12 VARNEY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
l41 J Department of Public Safety
Massachusetts State Building Code(780 CMR)
PU Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
ilding Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
X. and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2.PROPOSED WORK
_ Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alterations I Addition❑ 1 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 P,
Is an Independent Structural c
Engineerin eer Review'�re^quired? Yes ❑ No '�
Brief Description of Proposed Work: Nl ac,�c Nocy--Ct- �'J �l?c �� �l Or
P tj 4 6�r F fC-41
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/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-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ 1 M: Mercantile❑ 1- Residential R-10 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 ❑ HA ❑ IIB ❑ IIIA ❑ IIIB ❑ I IV ❑ I VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:i Permit.Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner C�
\ \� ', f RQ�
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
o», ,Q� Oct 5m `�a-1
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
�� ko�N\\,ems
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2) -
f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control Oren check here O and skip Section 10.1
10.1 Registered Professional Res onsible for Construction Control '
Cz; (ice- uu
e Re ' tr eph a No. mail a ess N Registration Number
a. 02-In ado
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor �\
�� (�UYI4- yC V\ bY'1
Cor Name \ p
Name of Person Responsible for Cons :lion License No. and Type if Applicable
Street Address City/Town � State Zip
�03_�S�_ "Q(ag (Do 3-a3S- -7 GaQ 1(��nC7 Jox� Cor4f�I&(in . l'-JZ�-
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? Ye No 0
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 mmu/nicipa
5.Mechanical Other $ Enclose check payable to / J
6.Total Cost $ C (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of knowledge and understanding.
�&3 ISI T19 - S
Please print and sign n e Title Telephone No. Date
Street Address City/Town State Zip
i
Municipal Inspector to fill out this section upon application approval: /10
e Date
The Commonwealth ofMassaehusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: �j3c gc\ Qoyt � i )c o r�
Address: 323� ��e��e(�'\1 Q 6
City/State/Zip: Phone #: 6D 3 - 1- 4U(o�S
Are,you an employer?Check the appropriate box: Business Type(required):
�Y'�Ly' �'am a employer with employees(full and/ 5. ❑Retail
or.part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl,real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers'comp. insurance required]• 11.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below sbowing their workers'compensation policy Information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#I.
I am an employer that Is providing workers'compensatlon Insurance for my employees. Below Is the polley hiforsnation.
Insurance Company Name: \� ��/� ,
Insurer's Address: Da
City/State/Zip:
Policy#or Self-ins.Lic.#\-�C_ Expiration Date: A - X6 4;,
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 MOL 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 her certify, under the pains n penalties of perjury that Ore Information provided above Is true and correct.
Signature: Date:l - (is —I
Phone#• C b'J - I Y) — "�tY
F
use only. Do not write in Otis area,to be completed by city or town ofJleial.Town of WatertownTown: Permit/License#
Authority(circle one):
of Health 2. Building Department 3.Cityfrown Clerk 4. Licensing Board 5. Selectmen's Office
Person' Ken Thompson,Inspector of Buildings Phone#: 617-972-6480
wt»v.maca.gov/dia
OCT/03/2012/WED,09: 49 AM Financial Insurance FAX No. 6034323852 F. 001/001
,4C�ORo® CERTIFICATE OF LIABILITY INSURANCE 10/3/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS 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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terns and conditions of the Policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements.
PROOUCER NU Patricia Blais
Financial Insurance Services Inc PMO°; (603)432-6414 FAAjC Np:<603I 9321i852
PO BOX 950 M..Pblais@fisins.com
INSURER(S)AFFOROWG COVERAGE NAIC0
Derry NH 03038 INSURERA:Peerless Insurance Co
INSURED - 1muRERB:Peerless Ins 4198
A T Wood Construction Inc INSURERC:
337 Haverhill Rd INsuRERO:
INSURERS:
Chester NH 03036 INSURERF:
COVERAGES CERTIFICATE NUMBER:CL117 2 00 37 07 REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 VMICH 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.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
POUCYEFF POUCYERV LIMITS
LN TYPEOFINSURANCE POLICY NMIBER MMI MMI
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
RENTED
X COMMERCNLGENERALLIABILITY ISES LEgocaunence $ 100,000
A CLNMSAIADE QOCCOR BP8706685 /16/2012 /16/2013 MEO EXPAM one wwn $ 15,000
PERSONAL BADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENL AGGREGATE LIMIT APPLIES PER: FRODUCTG-COMP/OPAGG $ 2,000,000
X POLICY PRO LOC $
SINGLELIMIT 1,000,00
0
AUTOMOBILE LIABILITY N
JJRY(Per PNsan) $
B ANY AUTO
�TOOV.NED x SCHEOU E0 693505 /8/2012 /6/2013 JURY(Par OaWen1) $
NON-0NNED V DAMAGE $
X HIRED AllT05 X ALTOS rt
$
UMBRELLA LIAB X OCCUp CURRENCE $ 3,000,000
E%CE55 LIAB ClA1MSMPDE TE $ 3,000,000
DED RETENTION O8B02 /16/2012 /16/2013 $
STATU- OTH-
WORKERSCOMPENSATON VSC
AND EMPLOYERS LIABILIN YIN
ANY PROPRIErORIPARTNERIEXECLTIVE E.L.EACH ACCIDENT $
OFFICEWMEMBER EXCLLCEDT El NIA
(Manddery in NH) E.L.OEiEPSE-EAEMPLOVE $
B- das-'*urger E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Adach ACORD Wl,Add%lenel Remvke 9ekedule,N mare apace ie required)
Description: Front deck, Staircase, Repaint foundation
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Mary Luther
14 Varney St. AUIMMZED REPRESENTATIVE
Salem, MA 01970
Sam Fragala/DEBRA
ACORD 25(2010105) O 1988-2010 ACORD CORPORATION. All rights reserved.
INS025(lOiMoT The ACORD name and logo are registered marks of ACORD
Ac'�o� CERTIFICATE OF LIABILITY INSURANCE °10002'/0201
u
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS 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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(Ees)must be ondorsfed. If SUBROOATION IS WAIVED,sub)Oct to
the terms and conditions of the policy,certain policies may require an endors°mont. A statement on this oerificate does not conlOT fights to the
Certificate holder in Seu of such endorsemon s.
PRODUCER CDWAM
Matthews Insurance Agency Inc PHONE• - FIVI
182 Parker St (978)601-1112 Nc N!, (078)685-3865
MAIL
Lawrence, MA 01843 INSURERS)AFFORDING COVERAGE NAIC0
WOURERA: Liberty Mutual �.
INSURED AJ Wood Construction INSURER B:
337 Haverhill Rd
Chester,NH 03036 INSURERc. _
INsuneR D:
INSURER
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 AFFOROED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE AOOt OU NUMBE0. LICY EFF pOMCrty LIMITS
GENERAL LWB61Tr EACH OCCURRENCE i
DAMAGETORENTED !
COMMERCIAL GENERAL�LIABILITY WAN
CLN L_
MS•MAOE I OCCUR MEOEXP An PM wAn 3
PERSONAL&ADVIWURY i -
ORNERALAGGREGATE i
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG f _
POLICY PRO- LOC S
IECTCO NEU SINGLE LIMIT
AUTOMOBILE LIABILITY (CROSM4 Air
ANY AUTO BODILY INJURY(Par PREell i--
ALLOWNED SCMOULED 606ILY PUURY(Pm v "Q i
AUTOS AUTOS
NO&O"EO P P AMA E
HIRED AUTOS AUTOS
i
UMBRELLA UAD OCCUR EACHOCCURRENCE f
EXCESS UAB CLM US.MADE AGGREGATE i
DED 1 1 go
WonXERSOOMPENSARON TIhLS OR•-
MR EMPLOYERS'UA®LITV
ANY PROPRIETOR IPARTNERIEXECUIVE YQ NIA WC23JS353619029 02/23/2012 02123/2013 E.L.f:ACJi ACCIDENT i� 100,000
OFIRCERIMEM ER EXCLUDED? 500,000
RMROANIy In NNI E.L.044FJISE•EA EMPLOYEE f _
o Sf:RI�iMMOPERAT10N5 E.L.DISEASE-POLICY LIMIT IS 100,000
ORSCRJPTIDN OF OPRINIIONS I LOCATIONS IVENICLEa (AfYLh ACCAD 1M.AEAXNnvI Ra SChetlule,It roan vpaviv mpulrvdl
front deck stalracase repoint foundation
CERTIFICATE HOLDER CANCELLATION
Mary Luther
14 Varney St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Salem.MA 01970 THE EXPIRATION DATE THEREOF. NOTICE Noll BE DELIVERED IN
ACCORDANDE WITH THE POLICY PROVISIONS.
04938-201DACOKD CORPORATION. All fights rosarvad.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD .
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Reqistration: 106603
Type: Private Corporation
Expiration: 7t24/2014 Tr# 228262
AJ WOOD CONSTRUCTION, INC.
Richard Smith
337 HAVERHILL ROAD
CHESTER, NH 03028
Update Address and return card.Mark reason for change. -
Address ❑ Renewal ❑ Employment Lost Card
oas-CAI is soo-n-o 04-Gim2is
v t'�Ii`"S`1frf ° License or registration valid for individui use only
^� Office`bf'�o �i�'��e �� a B' iKes evu a � 1" Y
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
t Registration: 106603 Type: Office of Consumer Affairs and Business Regulation
--v_ Expiration: 7/24/2014 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
AAaOD CONSTRUCTION,INC.
Richard Smith "
337 HAVERHILL ROAD
CHESTER,NH 03036 ,� F L7
Undersecretary Not valid without signafu e
— -- -- Certificate No: A041313 --
®\ THE COMMONWEALTH OF MASSACHUSETTS
_ EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT
DEPARTMENT OF LABOR STANDARDS
19 STANIFORD STREET,BOSTON,NWsACHUSETTs 02114
i
I
{ DELEADER CONTRACTOR LICENSE
I
AJ WOOD CONSTRUCTION,INC.
337 HAVERHILL ROAD
CHESTER NH 03 03 6
f �
LICENSE: 3DC001721 - E�TJ RES: Thursday,July 11,2013
Commonwealth of Massachusetts Dcpariment of Public SAO%
Department of Labor Standards ram, Board of Buildin, Regulation-sand Standards
Heather Rowe,Director Construction Supervisor License
Deleader Supervisor License: Cs 70882
RICHARD J. SMITH
Eff.Date 07/18/12
Exp.Date 07/17/13 w„., ,• RICHARD J SMITH
US90050513 S PO BOX 1769
WirkeroICONEs.T. hi SALEM, NH 03079
W - _..---
II"III�II'I IIIII II"II'III II'II"I HV-RENEW cmnnmc> Expiration: 013
Tr:F: 17308