12 WEBB ST - BUILDING INSPECTION G" 315Z
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards 1EGEIV D M
Q Massachusetts State Building Code, 780 CMR iNSPEC;T10NAl $ RY P evise to
A,<t•,i
Building Permit Application To Construct,Repair, Renovate Or Demolish°a
One- or Two-Family Dwelling Z01h MAR'`11 A q 41
M This Section For Official Use Only
1 Building Permit Number: Date Ap ied:
9 Building Official(Print Name) Signature WDt
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
—
Ill_f 1.la Is this an accepted street?yeses 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?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ _
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: �1
Cnl .11 i�
Name(Print) City,State,ZIP
k2 \til%r3VL) 51 tom% -fZOI LA
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildi Owner-Occupie Repairs(s)* Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': I AA
S1 GLU
11fe_ rc
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ I// y�
4.Mechanical (I VAC) $ List: 7 U
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) -D m � 1
{ \119 ��,.��;-�-� License Number Exptration Nate
Name of CSL Holder
List CSL Type(see below)
T Description
No.and Street
Unrestricted Buildings up to 35,000 cu.ft.)
Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�U �P SF Solid Fuel Burning Appliances
I
Y Insulation
Telephone Email address D Demolition
5.`2ReRegistered Home Improvement Contractor(HIC) O „ (I„/'mil �1 i 1 �l
' :) i A`�� C wSKK keH � HICC Registration Number E pirrat`i-oln Date
HHIIC3Crolmpany Name oQr ;Vst pnt Nae
nd St t �(f\ Email address
(� r . Z�k-eX' to �Qt
t /Town, State,ZIP 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........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPL;IIES_FOR BUILDING PERMIT
(i I,as Owner of the subject property,hereby authorize nk C 1 —hkse
to act o b h 1 in all matters relative to work authorized by As building permit application.
Print ner's me(Electronic Signature) Da e
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application i e and accurate to the best of my knowledge and understanding.
3111n �1 h
Print Owner's or Autho Ju
��')s Name(Electronic Signature) Date
NOTES:
1. 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. og v/dpS
2. When substantial work is planned,provide the information below:
Total floor 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/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
' X CITY OF S�'1I.E. I i XSSACHUSETTS
BUILDNGDEP1RTNIENT
• 130 WASHINGTON STREET, 310 FLOOR
\ TEL. (978) 745-9595
'FA.(978) 740-9846
(<I.\jBFRr F.Y DRISCOLL
NMAYOR THObtAS ST.PIERAE
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONLMSSIONER
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
111, S 150A.
The debris will be transported by:
A� �AYM o coffixtC
(name of hauler) ,
The debris will be disposed of in :
S
(name of facility)
cJ5nA �JH
(address of facility)
signature o plieant
Lb
date
dchriwf7dce
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
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):
1.21 1 am a employer with 5 employees (full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I 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, 11.❑Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box 41 must also fill out the section below showing 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'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:2/23/11
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
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties ofperjuty that the information provided above is true and correct.
Sienature Date:
Phone#:603-887-4468
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
�l�r�' '. . "�""""�"tt%tlt<'.CUt*\;itJd2JU2'Y1Gi�tldtcltd J"C1Y:dl1'S:i-Lt'JLTtc.".J�rivSatYt�r�3a� -++*�� -
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Rome Impro\tement•Contractor_Registration
'tr Registration: 106603
- Type: Private Corporation
f—Ezpdatton:-724110167 Trti 25M56
AJ WOOD CONSTRUCTION, INC.
Richard Smith f
337 HAVERHILL ROAD
CHESTER, NH 03028
• Update Address and return card.Mark reason for change
Address u Renewal Employment Lost Card
SCAC 0 2DRA 41 ry "
tfi<e of Consumer Affairs&Business Regulation before
or registration valid for individul use only
VME IMPROVEMENT CONTRACTOR before the expirationsdate. a found return to:
P
istration: 106603 Type: Office of Consumer Affairs and Busin¢ss Regulation
nation: 7241 16 r Private Corporation 10 Park Plaza-Suite 5170
.j s. ,,. - Boston,MA 02116
AJ WOOD CONSTRt1CTION,INC. ,
Richard Smith
337 HAVERHILL ROAD`
CHESTER,NH 03036
Undersecretary iVo[valid with t signatur -
x a Massachusetts Department of Public Safety �.
007e
Board of Building Regulations and Standards Department Of La 6oi Sfart�rds
i1SltLS
License: CS-070882 o '
leadxr-E`Roas,t)racM
Construction Supervisor ' 0 a
�ve,�.ix.a �� . ,�, rSupervisof
RICHARD J SMITH- &6, `=` 14CHAW J.SMITH
337 HAVERHILL RD, ER.D lj-
CHESTER NH 0303 x EW �Date 7/i6
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DS90060$
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(�� q.rt;.d �aatCO N,E.S,T
.:»,�.-•...,� Commissioner
Expiration:
C �.,-•..� ��� !® ����1 �����ommissioner 07/28/2017
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THE COMMON WEALTH OF MASSACHUSETTS I
—. EXEcunvE Omcr OF LABOR AND NV6R.Kr0RCEDEVELOPMEN7 _ t
DEPARTMENT OF U]IOR STANDARDS
�r I9STAtsIFoR6SiizEF-raBOSiaN,MAss4c,,HusEm. 02114
I .
DE LEADER CONTRACTOR LICENSE f
A.J. WOOD CONSTRUCTION, INC.
337 HAVERHILL ROAD .
CHESTER NH 03036
1
II
-._LICENSE:.DC001,721 EXPIRES: MondayJuly 11,20,16
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