3 SMITH ST - BUILDING INSPECTION VoOSetbocks(ft)
The Commonwealth of Massachusetts Town of
✓� VBoard of Building Regulations and Standards �w Massachusetts State Building Code, 780 Ch1R, T"cdiuon Budding Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish aOne- or Two-Fainrk Dweging
This Section For ORcial Use Onl Permit Number: Dat -Applied:e: I /Building o ssionert Ins t i i Date
S ON I:SITE INFORMATION
rty Address: 1.2 Assessors Map d Parcel Numbers
is an acce led street?ye no Map Number Parcel Number
ng Information: 1.4 Property Dimensions:
strict Proposed Use Lot Awe(sq ft) Frontage(fl)
. ing Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zane? Munici al O On site di sal s stem O
Public ElPrivarc O Check if sCl P sPo y
SECTION 2: PROPERTY OWNERSHIP' �f
V%k
VKkv1
We IPrmt) Address far Service:
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O All ration(s) O Addition O
Demolition O 1 Accessory Bldg.O Number of Units_ Other O Specify
Brief Description of Proposed Work':
J\d\ \ 10tryAnl
SECTION♦: ESTIMATED CONSTRUCTION COSTS
F2E;lectncal
Estimated Costs: Offlclal Use Only
Labor and Materials
g f I �� I. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
SZ40CQ • C OTotal Project Cost'(ite 6)x multiplier x
lumbing S 2. Other Fees: S�-2
1 Mechanical iHVAC) S List:
s Mechanical tFire S Total All Fees. S
Su remon
Check No. _Check Amount: Cash Amount:_
n Total Project Cost. S i ❑Paid in Full 0 Outstanding Balance Due
3d, Soo
!fero Ad wVwo
SECTIONS: CONSTRUCTION SERVICES
5.1 1 icensed Construction Supt� its or(CSL) Z 2U//
�•�,1.. \ m �� h Lwenw Number E•prtution au /
of L Hpt er List CSL Type la•r Iw jowl
T Description
AJdrc U Unrestricted u to 35,000 Cu. Ft.
R Restricted IR2 Family Dwellin
S nature (� M Mason Only
Y (0 �' RC Residential Roofin Coverm
Te ephone VS
Residential Window and Sidra
SF I Residential Solid Fuel llurrunjit Appliance Installation
D I Residential Demolition
5.2 Reg)st��H�omne 11s� _rovemeol Contractor(HIC) r/1/_ 3
HIC Co Name or HIC Repsu N Registration Number
Address . i f T2 17fi /U
Signature TeTe ephoni^n
;� Expiration Date
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2.J 2SC(6))
Worker Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavil will result in the denial of the Issuance of the building permit.
Signed AfTidavit Attached? Yes.......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
aulhorize d.N (76 to act on my behalf,in all matter
relative to work author red by this building permit application.
Si nature of owner Date T
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,� /� (0 as Owner or Authorized Agent hereby declare
that the state and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. 7L L L
Print Name _ i o 1 7 p-!.FS-rr
Signature of owner or Authorized Agent Date
St red under the pains and penalties ofperjury)
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), wi11 gg have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulalions I IO.R6 and 110.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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.baihs
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
I 'Total Project Square Footage"may he substituted for 'Total Project Cost"
J/ee '�roza�uo>uz�eall� o�'.,jrz�aac�utelle
:oard of Building Regulations and Standards
,t a 'onstruction Supervisor license
License: CS 70882
Birthdate: 7/28/1956
Expiration: 7/2812009 Tr# 16025
Restriction: 00
RICHARD J SMITH
PO BOX 1769
SALEM,NH 03079 Commissioner
BUp Q�
oard of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Construction Supervisor License
License CS: 70882
Restriction: 00
Birthdate: 7/28/1956 Tr# 16025
Expiration: 7/28/2009
RICHARD J SMITH
PO BOX 1769
SALEM, NH 03079
Update Address and return card.Mark reason for change
Address ❑ Renewal E Lost Card
DPS-CA1 0 5010-05/06-PCa390
` - Bo o ar uildmg egulatlons and�. d,
lug
One Ashburton Place - Room 1301
Boston. Massachusetts 0210$
Home Improvement Contractor Registration
-- - - -` - Re'
gistration: 106603
Type: Private Corporation
Expiration: 7/24/2008
AJ WOOD CONSTRUCTION, INC: --=---- - -
Richard Smith - --
I 5-7 DELAWARE DR --�- -. --- ._
SALEM, NH 03079
Update Address and return card.Mark reason for change.
Address) ❑ Renewal -.-I Employment Lost Card
DPS-CAI Ca 50M-05/06-PC6490 - - - ---
_.- ✓fie -ir�micvxo�uaeall� o`'✓laC�u6alld
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulatiors and Standards
Registration: 106603 One Ashburton Place Run 1361
Expiration:-.7/24/2008 Boston,Ma.02108
Type: Private Corporation I
AJ WOOD CONSTRUCTION,INC::r
r 1
Richard Smith
6-7 DELAWARE DR Not valid without signature
SALEM,NH 03079 Deputy Administrator
l
Commonwealth of Massachusetts
Division of Occupational Safety
Laura M.Marm,Commissioner
Deleader-Contractor
RICHARD S. SMITH
Eff.Date 07/10/07
Exp.Date 07/10/08
DC001721 4
Member of GO REST. 00
BO ,
-RE E
0001356.2 C E R T I F I C A T E O F I.N„S U A A N C E ' Issue date: " 5-06-08
Producer sThia certificate is Issued as a matter- of information only and
CESI Agency of New Enggland confers no rights upon the certificate 'holder.. lh'ia'
10 Chestnut Drive an it a certificate does not amend', extend or alter the*raverage
Bedford NH 03110 afforded by the policiea' below.
' COMPANIES AFFORDING COVERAGE
:Company letter A Nautilus Insurance -
Insured
A'JWOOD CONSTRUCTION CORP Company letter B
P.O. BOX 1769
SALEM NH03079-1769 Company letter C
Company letter D '
'Company letter E
COVERAGES . This is to certify that policies of insurance listed below have"been asudd to the
Snsured;named above for the policy period Indicated, notwithstanding any requirement,
term or Condition of any contract or• other document witb-zespect to which -tliia.certificate may
be issued or may pertain, the insurance afforded by the policies described herein i'e-*subiect Eo
all the terms, :excluslona sad conditions of such pollcie9: Limite anown may.*have been re aced
by paid claims.
Co Policy 'P,olicy
Lt Type of Insurance Policy number Effective Expire ALL"'LIMITS IN THOOSAND5
GENERAL LIABILITY General aggregg ate.. . .. .$ 2,000
A X Commercial General Liab. NC786388 5-16-0.8 "5-1'6-09 Products-completed
Claims .made operations aggreg ate.:$ 1,000
X 'Occurence Personal6
Owner's 'acontractars - advertising injury....$ 1,000
protective Each oCcuYrence. .c, .,.$ 1,000
... Fire da
m
sany. .
one Eire) _.._ . .. ... .. ..$ 50
Medical expense (any
one person) . . ..'.. . . ..t.9 5
AUTOMOBILE LIABILITY CSL $
Any auto
All awned autos Bodily injury
Scheduled autos (per person) $
` Hired autos
Non�owned autos Bodily Zniiury
-_ Garage liability (per acci8ant) .'S
Property damage , g'
EXCESS. LIABILITY Eachoccul'rence Aggregate
Umbrella form
Other than. umbrella form
WORKERS' COMPENSATION Statutory.
AND' $ (each accident)
EMPLOYERS' LIABILITY 8 (disease-each aylmim1 t)
OTHER '
Oeaciiptionr of operationa/location's/vehicles/special it"s
CARPENTRY 6 ROOFING-COMMERCIAL ,
Certificate holder - CANCELLATION Should any of the above described policies be
cancelled before the expiration-date thereof,
the issuing company. will endeavor to mail 10• da'ys written
notice to the certificate' holder named to the left,.but failure
to mail ouch notice shall impose no obligation or liability of
any kin u the camp is agents or representatives.
-A�thoz z se t tiv
..(OMM 7 CERTGA MAD01088MG0929)
ACORD CERTIFICATE OF LIABILITY INSURANCE ° '"""°°'
TM 02/20/202008
PROMCM THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Matthews Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
182 Parker Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Lawrence, MA 01643
978-601-1112 INSURERS AFFORDING COVERAGE NAICS
INSURED AJ Wood Construction, Inc INSUREAA: Liberty Mutual Ins
INSURER B:
P.O.Box 1769 INSURER C:
Salem, NH 03079 INSURER P.
1-603-235-7 624 INSURER 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ro POLICY POLICY EFFEL'NVE RATIMM
ON -
GENERAL LIABILITY MAGWE0A'M
f
CGMNERCIAL GENERAL LIANUTY f
CLAIMBMADE ❑OCCUR rwq JURY ATE 3
GENT.AGGREGATE LRAM APPLIES PER OPAGG 3
POLICY P LOC
AUTOM011KEUAOILRY COMBINED SINGLE LNVT
ANYAUM Rb AlridbAU $
ALLGWNEDAUMS BODLVRAIURV
SCHEDULED AUTOS (P-p ) f
HREOAUTOS BODLYINJURY
NON-OWNMAUTM f
PROPERTY DAMAGE f
(Peraatoenll
GARAGE UABRJTY A170ONLY-EAACCgENT 3
MYAUYO OTHEATNAN EAACG 3
AUTOONLY. AGG 3
DICESMMRPLIA LIABILITY EACH OCCURRENCE 6
OCCUR ❑CWMSMADE AGGREGATE 3
f
DEDUCTIBLE 3
RETENTION 6 vrc S
srATtF om
MDRNERSCDMPEIJ3ATONANO
E,PLOEWLIABILITY NC231S353819027 02/23/08 02/23/09 E.LEACHA000N-W 5100, 0
El.DISEASE-FA EWLOYEEI 500, 00
3PEC41LPNOVLTgN3 Bdow
tlyyroee,,CmDWAunOAr E1.DISEASE-POLICY UNIT f1 0,
000
OTHER
DEECNPTIGNOFOPERATWNSILOunOWIV84CLESIEMCLUMONSAMWBYMDORSEMEWISPECMPRO OOM
CERTIFICATE HOLDER CANCELLATION
.. .. SIIGLLD ANY GF TIE AS IVE DESCRIGIM POUCIES SE CANGELLEO 6IEROIIE THE EJIPIRADON
DATE THERWF.THE RNUN31N3URERY ENOFAVOR M"IL — DAYS VAMEN
NOTICE TO TN#CRRIRCATE HCLGER NAMED TO TIE LEFT,BUT FAILURE TO DUm SNLLL
SAMPLE IMPOSE NO OEUGATON OR LMWUTY OF ANY POND UPON THE MINER,ITS AGENTS M
RFPMEWATNEB.
AvnORDED REPRESENT
• ®ACORD coRPORATION 1666
ACORD25(2001108)
10 39Vd SNI SM3HiIVW 5986989BL61 9Z:ZL 80OZ/E1/10
'r CITY OF S.U.E.`[, ,NLXSSACHUSETTS
BUMI)ING DEPARTM04T
120 WASHINGTON STREET, r FLOOR
TEL (978) 745-9595
FAa(978) 740-9846
p.,iBEJUEY DRISCOLL TmomtsST.PmRu
MAYOli
DIRECTOR OF PL BLIC PROPERTY/gl'ILDLVG CONMrtSSIONER
Workers' Compensation Insurance AlDdavit: Builders/Contractor/ElectricianslPlumbers
Atiollcant Information n Please Print Lettiblr
NaineIdusineisorpritranorvindsvrd")! 6k]_ CJ MI) Cs,,
Address: 9 ., zaf-b(. S
City/State/zip: W A� n 0307� Phone a: (a0 3 Fg F u,q,GJ
,%re you an employer?Cheek a appropriate boa: Type of project(required):
1.❑ I am a employer will 1 4. ❑ 1 am a general contractor and I
employees(full and/or pan-time).• have hired the ad►contractors 6. ❑New construction2.❑ I am a sole proprietor or partner- listed on the attached sheet 7• ❑ Remodeling
;hip and have no employees These subcontractors have 8. ❑Demolition
workingfor me in an capacity. workers'comp.insttrstsoe
Y Pac tY• 9. ❑ building addition
[No workers'comp. insurance S. Cl We are a corporation and its 10.0 Electrical repairs or additions
required.] offleers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MOL I I.❑Plumbing repairs or additions
myself.(No workers'comp. C. 152.91(4).will we have no 12.0 Roof repairs
insurance required.)t employees.(No workers' 1 J.❑Other
comp. insurance required.)
-Any applitasa than chacta boa II must altos fin test the seslius below sliming their wwkera'compensation policy i runmdon.
'16wneowmas who submit this sflidevit indicating they are doing all work and thus him outside contractors mew submit a new aMjs,il inditading ask
:C.w ns,:u o shot cheh this hoot mud attached an additit al ahwst showing the trams,at no atrhtestsseton and tbalr worhem'camp poi y infarmosiow
/one an employer that b prov/d/nR workers'conapemmtbn lnaarvnee for my emp/aryeax edtrw/s the pNlsy an/JoI s/p
informal"
Insurance Company Name: L - Mt s t ua-L
Policy 4 or Self-im. Lie.N: i LLa3 I S I 2-4 Expiration Date: Z/2300
Job Site Address: City/Stala/Zip:
.knack a copy of the workers'compensation policy declaratba page(showing the policy number and expiration daft).
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 farm of a STOP WORK ORDER and a fire
of up to S250.00 a day against the violator. lie advised that a copy of this statement maybe forwarded to the OfAce of
I it veal t gations ol'the DIA for insurance coverage verification.
/de hereby cerrify it er rhr patina m penu/t/es of per/rrry that the hiformatlan provided above is true wild caned
Win• r t r (� 1M/
�(� p �� �
PFnne d' (Da? a V ` (a e
O,TriY!sae a/rly. Do trot write in rhir aver,rr br vump/erd by city or fawn n//lriatL �
Cityruwn•
or -- Pcrmit/Ltccnseft____ --- _ _-- - —
hsuing.\ulhurily (circle une):
I. Iloard of Ilralth 2. Building Departrrrcnt 3. City/town Clerk J. Flectrical luspector 5. Plumbing Inspector
6. thher
4Lunlact Perron:__ _ _. Phone is:
CITY OF SALEM
i Z rlizt \ PUBLIC PROPRERTY
DEPARTMENT
120\Y'.1 it IL.\I; S•\I f\I, S1.\si.\l
I n:v;s-'43-'w9s . 1:.\s:97sa4a9.446
Construction Debris Disposal Affidavit
(re(luired I-or 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 Ill.- _ is issued with the condition that the debris resulting from
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:
(name of hauler)
The debris will be disposed of in
(name oflacl Ity)
(addrexs of lauluy)
%1gliatulic of permit applicant
(late
-lohu.,.il d,w