14 OAK ST - BUILDING INSPECTION , r
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2077
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use y
Building Permit Number: Da Applie
ail
Building Official(Print Name) Signature Date
SECTION 1: STFE INFORMA
1.1 Property Address• 1.2 Assessors Map &Parcel Numbers
YEA c=-=CS+-
L la Is this an accepted street9 yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Requi
red 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 es❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSIIIPr
2t. Ownert of Record:
rut C \lc Y��.n ,. t'/t Olq-1G
Name(Print) City,Stale,ZIP
No.and Street elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building Owner-Occupied. Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description 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: $
4. Mechanical (FIVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
�r�l Check No. Check Amount Cash Amount:
6. Total Project Cost: $�' �J� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) M sa .. 2 1
— ]tYl 1Tr License Number Expiration Date
ame of CSL Holder 1 1
List CSL Type(see below) u\
o.and Street a Description
Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted M2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
tSD-'_J "t �COch/ I I Insulation
ele hoe Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) \ Z
P �-- N COQS' 1 \ , \fN%C _ HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
�'� �(�C>>C \-XQGh nF0 lQyOSt ��C �'Ct�1C C��• eJ��
o.and Street Email address
34� tN\ ��a ( �qg
City/Town, State,ZIP \ Tele hone
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 CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize r-iJ l,I,-rJC\3 cCY.�`�"Q�( 1(Y-1 _Inc
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'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 i ication is a and accurate to st of my knowledge and understanding.
� ���� 11
Print Owner's or Authorized Agent's Name(Electronic Sign e) Date
NOTES:
I. 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.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor 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 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"
1
CITY OF SAI..&M, TNLksSACHUSETTS
• BUII.DIING DEPARTMENT
120 WASHLNGTON STREET. YD FLOOR
° A TEL. (978) 745-9595
FAX(978) 740-9846
KIN
(BERLEY DRISCOLL
MAYOR Tliomks ST.PIERM
DIRECTOR OF PUBLIC PROPERTY/13UUMING CONL\USSIONER
Construction Debris Disposal Affidavit
for all demolition and renovation work)(required k
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
L. L . 3 S
(name of facility)
(address of facility)
signature of permtY applicant
date
dcbriutT.dux
j_ CITY OF SiU-F.M, N'L-kSSACHUSETTS
BUI DIING DEPAR—MCIRNT
• t 120 WASHINGTON STREET,3"FLOOR
"ILL (978) 745-9595
FAX(978)74048"
KIMBERLEY DRISCOLL
MAYOR DIRECTOR
ST.PIE]tRH
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG CO%MUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �n L Pleassee Print Legibly
Name (BusirwssiOrpnizatiorvindividtnl): PCS- ii.XxK:>
Address: W 00X 17( oq
City/State/Zip:--,,"�� ti cy- 7O� Phone I#�Cs
Are you an employer?Check the appropriate box: Type or project(required):
1�am a employer with `� 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sbeet 7. ❑Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
workingfor me in an capacity. workers'comp.insurance.
Y P tY• 9. El Building addition
[No workers'comp. insurance 5. ElWe are a corporation and its
required.] officers have exercised their
10.❑ Electrical repairs or additions
3.111 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'ctmtp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' tJ.❑Other
comp. insurance required.] fl
•Any applic am that chocks box►t must also fill out the section belowsbowing their wo,lo s'compensation policy information.
'I lomcowm rs who submit this affidavit indicating they ate doing all work and that hire moside contractors must submit a new,affidavit witamig sued
;Contractors that check this bolt most atgched an additional wheel showing the mane of the subCemfdetga wW their wod ere'comp,policy infmnatioo,
i am an employer that Is providing workers'compensation insurancer jar my employees. Below is the po/%y and Job site
information.
Insurance Company Name:_
Policy 4 or Sell-ins. Lie.1i: Li, �C �J)SC✓,J .� oC Expiration Date: 0I 3\\-?,
Job Site Address: \ 4 C)(—"k cam" City/StatriZip_
,mach 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 MGL c. 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. 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 of perjury that the Ltfo►madou provided above is true and correct
Sienature:-����•—�— Date:
Phone X•
Official use oiify. Do not write in this area to be completed by city or town offikial.
City or Town* PermittLicense N
Issuing Authority(circle one):
L Board of Ilealth 2.Building Department J.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone N:
A CORD DATE 0912 11
. iRDDDDER�—ry C�RTi1=1CATE OF LIABILITY INSURANCE o3/osrzoll
THIS CER IFICATE IS ISSUED AS A MATTER OF INFORMATION
Matthews Insurance Agency HOLDER. H SONLY AN ) OCERTTIFICATE DOES NOTAM ND,NO RIGHTS UPON THE CERTIFICATE
182 Parker St ALTER TH COVERAGE AFFORDED BY THE POLICIES BELOW.
Lawrence, MA 01943
978-661-1112 INSURERS FORDING COVERAGE NAIC#
INSURED A.J.WOOd Construction,]no. INSURER A: LI a MuJ.tual Ins.
P.O.Box INSUR=RE:
Salem,NH 03079 INSLTEP,C: ---
INGURERD: _ -
1 (.INSURER E _ .
COVERAGES
THE POLICIES OF INSURANCE LISTED.BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A OVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIT RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECI TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN P,EOUCEO BY PAID CLAIMS. _
POLICYEFFECTNE POLICYEXPIRATION LIMITS
INSR KOWL TYPEOrNSURANCE POLICY NUMBER
GENERALLIABILMY I EACIALE TO .E CE.
COMMERCIAL GENERAL LIABILITY eNiSESfERyttIAA�61,_S
CLAIMS MADE F—I CCCUR MEO EaP(Arty om emoR) S
PERSONALS AC/INJURY S
G.NERALAGGREGATE S
OEITLAGGREGATE LIMIT APPLIES PER: FRODUCTS-COMPIOP AC-G S
POLICY P�6 LOC
I AVTOMOBRE W0 LfTY
COMBINED SINGLE LIMIT S
(EA utlW+q
ANT..vro
ALL OWNED AUTOS BODILY INJURY
IFeT pttBOn)
SCHEDULED AUTOS
HIRED AUTOS SOCILYINJURY S
NONOWNED AUTOS I (PAwCtlEMU
PROPERLY DAMAO; S
IPernmJdpnil
GARAGEUABILRY AUTO ONLY•EA ACCIDENT `
A.9YAUTO OTHER THAN EA ACC 5 AUTO ONLY- AGG S
EXCESSNMBRELIA LNBILRY I EACH OCCURRENCE S
OCCUR n CLAIMSAIADE AGGRGCATE Is
I
DEDUCTIBLE
RETENTION S S
WORKERS COMPENSATION AND WC2-31S-353819-02t 02/23/2011 02/23/2012
EMPLOYERT LIABILrTY c,L.EACH ACCIDENT S =DU,OOQ_
ANY PROPMEORIPARTNEWCAECUIPIE
OFFrCMACMBER EXCLVDE07 SL DISEASE-EA EUPLDYEE S 500.000_
R yyea-GeSMoe I.Vor E.L DISEASE-POLICY UTAIT S 50 D00
SPECIAL PROVISIONS DPKN
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I E LUSIONS ADDED NY ENDORSEMENT I SPECIAL PROVIS DNS
CERTIFICATE HOLDER CANCELLA ION
SHOULD ANY F THE ABOVE DESCRIBED POUOUS DB CANCELLED BEFORE THE nVIRATION
BATE WERE P.THE RUIUING INSURER DULL ENDEAVOR TO MAIL_BAYS WRITTEN
NOTICE TO n CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO 00 BD RNALL
_- IMPOSE ND C JUGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR
REFRE9ENTA VE& -
AUTHORIZED Ar .lam
IL-
ACORD 25(2001108) / O ACORD CORPORATION 1988
`� oRQ® CERTIFICATE OF LIABILITYINSURANCE Dg DIYYYY)
7i26/26i2O11
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFE RS 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) mt st be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Pat iCia Blais
NAME:
Financial Insurance Services Inc PHONE ( 03)432-6414 aC No: (603)432-3852
PO Box 950 ADDRESS:PEI iis 0 fi si ns.com
INSURERS AFFORDING COVERAGE NAIC f/
Derry NH 03038 INSURER Pe rless Insurance Co
INSURED
INSURER B:Pe rless Ins 24198
A J Wood Construction Inc INSURER C:
PO Box 1769
INSURER D:
INSURER E:
Salem NB 03079 1 INSURER F:
COVERAGES CERTIFICATE NUMBERCL1172003707 REVISIONNUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSU D TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONT RACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE PC LICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCE D BY PAID CLAIMS.
INSR ADDL SU.. POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE S POLICY NUMBER MM/DD W Y MM)DO)YYW I LIMITS
GENERAL LIABILITY - EACH OCCURRENCE S 1,000,000
X OOMMERCl/LL GENERAL LIABILITY DAMAGE TD RENTED
A CLAIMS-MADE OCCUR P8706685 /16/2 11 /16/2012 PREMISES Ea occurrence S 100,000
MED EXP(Any one person) S 15,000
PERSONAL B ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO S 2,000,000
X POLICY PRO- LOC 5
AUTOMOBILE LIABILITY FOM BINEDlSINGLE LIMIT 1,000,000
B ANYAUTO BODILY INJURY(per person) S
ALL OWNED X SCHEDULED 693505 /8/20 1 /8/2012
AUTOS AUTOS BODILY INJURY(Per accident) S
X HIRED AUTOS X ANOTN�OcWNED PROPERTY DAMAGE S
Per mident
ATEXE S
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000
B EXCESS LIAB CLAIMS-MADE AGGREGATE S 3,000,000
DED RETENTIONS 802098 /16/2(11 /16/2012 S
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY Y I NLIM CRY
ANY PROPRIETORIPARTNER)EXECUTIVE E.L.EACH ACCIDENT S
OFFICERIMEMBER EXCLUDED? N I A
(Mandatory In NH)
E.
It yes,describe under L.DISEASE-EA EMPLOYE S
DESCRIPTION OF OPERATIONS bebw E L.DISFARF-POLICY LIMIT I S
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD let,AddItlona)Remarks Schedule,If more Pace Is required)
Job Loc. : 124 Camden St.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANN OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
_ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REP RESENTATIVE
/ J
Sam Fragatarkc
/DEBRA ��.�
ACORD 25(2010105) 1988-2010 ACORD CORPORATION. All rights reserved.
IN5025rvinnnerm Th.II nanm and Innn am ranidprad of ACrIRn
_ ._/ne Gy� e/t r w�c of c�vuvr�v►u
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
_ Registration: 106603
- - Type: Private Corporation
- Expiration: 7/24/2012 Trp 297944
AJ WOOD CONSTRUCTION, INC,
Richard Smith -
PO BOX 1769 _
SALEM, NH 03079 --
Update Address and return card.Mark reason for change.
U Address 17 Renewal Employment ❑ Lost Card
DP$-CAI 0 50M-0 /04G101216
Office of e..sa.- r Affairs&B si ess Regu�—�ia6o� - License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
r Office of Consumer Affairs and Business Regulation
�, Registration: -106603 Type: g
I 10 Park Plaza-Suite 5170
W
r Expiration: 7/24/2012 Private Corporation
Boston,MA 02116 _
AS OOD CONSTRUCTION,INC.-
Richard Smith -
4 RUSTIC LANE - g
DERRY,NH 03038 Undersecretary Not valid without signature
Commonwealth of Massachusetts 9 Massachusetts- Department of Public Safeh
Department of Labor Standards Board of Buildin—, Regulation, and St:mdard,
Heather Rowe,Director Construction Supervisor License
Deleader Supervisor License: CS 70882
RICHARD S. SMITH IV
Eft.Date 07/ 11 ^ _ RICHARD J SMITH
Exp.Date 07/04104/72 �'}j'f PO BOX 1769
DS001123 «.
+ SALEM, NH 03079
er MemhafCO.N.E S.T. i
WN --_—
Iilllllllilll�lllllllllllllllll loll IN11lll oil llll HV.NEW Expiration: 712MO13
t'„nnui..inner Tr--;: 17308
Control No: 36042
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF LABOR
DIVISION OF OCCUPATIONAL SAFETY
19 STANIFORD STREET,BOSTON, MASSACHUSETTS 02114
DELEADER CONTRACTOR LICENSE
AJ WOOD CONSTRUCTION, INC.
337 HAVERHILL ROAD
CHESTER NH 03036
LICENSE: DC001721 EXPIRES: Thursday,July 12,2012
i
i
Telephone: (603) 898-4468 CONTRACT Cell: (603) 235-7624
Toll Free: (800) 458-4468 Fax: (603) 898-6942
A.J. WOOD CONSTRUCTION,, INC.
P.O. Box 1769
Salem, New Hampshire 03079
Email: info@ajwoodconstruc ion.net
Website: www.ajwoodconstru.tion.net
ROOFING•SIDING •WINDOWS• DECKS•KITCHEN& BATH REMODELING
Workmen's Compensalion and General Lial ility Carried on All Work
Date Aueust 16,2011
I (we), the undersigned, hereby accept your proposal to furnish Labor and Materials to perform the following work on premises
located at the following address:
No. 14 Oak St. Salem MA 01970
(Street) (City) (State) (Zipcode)
Owner's Name Cheryl Callahan Telephone: 78 406-3172
Address SAME AS ABOVE Email:chery133 i2arhotmail.com
SPECIFICATIONS OF CONTRACT
• Rebuild chimney $3,000.00
All permits and debris removal included.
We guarantee our workmanship and provide a one(1)year Labc r Only Warranty from date of completion.
The contractor agrees to perform the work furnish the materials and labor s e ified above for the
Total Sum Of$3 000.00 Three Thousand Dollars and 00/00
Payments will be made according to the hillowine schedule:
1/2 due with signed contract: $1 500.00 One Thousand Five Hundred Dollars, and 00/100
Balance Due When Project Is 100%Complete: $1 500.00 One Thousand Fivc Hundred Dollars and 00/100
Required permits — The following building permits are required and will b secured by the contractor as the homeowners agent.
Proposed start and completion schedule will be adhered to unless circumstan es beyond the contractors control arise. The contractor
will start the project within 30 days and the project will be done within 60 day of the start day.
NOTES:
(*) Including all finance charges (**) Law requires that any deposit or dow i payment required by the contractor before any work
begins may not except the greater of(a) 1/3 of the contract price or (b) the actual cost of any special equipment or custom made
material which must be special ordered in advance to meet the completion of s hedule.
You may cancel this agreement if it has been signed at a place other than the ontractors normal place of business, proved you notify
the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery, not later than
midnight of the third business day following the signing of this agreement. See attached notice of cancellation form for an explanation
of this right.
DO NOT SIGN THIS CONTRACT IF THERE A RE ANY BLANK SPACES!!!
Two identical copies of the contract must be completed and signed. One cop3 should go to the homeowner. The other copy should be
kept by the contractor.
• All home improvement contractors and subcontractors shall be r gistered and that any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Office of Consumer Affairs and Business egulation—(617)973-8700
10 Park Plaza, Suit,5170
Boston,NIA 02116
Owner agrees that the title or equity in this property is his and is security for tl as contract.
IN WITNESS WHEREOF the undersigned has(have)hereunto set his(their) and(s)the day and year fast above written.
Buyer(s)Acknowledge Receiving a Completed LA gible Copy of This Contract.
This contract may be voided by the Owners giving written notice to the ontractor by ordinary mail within three full business
days following the date hereof.
By Richard J . Smith ' � -
L.S. -
(Richard J. Smith,President) (Legal own of property to be improved)
337 Haverhill Rd., Chester,NH 03036
FID: 20-0487037
RIC#: 106603