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17 APPLETON ST - BPA-14-749 RPR OUTSIDE: STAIRS, ETC Lt -7 Z- 3-- 114 <,;s) � The Commonwealth of Massachusetts RECEIVED Board of Building Regulations and Standards T�pNp SEVV"617 Massachusetts State Building Code,780 CMR IHSPEG SALEM d Revise Afer 2011 Building Permit Application To Construct,Repair,Renovate Or)� � p1 1F 73 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: ,52 Building Official(Print Name) Signature - ate SECTION 1:SITE INFORMATIdN 1.1 Pro erty A dress: 1.2 Assessors Map&Parcel Numbers Ll L l 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(it) Front Yard Side Yards Rear Yard Required Provided Requited 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 Ownert of Record: 0 0� o Name(Print) City,State,ZIPS r) q 4 ►3-950� No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify: Brief Description of Proposed WorkZ: DQ"C, -Cr tSCX- \\ (\ t WcN nd w 000f lL St &tCkr0-<-J '506c.,Q SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs:Labor and Materials Official Use Only 1.Building $ 1. Building Permit Fee:$ Indicate how,fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee 13 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 6. Total Project Cost: $ 'Q� ❑Paid in Full ❑Outstanding Balance Due: SMUT To G C, ql zg, ? SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) \' l \!r_`�-(`w('C�• CYl \" �l License Number Expiration Date Name of CSL Holder I�c,,.�e�h�� List CSL Type(see below) � a �� No.and Street Type Description C _ ,� 0 A O^� 1_ U Unrestricted(Buildings u to 35,000 cu.ft. X�Z.,Ct'. J�J lD R Restricted 1&2 FamilyDwelling City/Town,Stale,ZIP M Masunry 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) rT• l>�� COrS-"u0VNon IDIo (ni7 ?� �I, 1y HIC Compan1y Name or HIC ReB�strant_Name HIC Registration Number Ex nation Date Street 2�\11��\ QU ��.�cYx�C No.and Street Email address City/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 .........QB- No...........O 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 PfC' L.O C fnS+,(\-AC-h\CVQ to act ehalf,in all relative to work authorized by this building permit application. - - - - N �4-w� AINm Owner's Name(Electrod gnature)- - 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. Print Owner's or u onzed Agent'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.gov/oca Information on the Construction Supervisor License can be found at www.mass. ovg /dns 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"maybe substituted for"Total Project Cost" The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizaborAndividual): A.J. Wood Construction, Inc. Address:337 Haverhill Rd. City/State/Zip:Chester, NH 03036 Phone#:603-887-4468 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the'attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8, ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance." 9. ❑ Building addition [No workers' comp. insurance P required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comn. insurance required.] *Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Acadia Policy#or Self-ins. Lic. #:WCA5139636 Expiration Date:2/23/15 Job Site Address: sC City/State/Zip:3D�\p(`r1 �Pk o `q-1 o 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 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 ofperjury that the information provided above is true and correct. Signature: - 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.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: I IN Home Improvement Contractor Registration _ - Registration: 106603 - Type: Private Corporation I Expiration: 7/24/2014 Tr# 228262 i AJ WOOD CONSTRUCTION, INC - — Richard Smith = 337 HAVERHILL ROAD CHESTER, NH 03028 Update Address and return card.Mark reason for change_ r; Address Renewal ❑ Employment Lost Card DPS-CAT o. soM4MOLG101216 - — ---- '-'---'-'- - -" License or registration valid for indfvidul use only .� Office` liS Ss before the expiration date. If found return to: _ HOME IMPROVEMENT CONTRACTOR Type- office of Consumer Affairs and Business Regulation Registration 106603 10 Park Plaza-Suite 5170 t, Private Corporation a i Expiration 7/24/2014 Boston,MA 02116 5 AOO-61 D CONSTRUCTION.INC. Richard Smith 337 HAVERHILL ROAD CHESTER,NH 03036 Undersecretary Not valid without signa e ,�1, Commonwealth of Massachusetts V Massachusetts -Department of Public Safety Department of Labor Standards Board of Building Regulations and Standards r 3 rHe&ffETom,Daector Cun.tructionSupenisor 1 . _ -Deleader"Supervisor License: CS-070882 „ RICHARD P. SMITH RICHARD J SMITjI Eff Date06A9113 '' Date 06f19114 337 Chester NH 03037�3y DS001114 123 ,, „ t�rnher of GO.N.ES.T. MR Expiration -ate 07/2812015 IIIIIIII IIIIII1liltIIIIIIIIIINI _ Commissioner Certificate No: A042321 ' I I{ THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT {' n DEPARTMENT OF LABOR STANDARDS hIIi 19 STANIFORD STREET,BOSTON,MASSACHUS6TTs 02114 f DELEADER CONTRACTOR LICENSE AJ WOOD CONSTRUCTION,INC. 337 HAVERHILL ROAD CHESTER NH 03036 LICENSE: DC001721 EXPIRES: Friday,July 11,2014 IN ACCORDANCE WITH M.G.L.CH.+I 11, § 197B(b)AND 454 CMR 22.03,.TMS LICENSE IS ISSUED By THE DEPARTMENT OF LABORS OR To THE NG IN DEL TOR ABOVE WORK OR THE PURPOSE OF ENTERINGINTO ^`ACORO" AJWOO-1 OP ID: NB CERTIFICATE OF LIABILITY INSURANCE 7HOLDER 014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFIC . THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDEDLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: B the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS ject to the terms and conditions of the policy,certain Policies may require an endorsement A statement on this certificate does not to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Planright Insurance-Salem NAIVE: James A Santo 224.Main Street Suite 3C PHONE Salem,NH 03079 +eA"w E: :603 890 6439 FAX �;603-890.6521 AD James A Santo DRESS:jamie@santoinsurance.eom INSURER(Si AFFORDING COVERAGE NAICY INSURED A J Wood Construction,Inc INSURER A:Acadia Insurance 31326 337 Haverhill Rd INSURER B: Chester, NH 03036 INSURERC: INSURER D: INSURER E VISURERF: 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'ISSUEO 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN cam" LlR TYPE OF INSURANCE POLICY NUMBER M/DU E POD GENERAL LUUNUTY UNITS EACH OCCURRENCE s 11000,00 A X COMMERCIAL GENERAL LIABILITY CPAS136932 02/23/2014 02/23/2015 PREMLSEsIw s 250,00 CLAIMSVdAOE OCCUR MED EXP(Any one person) S $,00 PERSONAL B ADV INJURY S 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE UMIT APPLIES PER; I PRODUCTS-COMP/Op qGG $ 2,000,0 X POLICY PR6 LOC AUTONO&l.E LIABILITY COMBINED SINGLE UMrt A ANY AUTO Eaaaddem 1,000,00 CAA5136933 0212312014 02/23/2015 BODILY INJURY(Per perspn) S ALL OWNED X SCHEDULED BODILY INJURY(Per eordent) S X HIRED AUTOS X AUTOS P R�DDudAG § S X EXCESS E LA B X OCCUR EACH OCCURRENCE S 3,000,00 A °I � CLAJMSMADE CUA5136934 02123/2014 02/23/2015 AGGREGATE s 3,000,00 DED X RETENTION 4 O WORMERS COMPENSATION S AND EMPLOYERS'LIABILITY X WC STAB OTHH. A ANY PROPRIETOR IEX IPARrNERECUnVE YIN CA5136936 02/23Y1014 02I2312015 Off10Efewy In N R EXCLUDED? a N I A 3A.NH i9 MA E.L.E EACH ACCIDENT $ 1,000,00 If .dtory In Nn E.L.DISEASE.EA EMPLOYE $ 1,000,00 Dyes PTIOe antler DESCRIPTION OF OPERATIONS below � E.L DISEASE-POLICY LIMIT § 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Athph ACORD IM.AddNonel Rwurks Sohedul4 N more spew h repuNed) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN LForInfornrration Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD