131 BRIDGE ST - BUILDING INSPECTION (6) ( b � G<- 3133
RECEIVED
1USpFrTinNAL SERVICES
The Commonwealth of Massachusetts
Department of PublicSafe(g15 JUL -8 P 1: 45
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Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(rhis Section For Official Use Only)
Building Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1
No.and Street City/Town Zip Code Name of Building(if applicable)
` I SECTION 2 PROPOSED WORK
\� Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
lExisting Building❑ Repair bj Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
I_,`^I Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
-1L Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer R ew required? tt pp Yes ❑ No ❑
Brief Description of Proposed Work: Tr t P n(Jt ,
t n p H rA I �
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Buildin Investigation and Evaluation is enclosed(See 780 CNIR 31) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Fluors/Stories(include basement levels)&Area Per Floor(sq.ft.) _
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a livable)
A: Assembly A-1❑ A-2❑ Nightclub- ❑ -A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1 O. H-2❑ H-3 ❑ H-d❑ H-5❑
L• Institutional F 117 1-2❑ 1-3❑ h1❑ NI: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ 1 U: Utility❑ Special Use❑and Please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a livable)
IA ❑ IB ❑ 11A ❑ III) ❑ IIIA ❑ IIIB (3 IV ❑ I VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780.CNIR 111.0 for details on each item)
rmit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Pe Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be
Private❑ or indenti Zone: or on site s stem❑ required❑or trench or Specify:
-
Private y permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: 4,".mm,sision
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
C-dition ul Cudc Use Group(s): Type of Construction: . Occupant Load per Floor:
Does the building,contain an Sprinkler System?: Special Slipulatiuns:
S� �s D ro C-D r-) -
fY' (a,Utz -i( 10
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner _ ff _
IS/ GT"LA4J,�
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: �/ f
OWn'er - /Z� g� /UfANLCIL. �Ori7lLlf2Q� � vr�^
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(if building is less thin 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - -
Name
C t any v, r d S V 0�t (_
Name of Person Responsible for Co truction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No, business Telephone No. cell e-mail address
SECTION 11:VVORKERS'COMPFNSAl'ION WBUI NICE AFFIUAVII M.C.L.c.152.9 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes 0 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Budding $ Building Permit Fee=Total Construction Cost x—(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
J. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERhtrr APPLICANT
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this
appli 'on is true and accurate to �St of my knowledge and understanding.
Please riot and 'ign mm�e /-� Title Telephone No. Date
Street Address City/Town State Zip n
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusells
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,AM 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:�o31 � iJ0 r hl ( J 2t) r
City/State/Zip: l 6e r Al Phone#: � .��� (cob
Are you an employer'Check le—rshipand
appropriate box: - Type of project(required):
i.❑Ism a employer with employees(full and/or pact-time).* 7. E]New construction
2.❑I am esole proprietor or have no employees workittg to in g. E]Remodeling
any capacity.f No workers'-comp.insurance requh'ed.]
3.01 am a homeowner doing all work myself.[No workers'comp.insurance requited.]t 9. ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. twill" 10 E]Building addition,
more that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietor;with no employees. pm
12.E]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.,L�Y,���(o0f r airs
These sub-contractors have employees and have workers'comp.m ra ct l -
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.Q Other
and we have no employees.[No workers'comp.hsuraner required.]
-Any applicant that checks box pl wise also fill out the section below showing their workers'oompensaton"Ii mfomietion:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a ram-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 thou entities have -
employem If the sub-contractors have employees,they must provide their.wmkm'.gomp.policy mwber...
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job.site
information.Insurance Company Name: j k bed j 'M I ` )
Policy#or Self-ins.Lie.#: Expiration Date: (�
Job Site Address: �3 ( f�L➢ P cl+ City/State/Zip: R M ASr_�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 penahes ofperjury that the information provided above is true and correct
Suture• ' Date: ep
Phone
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 M
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for thew employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or writtep."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with thew certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employes other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or UP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-NMSSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
OTY OF SALEg MASSACHL SE nS
l BucwjNG DEPARTMENT
1 120 WAStIINGMNSMWT,3RDRoOR
7kL(978)745-9595
KRaERLEYDRISCOU FAX(978)740.9846
MAYOR THCMAS STYIEMM
DIRECTOR OF PUBLIcpROpERTY/BUIIAING ppMMISSIONER
Construction Debris Disposa/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 c40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
Al 6AD CO
(name of hauler)
The debris will be disposed of in:
-.12LI
(name of facility)
Ap Nq
(address of facility)
Si nature of applicant
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Commonwealth of Massachusetts v Massachusetts -Department of Public Safety
Department of Labor Standards Board of Building Regulations and Standards
+ jp_' HeaffwE Rom.Direcw Construction Supen isor
P Deleader-Supervisor License: CS-0708S2
1. 1 0
RICHARD P. SMITH � `�� ._ �'•
Etf.Date 06119113' V RICHAVE JS I_'R TZ
Exp.Date 0&19114 3 hester ERH 036 D50Chester NII 03034NEmher of GO.N.ES.T. i��1 �� �j Expiration
- I III'III IIIII'I"'IIIII�IIII IIII I'II 07f28l2015
W-RENEW Commissioner _
Office`SCoiY's �{fr`X?( � s&`BYrIi es u License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
VAOC
Registration: y106603 Type: Office of Consumer Affairs and Business Regulation
h 10 ParkPlaza-Suite 5170
Expiration 7/24/2014 Private Corporation Boston,MA 02116
CONSTRUCTION INC.r '
Richard Smith t !
i7
337 HAVERHILL
CHESTER,NH 0303fi\`F- Undersecretary Not valid without signs e
Certificate No: A042321
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTNE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT .
:. DEPARTMENT OF LABOR STANDARDS ;
a+ I9 STANIFORD STREET,BOSTON,MASSACHUSETTS O2I I4 -
DELEAIDER CONTRACTOR LICENSE
AJ WOOD CONSTRUCTION,INC.
337 HAVERFIILL ROAD
CHESTER NH 03036 '-
LICENSE: DC001721 EXPIRES: `Friday,July 11,2014 ;
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IN ACCORDANCE WITH M.G.L.CH. 1]l;§ 197B(b)'tYND 454 CMR 22.03,THIS LICENSE IS ISSUED BYTHE DEPARTMENT OF EABOR.STANDARDS TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF
ENTERING INTO OR ENGAGING IN DELEADING WORK:
r ,
THIS LICENSE IS VALID FORA PERIOD OF ONE YEAR.,
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THIS LICENSE MUST BE MAINTAINED-BY THE CONTRACTOR WHEN ENGAGED IN DELEADING
WORK IN ACCORDANCE WITH M.G.L.CH,111 §;197B(b)(2)AND 454 CMR 22 03. -
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CERTIFICATE OF LIABILITY INSURANCE 02ni12015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER-THIS .
CERTIFICATE DOES N07 AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PAUTHOLI IES-'
BELOW. .THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE-A CONTRACT_,BETWEEN THE ISSUING INSURERIS),
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. _ •�_
IMPORTANT: It the oertlOCate.holder Is an AIIDITIONAL INSURED,the policyhes) must be endorsed, If SUBROGATION I$WAIVED subject to
the terms and cpnditimis of fh0 policy, Cartain polictos.may r@quire an endorsemenf- A statement on#his certificate does not Confer rights to the.
coru0cate holder in Fieu of such endoTsemenf(s}, � -
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Planright Insurance-Salem � ?�HR^-o cx 603-890 6439 ��F{rc Not:603 590-6b24
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. 'Julie Smith - INSURER,r
337 Haverhill Rd - �
. .Chester, NH 03036 - :+suR R❑ _ ;:...--i. --
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INDICATED. NO^NITHafp!DING ANY REC'UIRtMENT,TERM OR CON0710N OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPEO7 TO NPr1lCN THIS
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Richard Smith ls excluded from work compcoverage;
CANCELLATIONCERTIFICATE HOLDER 4 • - -
• . :SHOULD;ANY OF THIS ABOVE OE
SCRBED POLICIES BE CANCELLED BEFORE
THE"EXPIRATION DATE..THEREOF,. NOTICE WILL '.BE DELIVERED 1N
.K`.ACCORDANCE 6VITH THE POLICY PROVISIONS
'For Information Only;.. '•: - ; ..! : - '.` "„
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