39 OSGOOD ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards Mmkwigpo
Massachusetts State Budding Cale. 780 Ch1R. T"edition Building Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a
One. or Tiro-Fainds Dire/ling
M This Section For ORaal Use On)
Q y `J\ Building Permit Nu r: Datt Applied: 9
Signature: & I
Building ommissioner/I(**ct of Buildings Dote
SECTION 1:SITE INFORMATION
1.1 Pr rty Addre 1.2 Assessors Map& Panel Numbers
I.la Is this an acre tad street? M yea no 'p Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area I II) Frontage III)
13 Building Setbacks(R)
Side Yards Rear Yard
Front Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flaod Zone Information: t./Sewage Disposal System:
Zorn: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Cheek if Wao
SECTION 2: PROPERTY OWNERSHIPi
2.1 Own lot eOrd. 19-P (1'Cy c_ — i lW
A-ddresa for S�e^�hce:
�<-_ 70:14 -('32
signal Telephone
SECTION 2: DESCRIPTION OF PROPOSED WORK'(chock ad that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) O 1 Addition O
Demolition O 1 Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proposed Works: l c \ k____7D
Kna
t
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OOlclal Use Only
Item Labor and Materials
I. Building f i � I. Building Permit Fee: f Indicate how fee is determined:
O O Standard City/Town Application Fee
2 Electrical f O Total Project Costs(Item 6)a multiplier a
) Plumbing f �Mo 2. Other Fees: f
3. Mechanical IHVAC) f List:
. Mechancal tfire f Total All Fees: S.
Su rescion
Check No. _Check Amount: Cash Amount:
6 Total Project Cost f 0 Paid in Full 0 Ountandmg Balance Due
SECTION !: CONSTRUCTION SERVICES
5.1 Li ns Construction Sttp.,er%isorlCSL) 0 L"l /
•• License Number L- Espuuu�"
of( L- IIpIJer
C7 03 List CSL Type IrY Mluwl
A a �' ( T Description
tion
U Unrestricted u io 11.000 Ctt. Ft.
R Restricted 1!1 Fame Dwelling
5 rulure
��6 y \1 .Ni Only
U R S Residential Raofin Covenn
Telephone K'S Residential Window and Sitting
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
3.2 Registered Home Improvement Contractor(HIC) U3
HIC Company ame me or HIC Registrant Na Registration Number
A �12-L4
C I. y �,Q kM. (n(�3 rJ'Q�(,(y(o Expiration Date -
Si viatuft lephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL/ 2SC(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 Issuanc f the building permit.
Signed AMdovit Altachesl7 Yes.......... No...........G
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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si atom of Owner - Date
SECTION 71b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the star rats and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Went Name
u IsJb5
Signatura o ner or Aut ized Agent Date �—
Sisned under the pains and penalties o(penury)
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 Sg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 10.R6 and 110.RJ, respectively.
2. When substantial work is planned, provide the information below
Total floors area ISQ. Ft.) (including garage, finished basement/anics.Jecks or porch)
Gross living area(Sq. Ft.) Habitable room count
,,Number of fireplaces Number of bedrooms
Number of bathrooms Number of half.baths
Tvpe of heating eystem Number of decks/porches
T�peof cooling cy\tem Enclo,cd Open
I "Total Pro)tcl Square Footage'may he.ub.tituted for 'Total Project Cost'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
120 WAM IIXG ION SI It LET • 5AI I'Nr, fit.\iiAl 'It d I'i+:1'r':.
'fGI:v78-N3-1i95 • fAs:978-74(4-9846
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 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
I11. S 150A.
The debris will be transportcd by:
(name of hauler)
The debris will be disposed of in :
(Ilam of act Ity)
(alfllrCS511f Iaclhlyf
.ignature of permit applicant
te
-"� CITY OF S.U_E.`I, ,NLkSSACHUSETTS
BL'BDLVG DEPARTULNT
r 120 W.\SHINGTON STREET, Sea FLOOR
j T L (978) 745-959S
F.%X(978) 740.98"
KI.%IBEIULEY DRISCOLL THOlwST.PffAm
MAYOR DIREcrot OF PLBLIC PROPERTY/eL1IDLNG CO.%c asslO%ER
Workers' Compensation Insurance A111davit: Builders/Contractor/Electric(anslPlumbers
annlicant Information 1 Please Print Legibly
N21nd (9us�w•say.00rrWiz31ionlndav,du:d): ./'S�S 1 A� Q(">(' as Ljc*x GJ,
Address: ' i J
City/State/Zip: fJw M, u* ki-2 12 phone is
Are you an employer?Cheek Rho appropriate box: Typo of project(required):
1.❑ I am a employe with---� e. ❑ 1 am a general contractor and I
employees(full and/or pait-time).e have hired the subcontractors 6. ❑New construction
2.(3
.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 7. ❑ Remodeling
,hip and have no employees These subcontractors have ti. ❑ Demolition
working for me in any capacity. workers'comp.insunaee. 9. Q Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its IO.❑Electrical repairs additions
required.) officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I-❑Plumbing repairs or additions
myself(No workers'comp. c. 152,410).and we have no 12.0 Roof repairs
insurance required.) t employees. (No workers' I3.Q Othv
comp. insurance required.)
Any applica l eb chocb boa of mum alas fill ua the seunis below showing their w'arkar'cmepets eden polity ine mtalma
'I t.vttvuwnes who submit etis aA1Mit indicating they aft doing all work one tbo hit dhoti&eeetmoton meat submit a now of elavil itdisasity seat
T.,nam:u n dot.hack this but mum snacked an aatitiewal dint showing the tame of na su►cemtecbm add their wotkase'camp.pdiry,inrmrotiot,
d am an emp/ayer that Is providing,workers'compenmaloa lnssronee jar my earp/ayres. et/ow/s fhepo//a7 sw1 Ja1 slto
irtjormadon. ^"
Insurance Company Name: F_kO `04--0A— L
Policy #or Self-ins. Lic.. t Expiration Date:
Job Site Address: � / �k]��{ G C�� City/StatdZip;D k 6 M
Attack a copy of the workers'compensation policy declaratlon page(showing the policy member mad expiration date)`
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of■
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$250.00 a day against the violator. Ile adviusi that a copy of this statement may be rurwurded to the Office of
I nvcoigmiuna urilia DIA for insurance coverage verification.
Ida hereby crril&under rho pains and pens/Nis of perjury that the inforn,tnlon provided above is true and carrres.
Phu d: 6 -3- kS 6 t U C O
o lciad use mdy. Do not write in this ores,to be.umpkid by city or town nfrial
City or fawn: Pcrmit/l.fcenst M
I%suing.%athurity (circle une):
I. Ituard u(Ilealth I. Ruilding Department J. Citytrown Clerk ♦. Electrical Inspector 5. Plumbing Inspector
6. Other
Lutttact Person: _ --, --. Phont N'
Massachusetts - Department of Public Safcry
Board of Buildin_ Rc�uLttiuns and Standard,
Construction Supervisor License
License: CS 70882
Restricted to: 00
RICHARD J SMITH
PO BOX 1769
SALEM, NH 03079
Expiration: 7/28/2011
('•nnmin�incr Tr': 19314
_ 91te
Bo rdPo Bui`l�ingegulffiteil�d °t� d
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.
Address [_] Renewal L jI Employment (-, Lost Card
0PS-CA1 0 50M.07/07-PC8490
Board of Building Regulations and Standards License or registration valid for individul use only
x _ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
l ti
� Registraon: 106603 j One Ashburton Place Rm 1301
Expiration: 7/24/2010 Tr# 270264 Boston,Ma.02108
Type: Private Corporation -
AJ WOOD CONSTRUCTION, INC.
Richard Smith (t
4 RUSTIC LANE �y �W+�•0^•'� z 1 — jk` —
DERRY,NH 03038 Administrator Not valid without-signature
Commonwealth of Massachusetts
Division of Occupational Safety
Lama M Marlin,Commissioner
Deleader-Contractor
RICHARD S. SMITH
Eff.Date 07/01/09 _
Exp. Date 07/10/10
DC001721 9 y!
Member of C.0WE&T.
BO
IIIIIIIIIIIIIIIII IIIII IIIII IIIII IIIII III II J�EW
_ IIIIIIIIIII BOffiON-RENEW
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATUMY/pNYWY)
PRODUCER 02/0 8/2 0 09
Matthews Insurance Agency ONLY AND CONFERS CONFERS NO RIGHT UPON THE COER�[IFICATE
La Parker Street ALTER HE COVERAGE AFFORDED NOT
POLI ES BELOW.
Lawrence, MA 01843
978-681-1112 INSURERS AFFORDING COVERAGE
INSURED AS Wood Construction, Inc NAICIt
INSuRERA: Liberty Mutua ns
INSURERS,
P.D.BO% 1769 INBURERC:
Salem, NH 03079 INSURERD:
1-603-23.5-7 624 INSURER I-
COVERAGES
THE POLICIES OF INSURANCE USTED 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 15 SUBJECT TO ALL THE TERMS,POUCIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS AND CONDITIONS OF SUCH
� PoUCYNUYSlR MCYEFFELTIYE P U
GPNEPAl.lU1BILTIY AT UMITS
EACH OCCURRENCE 6
COMMERC W IDENERILL,UABILT' .
CLAMISIA13E OCCUR PREMI j' Enre 3
MEOEIP All mroP,..on) j
PER$OtULSADVRUURY 3
GENERAL AGGREGATE 3
GENL AGGREGATEUMRAPPCIE6 PER:
POLICY PRO-JECT LOG PRODUCTS-COWICIPAGG 3
AUTONOSILO IARIUTY
ANYAUTO �P�N6INGULIMtJ 6
ALLO%k%EDAUTOS
SCXEDULEDAUiOS (P<�DI�Ln 'RV 3
HIRED AUTOS
NON-OVIIEOAUTOS _ SODILYUUURY f
(Pr,c aMl
PROPERTYDAMAGE
lP:+aiawxl f
GARAGE LUU71tITY
AUTCONLY-EAACCIDENT 3
ANYAVTO
OTHERTHAN EAACC I
AUTOONLY: AGO f
EIICIJWUMSRELLM1lAOYDY
EACH OCCURRENCE S
OCCUR IXAM/SMADE AGGREGATE 6
DEDUCTIBLE 6
RETENTION f
3
WORKERCOMPEN311TIOYNO
3
EMPLOYERSVABWTY WC231S353819029 02/23109 02/23/10
•�FPua9bloAPAIgDI�EINLi/AVE E.LEACHACCIOENY $100, O00
RiKEWYEM9(RpICUIpEq
It is d33RIYuyw E.L DISEASE-EA EMPLOYEE $5 00, 0 0 0
SO bALPROVISIONSWRM
GT/IER E.LOLWASE-POUCYL►IR 3100,
OERC W PTNNOFOPERATONRLOGTM]NS V IXICLCM EYCLU3NN1S10DELDYENDOR3EMENT3PiCUYPROVUMONR
Location:
CERTIFICATE HOLDER CANCELLATION
SHOULDANYOF THEANOVg WSCRIEMPOUCIe6x CANCELLEDeEFORETHE EXPIRATION
DATE THEREOF,THE ISSUING INSURERmLL ENDEAVORTO MAIL - DAYS WRITTEN
NOTICE TO THE CERTIRCATENOLDERNAMEDTO THE LEFT,GVTFAILURETO DO SO SMALL
S A P �• IMPOSE NODOUGAT10NORLMSIUTYOF ANY KIND UPON THE INSURMITB AGENTS OR
REPRESENTATIVES. _
AuTNoRDEDwP%vvENTArnE -•
ACORD26(200110Bj ®ACOROCORPORATIOMSU
60 39Vd SNI SM3HIIVW S98ES8981fT 7-R:CQ AAA7/F7I7T
nvuilaicuv�iRCD v�.4D rm ', Y, 001/001
ACORU®
CERTIFICATE OF LIABILITY INSURANCE DATE'�M°°" "
8/3-9/2009
PRODUCER (603)432-6414 FAX: (603)432-3852 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Financial Insurance Services inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PO Box 950 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
.ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW..
Derry NH 03038 INSURERS AFFORDING COVERAGE NAIC#INSURED INSURERA Peerless Insurance
A J Wood Construction Snc INSURER B.
PO Box 1769
[INSURER C
Salem NH 03079 INSURER D,
COVERAGES 4SURER E. . ..
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY.REQUIREMENT,TERM OR CONDRTON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE-ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OFSUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR O
LTR Nm TYPFOF1NmIRANrF POLICY NUMBER POLICY EFFECTIVE POLICY EXPIATION LIMBS
GENERAL LIABILITY FACHOCCIRRENCE i 1 000 000
X COMMERCIAL GENERAL LIABILITY
A - PREMISES na+elence S 50 000
CLAIMS MADE X oca1R sRDieG 8/16/2009 0/16/2010 meDEXP(mymle ) i 5 000
PERSONAL S ACV INJURY i 1. 000 000
GENERAL AGGREGATE $ 2,000,000
GENL AGGREGATELMR APPLIES PER: PROOULRS-COMPIOPAGG S 2 000 000
X POLICY PRO- 171 LOC
AUTOMOBILE LIABILITY
ANY AUTO cEa 1SINGLE LIMIT $ 1,000,000
A ALL OVINED AMOS 3AB693505 7/8/2009 7/8/2010
X SCHEDULED AUTOS BODILY INJURY
(PIIPemm) S
R HIREDAUFOS
X NO"VWEDAWOS BODILY INJURY
(PatecutlSM) i
PROPERTY DAMAGE
(Pwaccidm0 $
GARAGELIASILm
ANY AUTOAUTO ONLY-FAACCIDENT I;
- OTHER THAN EAACC i
AUUTO ONLY. AGG S
EXCESS f UMBRELLA LIABILITY
EACH g
OCCUR CLAIMS MADE OCCURRENCE
' AGGREGATE. g
DEDUCTIBLE i
RETENTION $ i
WORKERSCOMPENSAMON i
AN DEMPLOYEWUABRUTY YIN VIC STATU- OTH.
ANY PROPRIETOPoPACLUOEUEJECUTIVE❑ EL.EACH ACCIDENT
OFFICEFUn1EMBFH EJ21-LIDED? i-MR If ER
(Me .d=db NH)
SPECtl P Oa PROVISIONS
E.L DISEASE-FAEMPLO i
OTHER PROVISIONS Oellw
OTHER EL DISEASE-PoLICY LBIR i
DESCRIPTION OF OPERATIONS ILOCATONSI VEHICLES I EXCLUSIONS ADDED BY ENOORSEMENTI SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
-'--- SHOLLDANYOFTHEABOVEDESCMBEOPOLICESSECANCELLEDOEFORETHEEXPIRArON
DATETHEREOF,THEISSLXNGOJSURERWLL841DEAVORTOMAIL 10 DAYS WRNTEN
�T NOTICETO THE CERTIFICATE HOLDER NAMED TOTHE LEFT,BUFFAILURE TO DO SOSHALL
S/'1' ht P Le- IMPOSE NO OBLIGATION OR UABILm OF ANY KIND UPON THE INSURER,ITS AGENTS OR
FREPRESENTATIVES.