131 BRIDGE ST - BUILDING INSPECTION (4) 1$ A� 255 �
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The Commonwealth of Massachusetts 1,1SPECTIONAL SERVICES
1 Board of Building Regulations and Standar s CITY OF
Massachusetts State Building Code, 780 CMR ALEM
1�4 $Ci -9 P � 'Mar 2011
Building Permit Application,To Construct,Repair, Renovat r emolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: - Date Applie .
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prop Address: Z� 1.2 Assessors Map&Parcel Numbers
l.l a Is this an accepted street?yes �4 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'of Recor
f \AXYG Gam' - C4__201\() 2
Name(Print) City,State,ZIP
3 _ � �t c C
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Buildikk Owner-Occupied Repairs(s) Iteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Descripti Proposed Work': Q_ O(r Ory
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ �J to 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑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 $ 1��U ❑Paid in Full ❑Outstanding Balance Due:
�/ t3T l0! 1 c.
Vs,,� 0b
` SECTION 5: CONSTRUCTION SERVICES
-� 5. Construction Supervisor License(CSL)
G, '�
\('�(�,{� l�,C�(1't1 License Number Expiration Date
Name of CSL Holder
'�t List CSL Type(see below)
✓cn� \\\
No.and Street Type Description
1 pt{— T,, \ � U Unrestricted2 Fm(Buildings u to 35,000 eu.ft.)
1 lTown, Sta e 'R. v._x,� 1 MRestrictedMasonry
1&2 Famil_Dwelling
City/Town,State,ZIP M Mason
RC Roofing Covering
WS Window and Siding
SF Solid o Burning Appliances
1 Insulation
Telephone' " Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
P1 SI C I Regsr t ;&umber
Expiration`Date
RIC Company Name or HIC RegisgSKame
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 I V
ance of the building permit.
Signed Affidavit Attached? Yes .........JN11. No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize W
to con`my behalf allpmtters relative t o k authorized by this building permit application.
Q C�rY'12Af�Q �.
Print Owner's Name(Electronic Signature) ate
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
cocontained in this application is true and accurate to the best of my knowledge and understanding.
\� t\-C>\-o,- rd -)Yy-\ 16� � L
Print Owner's or Authorized 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.eov/oca Information on the Construction Supervisor License can be found at www.mass,Qov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemem/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"
CITY OF StUEM, 1NLkSSACHUSETTS
• BUmDING DEP,.RT\I&NT
130 W.\SHIINGTON STREET, 31°FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
K1.NtBERLEY DRISCOLL
NMAYOR T irtomAs ST.PIHRRB
DIRECTOR OF PLBLIC PROPERTY/BUILDNG CO\LUISSIONER
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
1 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
U'-�-t S
✓�J W r�CGNS-t Gull. OD -
(name of facility)
NVb
(address of facility)
signature of per 't app cant
date
Jcbri>a O.d�x
,per The Commonwealth of Massachusetts
`-\ Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
up www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elecctricianumbe
Please s/Plt Le rs
A licant Information
NaIDt: (Business/Organization/Individual):
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):
5 4. Q I am a general contractor and I (i New construction
1. I am a employer with have hired the sub-contractors
employees (full and/or part-time)." listed on the attached sheet. 7. ❑Remodeling
2.[� I am a sole proprietor or partner- These sub-contractors have 8. Demolition
ship and have no employees employees and have workers' 9 Building addition
working for me in any capacity. comp. insurance.*
[No workers' comp. insurance 5 We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their 11.❑Plumbing repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 12.❑Roof repairs
myself. [No workers' comp. c 152 §1(4),and we have no
I
required.] t 13.❑ Other
employees. [No workers'
comp. insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are, all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors
Conti ctorsit the at heck this
box
ors have attached
ack yan additional
mast Provide wing the name
'o the
sub-contractors
ub-policy tbtt and state whether or not those entities have
employ
sub-
empl
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:Acadia
Policy# or Self-ins. Lic. #:
WCA5139636 Expiration Date:2123/15
City/State/Zip:
Job Site Address:
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 S1,500.00 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 of perjury that the information provided above is true and correct.
Signatum 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: Phnna lb
^�'"°� '�^"�°""c"'''^v'r11Ce ut t;url�turic>:r-irrair�nrna=uuarric��B��cgurac�..r.��.�
10 Park Plaza - Suite 5170
` Boston, Massachusetts 02116
J Home Improvement Co ,n ator Registration
- Registration: 106603
- Type: Private Corporation
Expiration: 7/24/2016 Tr# 253856
AJ WOOD CONSTRUCTION, INC.
Richard Smith
337 HAVERHILL ROAD
r-` 4
CHESTER, NH 03028
�t s
0
A, ye"Update Address and return card.Mark reason for change.
'�--' Address Renewal ❑ Employment ❑ Lost Card
SCA1 0 20M-05111
.__ _ VIZC lPanNYtdJt[Il¢(lUfL a�Vl�laddacftt(42�d —^� _�"--- --."�•__.__._._.__._..
tfice of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
gistration: 1'06603 Type: Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
xpira0on 7l24/2016 Private Corporation .
� •s%/ Boston,MA 02116
AJ WOOD CONSTRUCTIONS IINC �-
Richard Smith
337 HAVERHILL ROAD�v,
CHESTER,NH 03036 ` Undersecretary Not valid with t signatur
Massachusetts -Department of Public Safety -'Com. monWea(fh of MHSSacllluseffS
Board of Building Regulations and Standards i DePartmevd of Labor Standards qp�,
Construction Supervisor - 4eaf1ERowa"rpaectar
License:CS-070882 I ��Deleader Supervisor 01
RICHARD J. SMITH
MITE
RICHARD J S
�' Eff Date OfiOMt4"� n
337 HAVERHILL _ Exp.Date 06MI -,.,�
Chester NH 03039 1 . DS9W5W
O
HvR
Akr�erd GO N:E.S.T
954.+ .lJf �'rre" Expiration I I rtvR ENtw
Commissioner 0712 8/2 01 5 L..Im��I'�L.'I��I"tLnllfr�l.�'�
r ." $Certificate No t00099
-n
THE COMMONWEALTH OF,MASSACHUSETTS
EXECUTIVE.OFFICE oF,LABOR AND WORKFORCE DEVELOPMENT
_
1 ]DEPARTMENT OF LABOR STANDARDS
« �19 STAN1foRD STREET,BOSTON;MASSAC41J ETTS 024
DELEADER CONTRACTOR LICENSE m�
AJ WOOD CONSTRUCTION,INC.
337 HAVERInL ROAD :
CHESTER NH 03036 ,
Asa LICENSE: DC001721 EXPIRES: Saturday 'July'11,2015
ACGORDAtsCE .WG�L.CkI.111,j 197B(b)AND 454 CMR 2103,TEAS LICENSE IS ISSUED B