12 PRINCE ST - BUILDING INSPECTION (2) � � r
�oL
ThC ('unmat:maaealth Of �,\tassaChusetts �
1 t y Boded of 81111di2tg RCgLl1aIi01S ;utd Standards t H2
INIassaClm.SCUS Stale Building Code, 7S11 ('N1R. 7'I�I C�i;iun mt 'Nl( it, V1 I I 1
Building Permit Application To (instruct. Repair. Rrnoa:dr Or !)emulish a I ilrl n„/l,ou,,,r .
Onc- or T,ru-hiunih,/hrc/lirl,q II;s
This Section For Official Ilse --
Budding Permit umh• : Ume Applied:
RwlJln)_Conuni„wneri In>penor ul 13uddmgs U:ua
SECTION I: SI'fF: INFOR:YI:\'r10N
j i.l Prcperts address: 1.2 :(sses --
su rs Alap & Pa reel .Numbers ---__
l—I- t;r !1 II_i5 an 1ICCe nICJ �(ra'CL� a.� ✓ no, :1'u mha•r --_.
--- - --i'..3 .lccsing Infoe-station: :i Pru}:•ecl,; Uiman:;ions:
lo, anaIv{ tit Pruil :. Ilil
.5 Ruil3:ng Setbacks (ft) ------- - - -------_____._I
Fnmt Yard Side Yards
Rear Y:ud
I RcyuirCJ Provided RC urreJ —_—�T::T
4 Pnn;JCu cJ -_.. Pn„iur,.i
-- -- - �--
f.( Water Supply: ob1.G.L c. 10. §51) 1.7 Flood Zone In 1.8 Sewage Disposacm: - --- -';
R.;,iic PrS,ute ❑ Zone: Outside Flwrd Zone I
Munici al ❑ On ,,Ie disposal sv,tam Q Check if yes❑_ P I
_ SECTION 2: PROPERTY O�V'NERSHfPt
i s.l G` � ern cord:
�`
- _�M
,N'.u�11'rmll Address time Service:
Slen:uuc _ 'Tc!rph„ne t
- SECTION 3: DESCRIPTIONF PROPOSED WORKz I (check t! th• t apply)
�
—�-- —. -—
i _v !ur ? :a '%;n ❑�E cistirip Building Dune l)c.up:ed O Lftro
-_. . --
?,mul h m G Acceuor• 91dg. ❑ I Nuntbe. of Units I - ..J
`ir et ;� :. •'Ipti:>n of Proposed W'nrK': ��__eS"'�p-�tJ�___.__.��T-_ CCJ±yE,t'�•ice. ... I
SECTIC' : J: ESTIMATED CONSTRUCTION COSTS
j hem E,timat,(! Ursa::
_ ll_ahor ;:n:i �la:erudsl�--- Official Use Only
'--------
1. li uJJirg -,-- - I. Building Permit Fee: $ L indicate huu fee n drlrrnu nrJ:
2. Flectrical g ❑ Standard City/Town Application Fee
-'- O Total Project C'uot' (Item G) x multiplier _ x
;. Plumbing S -
- _. Other Fees: S
4, Nfechanicnl IFIVAC) 'S List:
5. Nfechanic:d !Fire
Sum resslnn! S Total Ail Fees: S -------------
--- Check No. `Z_�-C'heck :\moire ,
b Total Project Cost: 5 e (�� ��--(',r>h Am„unt -- r
J( V U I Paid In Full ❑ OtnsCmdm,1 Balance DLIC.
l 5 /1s3r pE/z / T To -—
L S !d err"-rA/VT S—T_
f;
e
SECTION 5: CONSTRUCTION SERVICES
a.MLidConstructionSil jsorCSLICod � Luense Nuuthei I`.ynrau On Uule
Nam• . CSI olds , r Iasl C'SI_ ft pr i. CIO" —_-_
1-,, r Desrri now
— ) ,L_ C direst"
R Rrsuided L\r' Fainils Dwrlhne �
Sift:uuar f C RC Reader%al Ruohnc
\\'S Rradrnual W ndott .md Snliny
I'rlephanc _ jL—.__ -
SF Read.nual SOLJ furl 8w ni n�_\ +di.n.. lu.i.11ai n'I�U Rradrnu.d Dcol"ho ll _
5.2 Registered home Improvement Contractor 011C1 U 03
Regutrauo❑ Number
HIC Company . all •or ICI I(�,RcN'Wtf�h` vante w:Jl.J�� 0 / �h to� _--
Addres O Vt I ,�� /Vl. vr � `(� F\piraliun Date
I clephone
� Siguawre '—
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT IM.G.L. c. I5'_-• 5 25( 161)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure it, pnn ide
this affidav
it 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
/ S' Q �/�/ as Owner of the subject pnrperty hereby
f�A /� . . t all mattes
half, u
m act on my be
. iauthorize ' (�
-•!alive t t: :iuthorized by this building permit application. C
Dale -- -----..--- —�
Si nature tit Owner
SECTION 7b: OWNERa OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent heroby Jeclarc
1, 1VV
that the state a is and information on a turegomg apphwuan are true and accurate. at the best of my knowledge an
behalf.
Print Name Date to IZ Ice--
Signature of Owner or:\u;horizeJ Agent
I Signed under the arcs and enahies of era a NOTES:
-1—An Owner who obtains a building permit nt do his/her own work.or :m Ow"nor who foresail it)
hied contra.loi
(not registered in the Home Improvement Contractor (1-11C) Program). will not have access to the arhitratum
'
program or guaranty fund under M.G.L. c. 1�1'_A. Other important information on the HIC Program anJ
Construction Supervisor Licensing (C•SL) can he titund in 780 CNIR Regulations I l0.R6 and 1 10 R5. rCspecm C1v
' When substantial work is planned. pasty ide the inform (ton below:
including ng garage, finished basemenuatiics, decks Or pOrChi 1
Total flours area (Sy. Ft.I Habitable rourn count --"---
I (boss living area ISq. Ft.) Number Ot hcdruoms ----_--__----
Number of fireplaces Number of hilt/h.uh. _—_._-------- —
Number of bathrooms * Number of deck./ pomhes
Tope Of healing system _— — FncL red -- —llpcn
Type of COOhng sy"stem -
3 Total Project Square F )otage may be substituted for ,total Project Cost' _
CITY OF SALEM
PUBLIC PROPRERTY
DEPART'NIENT
. \I ,+. ,a I.. Us^i,.+. ,:,,� i.:� ii • < ,... \I. \I sue.s . . . =1 t`�
N orkers' ('ontpensation Insurance it: liuilders/CuntructorsiElectricians/Plumbers
li t Aicant Inforn6tion ^ Please Print Legibly
('it} tit:tte.Zip: S�tQ,a,.. 0767 Phone 4 ( 1 (n
tire you an vinploser? Check the appropriate box: Type of project(required):
1. ❑ I fill a general contractor and 1 6 New cunstruction
I ❑ I am a cnlpluyar w ith � ❑
eulpluyces (full and'ur part-tine).' hale hired the sub-contractors -
?.❑ I fill a sole proprietor or paruler-
linred on the attached sheet. 7. ❑ Remodeling
,htp and have nu employees I-hose sub-cuntracturs base g. ❑ Demolition
in any capacity. workers conlp. Insurance. y, Q Iluilding addition
working for
No workers' cons insurance 5. ❑ We are a have
exercisioned
and its
p. Q.Q Electrical repairs or additions
reywrcJ.l officers have e.xerciseJ their
fi ht of exemption per MGL 11.❑ Plumbing repairs or additions
}.❑ I am a homeowner doing all work b Ption
myself. [Nuo workers' sump. C. 152, §I(4), and we have no I'_.Q Roof repairs
insurance wired., t employees. [No workers' Id,❑ Other d (Q//Lr�`-
comp. insurance required.[
•:\uy.µlpl ICJ III that checks box NI Inu,a also till out the section below showing their workers compensation put icy information.
t I lomcuwncrs who submit this aIfidav it indicating they ire doing all work and then hire outside contractors must submit anew affidavit indicating such.
'('„,nr:mmrs that check Ihis box must attached in iddlnonaI+beef.howing the name ofthe sub-contractors and their workers'comp.put icy information.
l urn tin employer that is providing workers'compensation inssurunce for my employees. Below is the policy and job site
information. ( p s
Insurance (bmpany Name: c�
Policy q or Self-ins. Lic. q: �__� 3( ` 0762-'—? Expiration Date: nAA
(
Job Site Address: i, rl INC P t C'ity,Stute/Zip: s l/V s�M
L-
.littach a enpy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure co%crage as required under Section 25:\ of NIGL c. 152 can lead to the imposition of criminal penalties of a
line up to S l,ioo.00 and'ur one-year unprisomnent. as well :Is cis it penalties in the form of a STOP WORK ORDER and a tine
rl till to S250 III)a d.ly ,ILJlllat flit: t tolator. De ad\Ised that a Copy of this statelllellt I11Jy be forwarded to (he Office of
Ir,e.n•:du.m; ul die DI:\ far insurance co\er:ige \colic:nton. -
IF do herrhy ertilr 1 der the pains andpenallies of perjury that the information provided above Atrue and correct
fL O
Date (of
tlllicial use nnlr. no not write in this arttu, to he Lmolyleted by oily ur town o/jiciat
( in or .—
Ivsuint; \uthorify IvircIv Line,:
1. Board nt liealth 2. Building Department 1. its, I'imn Clerk J. Electrical Inspector 5. Plumbing Inspector
6. other _ _ -- - - -
('ontact Person: __---- -- _----__---- Phone ---
Information and Instructions
\I.I„an 1 n I ctI, ('cncral I a%%,clt.I tier l Ir,{ua c, .11l CiIII Io\eis to pn,s ide „orkcrs tompcns,unm for IIleo cnlp lo\cc s.
I'ui,u.uu uI dos ,t.tlutc. .ul rnt/durre I, dcllrcd as ct er\ Person in the wi%z,e of .mntllcr under .mv cautuct Of hue.
c,, or uq,!tcd. oral or „I incn...
mploi er I, delincd is .in :n,lr,:dust I. P.0 wcr,l up. a„acla IIo,1. .orparai on or ,alet !cgal cntits. or .in hso or mare
,.I Ilse fivccaulg cn vaced tit a Pant cntclprne. and mclwlulg [Ile le of rrprescntam c, of a dC:e,t,ed wnplater. or the
:c.cl,cr or tau, ce of an Indlt(dual, p.ulncr,hip, .1„oUatluo or other ICgal entity, clnp101 ill_L' cnghlotees I lo,scter the
..ter of .I .h,clluhg house 11.1%utg not snore than three .Ipartnlcnts and tsho rc,idc, Ihcrcin. or the oc:upant of the
d\,c l�alg Iwti e of an,It her „ha cn If,Io„ person, to do nlauacname. am,truction or rrpatr hark on such ,bs el It rig house
.1 m the _lam Lis or building appunCtant Iltelcw shall lot be:.ul,c of (Jeff cluplo-%nlcnt be deemed it, he an emplosev
\I(II. chapter 1+', ,,'5( If,) also ,talc, that -'esery ,fate or local licensing agency .halt nithhuld the issuance or
renewal of a license or permit to operate a business or to construct buildings in the comnsonwealth for any
applicant a ho has not produced acceptable es ide nee of compliance with the insurance cus erage required."
\ddlnonally. SIGL chapter 152, �25( (-) states "\'cldter the :,munonweahh nor any of us political suhdis awns ,hall
enter into any contract for the per Iminance of pub he ,sork until acceptable c\Nance of compha nee w uh the insurance
rc,luncments of this chapter hate been pte ented to the contracting authority."
Applicants
Please fill out the workers' compensation aftidavit completely;by checking the boxes that apply to your situatiun and, if
necessary. Supply sub-contractors) nante(s), addresses)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
nicmbers or partners, are not required to carry workers' cumpensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this atfidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the afridavit. 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. Self-insured companies should enter their
,elf-insurance license number on the appropriate line.
('icy or Town 01`111chals
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
tit the affidavit for you to fill out in the event the Ott-ice of Investigations has to contact you regarding the applicant.
Please he sure to fill in the permit,license number which will be used as a reference number. In addition, an applicant
that must submit multiple pemtivlicense applications in any given year, need only submit one affidavit indicating current
policy infbrmation (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
taw n).- A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
.Ipplicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. 11k'here a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i c. I dog license or permit to burn leases etc.)said person is NOT required to complete this atfida%it.
I-he (mice of Investigations Would like to thank you in advance for your cooperation and should you hate any questions,
plca,c do not hesitate Ill glse us a all
I Ile Ilcp.ututcnt's address, telephone and tax nlonher:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investigations
600 Washington Street
Boston, MA 021 1 1
Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia
Jun 02 08 ,11:17a AJ WOOD CONSTRUCTION 603-898-6942 p.2
asrd of Building Regulations and Standards
construction Supervisor License
License: CS 70882
Blrtt idate: 7/28/1956
Expiration: 712812009 Tr✓3 15025
Restriction: 00
' RICHARD J SMITH
PO BOX 1769 T
SALEM.NH 03079 Commissioner
kos Board of Building Regula aind Standards
One Ashburton Place - Room 1301
Tv�' Boston, Massachusetts 02108
Construction Supervisor License
License CS: 70882
Restriction: 00
Birthdale: 712811956 Tr# 16025
Expiration: 7/2812009
RICHARD J SMITH
PO BOX 1769
SALEM, NH 03079 -- - ---_
Update Address and return card.Mark reason for change
_-I Address [j Renee•al Lost Card
tIPSQAI 0 S Dh 06-nG %
Jun 02 08 .11:17a AJ WOOD CONSTRUCTION 603-898-6942 p.3
SI-N
J�iid Ii ing Regulat�6 ta ards
BoarZo'� i !(;' �i'
One Ashburton Place - Room 1301
Boston- Massachusetts 02108
Home Improvement Contractor Registration
Reciisttatiow 106603
Type: Private Corporation
Expiration: M412008
AJ WOOD CONSTRUCTION, INC.
Richard Smith
5-7 DELAWARE DR
SALEM, NH 03079
Update Add:ress,and return card. Marl:mason for change
F-1 Address i I Renewal - Employment Lost Card
DFS-O l 0
01Td of Building RegaiRrions and Standards License or registration valid for individul use only
ration date. if found return to:
HOME IMPROVEMENT CONTRACTOR before the expiration
Board of Building Regulations and Standards
Registration: 106603 One Ashburton Place Ran 1301
Expiration: 712412008 Boston,Mo.02108
Type: pdvatoCorporatlion
AJ WOOD CONSTRUCTION.INC.
Richaid Smith
5.7 DELAWARE OR
K NH 03079 Deputy
valid without Sig
SALE
Jun 02 08,11:18a AJ WOOD CONSTRUCTION 603-898-6942 p.5
1)0013562 - C E R T I F I C A T E O F I..R.�S U RAN C E ".-Issue date:
Producer ;Thia certificate is- Issued as a matter• of''inPonuat'Lon only and
CESI estAgenc of New Eneela nd confers no rights upon cHa 'certificate b'older.. dati9' .
10 Chestnu Dcive Unit E certificate does not amend', extentl or alted r.. th'", -ge
Bedford NB 03110 afforded by the policies- below. -
COMPANIES AFFORDING COVERAGE
Insured :Company letter A Nautilu'a Insurance -
A J WOOD CONSTRUCTION CORP Company letter B
P.O. BOX 1709
SALEM NH 03079-1769 Company letter C
' -
Company letter D _ - -
'Company letter E
COVERAGES . This is to certify that policies of insurance. listed below have'b'ae{i eeuad to the
dished;named above for the policy period indicated, notwithatandiin- any requirement,
term or co..dition of any contract 0r other document wit Co which tl. 9 anyi#Scats may
be issued or maypeztaln, the insurance afforded by the policies described herein ra. subiect to all the terms, -exclusions and conditions of ouch polic-ieg.' .Limits eLown may:�have been.raauced
by paid`claims.
Co Policy 'Policy
Lt Type of Insurance Policy number Effective IP pire - ALL''LIMITS IN THOUSANDS
GENERAL LIABI'LZTY - General Aggreyate.......$2,000
A X Commercial 'General Llab. NC785388
Claims made 5-16-0.6 ;-5-1.6-09 Product e--cotap eted
R 'Occurence Pepeonalb6s a0gregate.:$ 1,000
Owner t
s t*contractors advertiging inj uz--y..,.;1,000
protective - Each oCcuYrence- :.,.9 1,000
- Fire
fire e,.(any,. . .$ 50
Medical expense (any
one personl ...... .. ..t:9 5
AUTOMOBILE LIABILITY CBL $
Anyy auto
A11 owned autos eodil In
- Scheduled autos yernany(per
- Hired autos person) $
_ GaragecowAed llability - Bodily In*7lry '
• _ (per acciddent')
. PropsrEy damage— , •s
NXCE53, LIABI2f1TY - Each"d'ccurrencc - A Ombrea,la farm Aggregate
OtLaer -than. umbrella form
WORKERS' COMPENSATION $Catutery, li
AND S ' (each accident)
EMPLOYERS' L;ABILITY SS (diseaaa-policy limit)
_ (di aease-eacli empl.)
OTHER � � - � � I,
Deecciption' of- operations/lOcati?cis/vRkiicles/special i-te`ma
CARPENTRY H ROOFING-COMMERCIAL -
Certificate holder . CANCELLATION Should ;ny.of the above de scribed'-policies be
gg cancelled before the eapi'ratieq-date thereof,
nbticeatonthamcertificateeholdErrnamedato Cho lelt,Wbutt failure
to mail uch notice shall impale no obligation or liability of
any k1n a the camp is agenta or representatibes.
•Author z Se t tiv ,
e
. . . ".(De1i7 GEATtIA-0nwaeaBH5Hm9aH)
. '� CITY OF SALEM
y` *\
PUBLIC PROPRERTY
DEPARTMENT I'I'I I); ♦ 1'\s: 778-'J„'1.9ae
Construction Debris Disposal Affidavit
(rcyuired liir all demolition and renovation work)
In accordance \�ith the sixth edition of the State Building Code, 7S0 CMR section 1 1 1.5
Debris, and the provisions of h1GL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
- - - Iname of hauler)
The debris will be disposed of in :
(name ul facility)
laddres u(Iucilityl
--- NILnalure of permit applicant
- dale -- ---
Jun 02 08 1118a AJ WOOD CONSTRUCTION 603-898.6942 p.6
ACORDn CERTIFICATE OF UABILITY INSURANCE YM
A Doe
M;LTHIS RE IS ISSUED AS A MATTER OF INFORMATION
Matthews Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
182 Parker Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Lawrence, MA 01843
970-681-1112 INSURERS AFFORDING COVERAGE NAICF
INA� AJ wood Construction, InC NSUrIEA A: Lz erty Mutual Ina
NSUFWA
P.O-Box 1769 N$MIERc
Salem, NH 03079 N�+lRD
1-603-235-7 62 4 INSURER e
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE WSUAED 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 AFPORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCEDBY PAID CLAIMS.
.A POUCYMA6PA PGuCY ISFFTDVE TON LMTTO
DEHERAL uARll EACH OCCURRENCE i
cDAVAERCULGENEAAI IMBILIIY R i
CLAIIASMLDS ❑OCCUR AIED FYDIM n� endlJ f
PERSONA &ADVNNRY 3
GENERAL AGGREGATE 3
GENL AGGREORIE LINT APPLIES PER PAOIXICT9-COWA'W AG-a— 3
1=7POLICY LGC
AUTOAIOBILELIA0IV" COMSNEOS"MELW 3
AW"M IEB AodabnU
ALt CWNEDAUTOS BOOLYaN{niY
SCHEWLEDAVIOS
HA>EJSAVTOS
BDDLYIHIURY f
NONdNNEOAlITA9 (Pdbatldenl
PROPERTY fA m 3
(Pdbarl"I
GARAG!UABIUIY AUMONLY-EAACCOENT S
/WYAUTO 0l11FRTHAN EAACG f
AJTTDNLY: AGG S
Excessodim FilA LLLBAAY EACH OCCURRENCE S
OCCUR ❑CLAIMSMLGE aGGREGIIE $
S
OE0IFCTIBLE 3
RfTENIgH 3 3
VARNEPECOMPENI AT MIM WCSTATI/- OM
EwLorER9'uABIUTv C231S353819027 D2/23/09 02/23/09 E.LPAGHACCID@!T f100, o
&L.=EkSE EA EWLOtWj S500,OUU
A3aNbd,POAdC>' E1.DI SE-MUCYLIIUIY jJ1U0.UUU
SPC3:NLPROYISgN9briOCr
07H9t
OE=LIPTMOPOPS]NTIONHROCLTXMIVENCUB/SiCLUSOM ADDED oyeI '°'" JSPE=PAW&ONS
CERTIFICATE HOLDER CANCELLATION
_ IDgL(D ANYOf TIE A¢OVl r�CGWB[DPOl1PI36Bl CAIL1111'O INSOIIl TtE 3YlAAT10N
DATE TIER®P,TIE ISSUNO nv3LalR MLLI-NOEAVOR TD MAIL ��GAn NRITfEM
NOTICE TO 710 Ca nMATE MOLDER HALED TO TIE LLiT,BUT PAI'LUR!TO 00 80 p4t1
SAMPLE MODE!NO OBUGAl1ON M UMR DF ANY LAIRD UPON TIE VWJRM 113 AGENTS DR
REPRESBRTAVAIL
AUROIREP REPRLSWT
AGORD25(2D01108) ®ACORD CORPORATION ISM
TO 39Vd SNI SM3HJ LVW 998ESS98461 9Z:ZZ 900Z/£I/TO