2 GRANT RD - BUILDING INSPECTION The Commonwealth of Massachusetts
ri Board of Building Regulations and Standards CITY OF
b Massachusetts State Building Code, 780 CRECEIVED SALEM
bo W �PECTICN;PAL SE IWXUI Mar2011
lv Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling 7 15 NOV 18 P 4: 31
This Section For Official Use Only
1 Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map &Parcel Numbers
1.1 a 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:
Public ❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner ofRecord•
-Eb Lk)a
a
Name(Print) � City,State,ZIPS
az
No.and Street Telephone Email"Address
SECTION 3:DESCRIPTION OF PROPOSEDWORK2(check all that apply)
New Construction ❑ Existing Building h] Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑ `
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWorkz: V� C) GCS(- cc
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ SSV - 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
Suppression) Total All Fees: $
\ Check No. Check Amount: Cash Amount:
,N
6. Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
M'Pr\L -ro C@�tJ-CTS-RC,rp(�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �L ��
�6
o
License Number Ex Yatio Date
Name of CSL Holder
List CSL Type(see below)
No. and Street e Description
U Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
1�_l�1 ( c�Sfi?�1( ��l N \k--kA is CS?� U
HIC Registration Number piratio Date
HIC Compan Name or HIC Registrant Name
�-�
ICM
Irl
_ No.and Sir t� (J ''�n (DL'�ii�Ouu Email address
Cit /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 .........N-41 No........... ❑
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 p Nn nQ d CJS s
to act on my behalf,in all matters relative to work authorized by this building permit application.
E V), A \(1,\s1/1 l
Print Owner's Name(Electronic Signature) Date
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 is true and accurate to the best of my knowledge and understanding.
P wner's rzed Agent's Name(Electronic Signature) ate
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),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. oe v/oca Information on the Construction Supervisor License can be found at www.mass.gov/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"may be substituted for"Total Project Cost"
The Commonwealth ofMassaehusetts
s 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 Leeibly
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):
1.23 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]* 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 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:2/23/16
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
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.
Ido hereby certify, under the pains andpenalties ofperjury that the information provided above is true and correct.
Sumature: 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
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10 Park Plaza - Suite 5170
r --.—Boston, Massachusetts 02116
Home proNfement Contxactor.Registration
Registration: 106603
•- - Type: Private Corporation
a.
E4(rafion^7/24/2018 Tir{ 253858
AJ WOOD CONSTRUCTION: INC. `
Richard Smith
337 HAVERHILL ROAD - "--
CHESTER, NH 03028
Lpdate Address and return card.Mark reason for change.
"-' Address Renewal --' Punpioyment " Lost Card
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`sem tate otConsur ARnim&Business Regulation License or registration valid for individui use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
istration: 1:06603 Type: Office of Consumer Affairs and Business Regulation
piration: 7124W6 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
AJ WOOD CONSTRUCTION,INC..
` 1ST
Richard Smiih
337 HAVERHILL ROADtV�� -.----'"
CHESTER,IVH 03036 �..-_ — --� id
Cadcrsetr¢tary' Not valid with t signator .�
s
Massachusetts Department of Public Safety - ..�
Board of Building Regulations and Standards Comfwnwea(t1 ofAf'wwchusetts
License: CS-070882 Delaa`tmeewofLarbor Ms y
Construction Supervisor sura „°'1B Dry
�ea:l Ai. .475rRgy,4. iXSUpervl5tx
t RICHARD i SMITH tet "".^. Rt'CHA.Rt3 J. SMITH
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337 HAVERHILL RD..CHESTER
CHESTER NH 08036
'r /FXPp�Da�-tee 05/27/16 "u...
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Expiration: NVR
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Commissloner 07f28720y7
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CertficateNo..` .t•
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EXECC TrvE OFFI s,OFLABOR Area Woxtr(lltCe Dmf pr eta r
DEPARTMENT o L OR$7-AN Alzl}s r
:- 19 STANWORO STREer,BOSTON,MASS 11Lt$Bt r5 02114
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DEL ADER CONTRACMR LICENSE !
( A.J. WOOD CONSTRUCTION,INC. i
.'. 337.14AVER14ILL ROAD
CIIEST'ER'NH 031336
a a __LICENSE RCa01 Z2I o� EXPIRES: Monday,`"July it 2016