10 WARNER ST - BUILDING INSPECTION (3) c 2-
The Commonwealth of Massachuse",r CITY OF
I +E j
Board of Building Regulations ar c4 ., SALEM
Massachusetts State Building Code,"7 �
Revised Mar 2011
C� Building Permit Application To Construct,Repair?fetovrtj gr]�jrya I f.
[— One-or Two-Family Dwel ing r��' �`[L
This Section For Official Use Only
Building Permit Number: Date pplied:
' Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prope Address: 1.2 Assessors Map& Parcel Numbers
IO ��,mo�'sf' lR..01 Ml��
L la Is this an accepted street?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(ft)
Front Yard Side Yards Rear Yard
Required Provided Required 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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwner of Record: _� S� I k 4�O 1 9 , (�
Name(Print) City,State,ZIP
lD "II.l (WO- = S'75-741 -/ /
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 0' Owner-Occupied Or. epairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Number of Units_ ther ❑ 'Specify:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
�n6.Total Project Cost: $ . ❑Paid in Full ❑Outstanding Balance Due:
I'`RIL. iD CON'T"If`
MaAL-Ie7l�>
Mn'tutt50 2N)b
MNt`E:0 3rz0 oNS� : Z-1 16 1 t7
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C 5-'n7o O--
S'M ILL License Number Expiration Dale
Name ofCSL Holder ^- \ yt List CSL Type(see below)
MUnreStriCteA
..Description No.and Streetted Buinmi s u el in 000 ca ft.d l&2 Famil DwellinCity/Town,State,ZIP Coverin andSidinLI " . el Burning Appliances
�p�j�-711 �j� �p.)kl)9 uygt(M1�Awl. 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /U 6b 3
�-� („�y11,y1rfriD, M HIC Registration Number „ Expiration Date
HIC Co3N d-
,,jstra nine
a iwLnc�(arS� ✓ �@4mr4l,c
No.andS_tTet `�r �� ��1_ /.���'yy6� �-- Emadaddress T—
City/Town, State,ZIP 6 Telephone
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...........0
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 d ciy Y A f'( A c
to act on my behalf,in all matters relative to work authorized by this building permit application.
GYr
Trifit wuer's Name(Electr is Si re) 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
con in this applicatio is true and accurate to the best of my knowledge and understanding.
I 'Date
Print Owner's is Name(Electronic Signature)
- _ NOTES: _.
l. 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 og v/oca Information on the Construction Supervisor License can be found at www.maSs.goy/dRs
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
I TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le Ably
Business/Organization Name:AJ Wood Construction
Address:337 Haverhill Rd.
City/State/Zip:Chester, NH 03036 Phone#:603-887-4468
Are you an employer?Check the appropriate box: Business Type(required):
1.❑✓ 1 am a employer with 5 employees (full and/ 5. ❑Retail
or part-time)." 6. ❑Restaurant/Bar/Eating Establishmltte
t 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]*
4.❑ We are a non-profit organization,staffed by volunteers, I L[I Health Care
with no employees. [No workers' comp. insurance req.] 12.❑Other
r 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
••lrthe 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'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:Acadia (Agent-Santos Insurance)
Insurer's Address:224 Main St., Suite 3C
City/State/Zip: Salem, NH 03079
Policy#or Self-ins. Lic.#WCA5136936-10 Expiration Date:2/23/16
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 MGL 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
E 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 information provided above is true and correct.
Si nature: ---^�•� Date•Phone#:603-887-4468
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www,mass.gov/dia
IOPar_
k Plaza = Suite-5170
Boston, Massachusetts 02116
Home Improvement (Ehctor Registration
Registration: 106603
Type: Private Corporation
m AJ WOOD CONSTRUCTION, INC. s - Expiration: 7/24/2018 Trk 419291
9
Richard Smith y
337 HAVERHILL ROAD
CHESTER, NH 03028 i
TCG�M SVev`ew Update Address and return card.mark reason for change.
--SCA1 0-20M-05r1 I _ _ _ Address Renewal Employment El Lest Card
V/tapo�nnaauu�ral!/o�P�/.amae/aeeda _ _ - _
9 Office of Consumer Affairs&Business Regulation I License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 106603 Type: Office of Consumer Affairs and Business Regulation
Ezpiradon•-7 2_[2018 Private Corporation 10 Park Plaza-Suite 5170
AJ WOOD CONSTACTI- ,1 tz,; Boston,MA 02i16
Richard Smith
337 HAVERHILL ROACD�-11". ,CHESTER,NH 03036 �—''" Undersecretary ,
Not va ' on 'gnature _
Massachusetts Department of Public Safety Commonwealth of Massachusetts
i I Board of BuildingR .j
-Regulations and Standards DepartmeMof Labor Standards
+ 'License. CS-070882 _ @�,\1@Y�1�/Jy� N •
.:try it '. + IYlierinfl:•MdGnDi'ecla'
ConstructionSupervisor }
`>t.l I t r� Deleader Supervisor
RICH ARD f1 SMITH*%` RIICHARD J. SMITH
337 HAVERHILL RD"
CHESTER NH 0�03 ` _ f r`` ER.Date 061017f8 4
. ` - ' ' '. ER.Rate 0531/17 .
a ' ' J DS900505 '.
WMbird CAKES.T. ,
M 1 '.µ W-R 1 HV-05JryW17 i1�' `•.
Commission Exp07/2182o17 'II�IIIIII��'IIIII"III'II'��'I�'�I
a . < 4
'A04557S
Certificate No: -
` THE COMMONWEALTH op,MASSACHUSETTS - '
EXECUTIVE.OFFICG OF LABOR A34D NVORICI'ORCE DEvELop�gENT
7 - DEPARTMENT OF LABOR STANDARDS kr .
t 19 STANIFORD STREET,BOSTON,MASSACHUSsrrS 02114
DELEADER CONTRACTOR LICENSE �r
' 1 ,
A.J. WOOD CONSTRUCTION,INC.
1 ?_ 337 HAVERHILL RDAD r
CHESTER N14 0303E
LICENSE:,DC001721 a y x WIRE& Tuesda July I1,20I7 �
IN ACCORDANCE WITH M.G.L. C14 111, e 197B AND 454 CMR 27 3'T`
7 h III
THE DEPART NT OF LABOR STANDARDS TO THE CONTRACTOR,ABO-VF EDIi�_l P-.nSnraED BY "n
10 Park Plaza - Suite 5170
Boston, Massac usetts 02116
Home Improvement actor Registration
Registration: 106603
Type: Private Corporation
? Expiration: 7/24/2018 Tr# 419291
AJ WOOD CONSTRUCTION, INC. a
Richard Smith
337 HAVERHILL ROAD A a
CHESTER, NH 03028 e
s+e Update Address and return card.Mark reason for change.
SCA t o s014-0sm - m Ej Address Renewal Employment Lost Card
da �pammwnwea ,o�C�/f'�amac�iueetld - -�'• .
Office of Consumer Affairs&Business Regulation License or registration valid for individual use only _
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Regiatratl n; 06603 Type: - Office of Consumer Affairs and Business Regulation
Expiratio 8 Private Corporation 10 Park Plaza-Suite 5170
go -
Boston,MA 02116
AJ WOOD CONS (t CTJON,J C;
Richard Smith
337 HAVERHILL ROAD
CHESTER,NH 03036
Undersecretary Not v ou 'gnature .. .
+r
r Massachusetts Department of Public Safety Commonwealth of MBssachus2ns ;Board of Building Regulations and Standards L .
+ License: CS-070082 r _ 1 Department of Labor Statdards .
•, .-• Construction Supervisor. - „. - . W'k'am.B:.MdCxv'r y*piecior� - t'}
' - l Deleader Su isor
RICHARDG SMmt- WPoCHARD J. SMITH ILI
337 HAVE kHILLJtD` y r+ ' Ell.Date 0607718CHESTER NH q03 { Exp.Date 05MI17
l I DS90MIVINTiterdC.O.N.ES.T.
—'1' Expiration: IICommissioner07/28/2117 ,
r
.. -....,.. .--�--• ...._— -<•--,• `.,,,,,_.:w_ - Certificate No: .A0455575
THE COMMONWEALTH OF MASSACHUSE'iTS °
._EXECUTIVE OFFICE OF LABOR AND WORKFORCE:DEV' 7
DEPARTMENT OF LABOR STANDARDS
19 F STAMFORD STREET,BOSTON,MASSACHUSETTS 02114 Y A
DELEADER CONTRACTOR LICENSE
a
AJ.WOOD CONSTRUCTION,INC.
337 HAVERHILL ROAD t
CHESTER NN 03036 I
L]CFNSEy DC001721 EXPIRES: Tuesday,July I1,2017 S
,ate s .,.. :_.�,
IN ACCORDANCE WITFI M.G.L.CH 111, §:1g7B(b)AND 454 CMR 22.03,THIS'LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR STANDARDS TO THE CONTRACTOR.ABOVF EaR�791.E Dt1n n�c�_nr
CON➢L$7 Commonwealth of Massachusetts iaN .
A City of Salem IV �
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Permit No. B-16-1177 PERMIT TO BUILD
FEE PAID: $119.00
DATE ISSUED: 10/18/2016
This certifies that MARQUEZ ZOILA M
has permission to erect, alter, or demolish a_building,lQWARNER_STREET Map/Lot: 360382-0
1
as follows: Roofing STRIP & REROOF
(2nd permit sent 01/27/2017)
(3rd permit sent 0 2/1 612 0 1 7)
Contractor Name: Richard J. Smith E::
DBA: A.J. Wood Construction, Inc.
Contractor License No: 106603
I 10/18/2016
Building Official / Date
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request.
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
I
All construction,alterations and changes of use of anylIbuilding and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. }I
The Certificate of Occupancy will not be issued until all applicable signatures by the_Building and.Fire.Ofcials are provided on this permit.
1
I j
HIC#: 106603 "Persons contracting with unregistered contractors do not have access to the fund'(as set forth in MGL c.142A).
Restrictions: IL
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
Commonwealth of Massachusetts
9 City of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Structure CITY OF SALEM BUILDING PERMIT
Excavation PERMIT TO BE POSTED IN THE WINDOW ' t
Footing INSPECTION RECORD
Foundation
Framing
Mechanical
Insulation INSPECTION: BY DATE
Chimney/Smoke Chamber
Final
Plumbing/Gas
Rough:Plumbing
i
I
Rough:Gas
Final
" , Electrical
Service I
Rough I
Final
Fire Department
Preliminary
Final
Health Department
Preliminary
Final