Block 0 and Lot 0 for locations for which a street address is not available) 12 Sf - S?d No. and Street City /Town Zip Code Name of Building(if.applicable) A SECTION 2: PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 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 ❑ , Is an Independent Structural Engineering Peter R view required? Yes ❑ No ❑ Brief oer tp�i�nofProposes)Work: T-f /7 a/�� rerm`� Ir- rr-- C—A4 / SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR 1 CHANGE IN USE OR OCCUPANCY •'Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): r Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/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-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 8: Business ❑ E: Educational Cl F: Facto F-1 ❑ F2❑ I H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1.1 ❑ 1.2 ❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1 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 ❑ fill ❑ IIIA ❑ I(IB ❑ IV Cl VA ❑ VB ❑ SECTION 7:51TE 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 it oubide Flood Zone❑ Indicate municipal ❑ A trench avilf not be Licensed Dsposaal Site required❑or trench ur spacilc: I mate❑ or mdenlik Zone: or an site st,tem El permit is encluseal ❑ Railroad right-of-way: Hazards to Air Navigation: xIA I1,1,-n.( , mmi-w,,141,st . I•n \ul :\ppLial+la•❑ Is tilruCture tcuhut airport appn,ach arr,t' Is their re%ietc completed.' ,a C,msavtl to 11u Jd vnclosa•d ❑ Ye.❑ r,r No❑ 1'e,❑ \o ❑ SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY 1[.I m,m of ( „dc: L.e Grouplsl: rt peot Constn,Ct,un: Occupant Load per 11,,or: 1)oe.the I+u,ldml;contain an Sprinkler S\ win.': Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION N e and A. der . ytl-Properl • Owner Name(Print) Nu.and street C ilv/Town Lip Pruprrh• (honer(-onlact Information:_� - Title Telephone No. (business) Telephone No. (cell) a-mad address It p)plicablr, thr +n+p N�o0nrrhrr;by.wt�hqu Name .. Street Address Cily/Tupvn state Zip' to act on the properly owner's behalf, in all matters relative to work authorized by INS building permit application. - ` SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If Inuldin•is lass than 35,(tx)cu.tt.of endosevl s+ace and/or nut under Construction Control then check here O and stop Section IU.U 10 a istered Profiftrwitmal Responsible for Construction Control Regi I a nt) �"�Rti Tr ephone No. a-mail address Registration Number Street Address .sty/Town State Zip Discipline Expua un Date 10.2 General Contractor r �(U)J C an Name: l !(Xf Name of Pe . t n 4 fur Co n uV ^ (�� License No. and Type i Ap licable G Z $street A -1 C ID kgf- ,.,lD ^i__ _ _ City/Tow 1C��� State, 1-w t- 7 Tele hone No. (business) Telephone No(cell) e-mail address SECTION 11: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated.Costs: (Labor and Materials) Total Construction Cost(from Item 6) =$ 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) ,. S. . - E ..-. nclase check" pay ible•to'._ 6. Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By en lerin name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this applicali n i. true and accura h the best of my knowledge and understanding. 64 #w, agn n j title ielephuUale ?tree 19 City/Town State Lip Municipal Inspector to fill out this section upon application approval: .N'ame U,p le The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,-MA 02111 ' M www.mass.gov/dia Workers' Comp ens ation.Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ; Please Print Legibly Name (Business/Organization/Individual): 03- A D:A ((6 QO , 0C_ Address: O k n q City/State/Zip: �➢)v111ti� 02CP , Phone#: Are you an employer? Check the appropriate box: Type of project(required): Lal am a employer with 457 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 g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp, insurance.t required.] 5. ❑ We area corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I 1 pPlumbing repairs or additions self.m o workers' right of exemption per MGL Y � comp. 12N Roof repairs insurance required.] t c. 152, $1(4), and we have no nn/ ' employees. [No workers' 13N Other �M({)t comp. insurance required.] WmcmewtLf tlT *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have 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 job site information. 1,* nn11 1 Insurance Company Name:_ \ �y� Policy#or Self-ins. Li c.#: ( `/p7 Sj)J 26 T6 I IQo. � t Expiration Dat . Job Site Address: 2 'L City/State/Zip; Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of M.GL c. 152 can lead to the imposition of criminal penalties of a fine up to$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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Signature: 0/0" Date: _ Phone#: 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 Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service.of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or:to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neitherthe commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted.to the Department of Industrial Accidents for confirmation of insurance coverage. Also- e sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the;permit or license is being requested,not the Department of.. Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the.number listed below. Self4risured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete-this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia g�ieB ara f Bu n g la on7��d=� s t ' One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration - - - Registration: 106603,-' Type: Private Corporation Expiration: 7/24/2010 Tr# 270264 AJ WOOD CONSTRUCTION, INC. Richard Smith PO BOX 1769 SALEM, NH 03079 Update Address and return card.Mark reason for change. F-1 Address ❑ Renewal ❑ Employment I—j Lost Card nPSCAI Co S%A-071U-PCN90 pp ..�� 91e@ONLJilGltfr%2Q�1� C.f:a'lauuc/u.:oll Board of Building Regulations and Standards License or registration valid for individul use only 6' ( HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: .� -�£ 1 Board of Building Regulations and Standards } Registration: 106603 t One Ashburton Place Rat 1301 Expiration:. 7/24/2010 Tr# 270264 Boson,Ma.02108 Type: Private Corporation AJ WOOD CONSTRUCTION, INC.- - Richard Smith 4 RUSTIC LANE 'a DERRY,NH 03038 Administrator Not valid withou signature Commonwealth of Massachusetts Division of Occupational Safety Massachusetts - Department of Public Sarcrn Laura M.Marlin.Commissioner may, Board of Buildin- Re_ulations and Standard., Deleader-Contractor Construction Supervisor License RICHARD S. SMITH l4U License: CS 70882 Eff.Date 07/01/09 Restricted to: 00 Exp.Date 07/10/10 >� ® RICHARD J SMITH DC001721 "{ Member of C 0 N ES T. PO BOX 1769 eo - SALEM, NH 03079 IIIIII INIIIII IIIII'lllllllllll'II INIII IIII�pf I IIII aosroN-a ��.��y� Expiration: 7/28/2011 r'„mmi+.inx•r Tr': 19314 v ACORD. CERTIFICATE OF LIABILITY INSURANCE °03/10/2010' 03/10/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Matthews Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 182 Parker St HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lawrence, MA 01843 978-681-1112 INSURERS AFFORDING COVERAGE NAIC# INSURED A..I.Wood Construction, Inc. INSURER A: Liberty mutual Ins. P.O.Box INSURER B: Salem,NH 03079 INSURER C: NISURER O NSURER E: COVERAGES 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 WH)CH 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR�� POUCY NUMBED FOLICYEFFECTME POLICY"PIRATION LIMITS GENERAL UABILRY EACHOCCURRENCEtMWGS TO I S COMMERCIAL GENERAL LIABILITY PREMISES Ea RM RENTIED S l CLAIMS MADE FJ OCCUR I MED E%P(Arry Ane per6nn) $ PERSONAL S ADV INJURY S GENERAL AGGREGATE S GENL AGGREGATE LIMIT APPLIES PER: ,PRODUCTS-COMP/OP AGO S E POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT T: ANT AUTO (Ea attMeN) ALL OWNED AUTOS Booe.Y INURY T SCHEOULEOAVTOS (P�pimcU HIREDAUTOS B ULY eracci WURY S - NON-OWNED AUTOS (PeralziDenp PROPERTY DAMAGE S (Peracvlenq GARAGE UABIUTY i AUTO ONLY-EA ACCIDENT S i ANY AUTO OTHERTHAN EA ACC S j iIq AUTOONLY: AGO S EXCESS IMBRELLA�UAjBIUTY EACHOCCURRENCE S L OCCUR .J CLAIMS MADE AGGREGATE S S DEDUCTIBLE S RETENTION SWC S WORKERS COMPENSATION AND WC231S353819029 02/13/2010 02/13/2011 FEL ORY UMffS WER WI ANYPRDEP IRRIIEETORIP RA�TNERIEI(ECUTNE S $QQ QQQ OFRCERMEMBEREXCLUOEDT ISEA$E-EAEMPLOYEE S 500000 1/yyeess OesulCe WiderSPEdMLiNOVISIONSEebr DISEASE-POLICY LIMIT S $QQQQQ OTHER DFSCMPRON OF OPER ITIONSI LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVLSIONS CERTIFICATE HOC CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO NAIL_ DAYS WRITTEN - - NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,SLIT FAILURE TO 00 SO SHALL °IPOSE NO OBLIGATION OR LIABILITY OF ANY HIND UPON THE INSURER,ITS AGENTS OR REPRESENTATN AUTHORQED R - - ACORD 25(2001108) s - ©ACORD CORPORATION 1988 T •d dZS =EO 01 LT JeW "� CERITICATE OF LIABILITY INSURANCE 9/i o' PROmsEL (603)432-6414 VAX: (603)432-3952 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION E CERTIFICATE POBOX 95 T^m+ranCe Services T,nC HOLDER. TMS CONLY AND ERTIFICATE DOS NO ES NOT AMPON END,_EXTEND OR PO Hog 950 ALTER THE COVERAGE AFFORDED_13Y THE-POLICIES BELOW_ Derry _._,MR 03038 INSURERS AFFORDING COVERAGE NAICO INSURED - .. TNSUREVAPe SZ1dZS Insurance Co, A .7 Wood Construction Inc WSURERe PO Box 1769 MSURERc INSURER O: NH 03079 INSIRETE - COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOT VMHSTANDING ANY REQUIREMENT,TER M OR 00NDITTON-OF ANY CMITRACT 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 OFSUCH POLICIES.AGGREGATE LIMITS SHONM MAY HAVE BEEN REDUCED BY PAID CLAIMS MSR AOUL POLICY NUNBER PoLIC(EFFECGYE PoUCY EIWIRATWN UNITS GENERAL UABAJTY EACH OCCURRENCE ; 1.000.000 X COMMERCIAL GENERAL LwaILrry PREra6EG e22IMS- S 50 000 A CLAWS MADE rR bOCM P ENDING 8/16/2009 8/16/2010 MtD EXP one ; _ 5.000 PE2SOWN.AADVIMDRY i 1,000,000 GENERAL AGGREGATE S 2,000,000 GENL AGGREGATE LMIT APPLIES PER. W20WC'TS- IOPAGG S.. _ 2,000,000 X POLICY PRO` - LOC AUTOMOBLEUASILDY —IT COMBBNED SINGLE LPAIT ANYnuro IEaar�a> a 1,000,000 A ALLOYINEDATOs IU693SCS 7/8/2009 7/8/2010 eODLYMLBNY X SCHEDULED AUTOS (Perpe ) S X HIRED AUTOS X NON-OAHED AUTOS BQDIeYM'jRY 5 PROPERTY DAMAGE i TPurSo7Q GARAGE UABWTY AUTOONLY-EAACCIDENT ANY AUTO OTHERTHAH EAACC ; AUTOONLr AGG plCESSIUMI Ro,A VARRM EAai OCd/RRENCE OCCUR ❑OANSMADE AGGREGATE ; S i OECUCrIBLE REIBMON S . ._ WORKER ANDEMPLOYERW NSATION vlcsrATu- SER - AHDEMPLovNBTSLUNewTY YIN ANY PROFRIETORPARTNERIBEamVE ELEAaIAmoBiT ; �OFFICER&REMSER 9=UDEM El-DSFwE-EnEeePLo i nyas,aeml0evnaer SP[:a111.PROVL90M5 Ceiw I ._•.EJ-DISEASE-PoLLYLAdR ; _... OTHER OESCWPTION OP OPERATIONS ILOCATNOm awmEa I MCLiS10NS AMID 6Y BNOOR6ENHNT!SPEML PROVISIONS CERTIFICATE HOLDER_ CANCELLATION SHO{LDANYOFTHEA60VEDESCMBEOPOUCOSSECANCHLWBUGRE'MMEXWRATON DATETHEREOF,THE ISSUING INSURERVm2 EVDEAVORTO MAIL 3-0 DAYS VIRRTEN NOncEtom ECBMF=TENDLOBZNAMEDTOTm LEFT.BUTFALURETOOOSDSHALL S t-t PL-e- NROSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TXEINSURER,ITS AGENTS OR REPRaairnnvE9. AUTHORIM REPRESENTATIVE Sam Fragala/DEBRA •��• -e._ _!�:�•"'• 5 -, «.. .: 009101 ACORD 25 (2 ) . . . . . - - ®1988-2009 ACORD CORPORATION. All rights reservelL IN5026TtaMmT The ACORD name and logo ale registered marks of ACORD