13 GROVE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
\ Revised Mar 2017
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official se Only
Building Permit Number: Date p'pried:
Building Official(Print Name) _ Signature Date
SECTION 1:SI ORM O
1.1 Pro erty Address. 1.2 Assesso ap&Parcel Numbers
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 R) Frontage(ID
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'
1 Owner
,rl,.`��of Record•
Sk
Name(Print) City,Stme,ZIP s
QY Go
No.and Snee Telephone - Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ 1 Existing Buildink4l Owner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of ProposedWork2: E ge
n
i
1. SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ p 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: $ DOW 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) &) �� 1
Ql C, X d, SA—z� License Number Expiration Date
Name of CSL Holder
9� List CSL Type(see below)
Description
Me..and Street 1
Q,�I w t, \ \ Unrestricted 2 Family
s u el ing cu.ft.
x '/k � V ill ( "I R Restricted 1&2 Famil Dwelling
Ctty/fown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
J Insulation
�Feleohurie EmO address D Demolition ,At 5.2 Registered Home Improvement Contractor(MC)
(w �) l c'1\Z,Z � HIC Registration Number Expiration Date
H1C Companyme or HIC RVan
Te
No and Stre t Email address
Cy
City/Town,State,ZIP_ Tele hone
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 APPLIES FOR BUILDING
PERMIT
1,as Owner of the subject property,hereby authorize PiN ujoc-k�t Q 0�j
to act on my behalf,in all matters relative to work authorized by this building permit application. 11
Prim er's Name(Electron' igmture) Date
SECTION 7b:OWNER' 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! this ap tion is true and accurate to the best of my knowledge and understanding.
Print— Obi r er�Aut d 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.eov/dos
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"
CITY OF Smym, XWSACHUSETTS
• BUILDING DEPjkRTJI&NT
130 W 1SHINGTON STREET, 3i0 FLOOR
`N� ' TEL. (978) 745-9595
FAX(978) 740-9846
KIN{gFRi EY DRISCOLL
MAYOR THOAIAS ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/Bt:1LDING COIDUSSIONER
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-7 ( n3�3C'2�
(name of hauler)
The debris will be disposed of in :
T (name of facility)
(address of facility)
ignature o rmit a ►icant
date
1 The Commonwealth of Massach usetts ;`77
Print Form
Department of Industrial Accidents
Office of Investigations
I 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
(Business/Organization/Individual):Name (Basiness/Organ'h ):AJ'Wood Construction,Inc.
Address:337 Haverhill Rd.
City/State/Zip Chester, H 03036 Phone#:(603) 887-4468
Are you an employer?Check the appropriate box: 77. C]
roject(required):
1.❑� I am a employer with 5 4. ❑ I am a general contractor and I w constriction
employees(full and/or part-time).' have hired the sub-contractors
listed on the attached sheet. modeling
2.❑ I am a sole proprietor or partner- These sub contractors have molition
ship and have no employeesworking for me in any capacity. employees and have workers' y ❑Building addition
workers' com insurance comp. a corporation
[No P• 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their 11.❑ Plumbing repairs or additions
3.El I a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.❑ Other.
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compcnsation policy information.
t Homeowners who submit this affidavit indicating they are doing an 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'camp.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:Liberty Mutual
Policy#or Self-ins.Lic.#:
WC2-31 S353819029 Expiration Date:2/23/13
Job Site Address: 1', el f wQ Sy- City/State/Zip:f3w 0 W "_
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 hereb certi under the and enalties o e that the in ormation provided above is true and correct.
Sienattue 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#•
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 106603
_ Type: Private Corporation
w 229262
Expiration: 7/24/2014
AJ WOOD CONSTRUCTION, INC - a `
Richard Smith -
337 HAVERHILL ROAD
CHESTER, NH 03028 3 -
Update Address and return card.Mark reason for change.
Address Renewal ❑ Employment i] Lost Card
DPSCAI 6 6oM04104-Cito1216 .-
,p License or registration valid for indii ul use only
r
before the expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR
Registration 106603 Type Office of Consumer Affairs and Business Regulation
t? oration -Suite 5170
Expiration: 2 Boston,MA 02116
4/2014 Private Corp 10 Park Plaza
7
OD CONSTROCTIONi:INC.-:;
Richard Smith
337 HAVERHILL ROAD - -- t signa4u e
CHESTER.NH 03036..
}:a , t `..';h a) , !r l tut U{,iir �arei%
rt ii ; rst .lit , t1i .ra�t�i;r:^i. Commonwealth of Massachusetts
9 ,J Board �: Department of Labor Standards
Heath6rE Roae.Dvedor
License: 70882 Deleader Supervisor
RICHARD J.SMITH
RICHARD J SMITH EH.Date 07/1
PO BOX 1769 DS930505
Date 07/17/113
SALEM, NH 03079 R
-_ — n�, ac.o.KEs.r. 13
r;
HV
=_::e:.aticn, 13 A7308
Certificate No: A041313
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT - f
DEPARTMENT OF LABOR STANDARDS
19 STANwoRD STREET,BOSTON,MASSACHUSMS 02114 -
.
DELEADER CONTRACTOR LICENSE
AJ WOOD CONSTRUCTION, INC. I
337 HAVERHILL ROAD j
CHESTER NH 03036
r
LICEN8I—IDC061781- =1�' ES: Thursday,Jniy ll;201�
IN ACCORDANCE WITH M.G.L.CH. 111,§ 197B(b)AND 454 CMR 22.03,THIS LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR STANDARDS TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF
DAYS(Will
co v® CERTIFICATE OF LIABILITY INSURANCE 031141ao+s
PON THE C TIE CERTIFICATE DOES ISSUED AS ilk fluill AMATIVd-Y OR ER.THIS
FNEGATNELY ANRtm I Fa Y AEXTENND 0 OR ALTER TM COVERAGE AFFORDED Y THE OPOLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE MOLOEFL moat be endorsed• If SUB TION IS WANED,aabject to
IMPORTANT: If thR cANRteto helder to eh ADDITIONAL INSURED.dte polley(fee)
the tefma and conditions Ol tlIe PC8C1r.certain policies may mQutra en endorsemeln. A aptemant an this eertilleete does noteollfer rlgtlts to the
eartitioate holder to 8au of eudh endolsemerl e>.
PRDOUGER MalMws e Insurance Agal Inc PNDNM (978)881-1112 ( � .(878)6863855
182 Parker St
ROI G e NAIaa
Lawrence.MA 01 B43 Uberm Mutual
R .
nMUREO AJ Wood Construction inSU as:
337 HaveAull Rd I xd: -
Chester,NH 03M
e•
wsuREaP:
COVERAGES CERTIFICATE NUMBER:
REVISION NUMBER:
THIS i6'TO CERTIFY THAT THE POLICIES OF INSURANCE USTBD BELOW NAVE BEEN ISSUED TO THE INSURED NAKED ABOVE FOR THE POLICY H THIS
INDICATED. ERTy(RT-MT 1OIHG ANY REOUatEMENT.TERM OR CONDITION OF ANY CONTACT OR OTHER DOCUMENT WITH RESPECT TO T H T THIS
CERTIFICATE
ER U ICATE MAY BE ISSUED
OR MAY
tl ERTAIK-r"E IN SHOWN MAY HIIVEEBEEN RFAUCF�OSY PAID AIMS HEREIN IS SUSJECY TO ALL THE TERMS.
fTf Lima
TYPEOP MsuRAxee P NUMBER y
EACH acclmn
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CANCELLATION
CERTIPICAT'E HOLDER O BEFORE
SHOULD ANY IO THE ABOVE DEEOF, N iVOE WILL
L e DSLIe
TxE EXPIRATION OATS THEREOF, NOTICE WILL 83 DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
PUnIDiDSED REPREif11A� __ -..
— —- T888 3010 tiORO RPORAT�N. All rights reserved.
AlO7R0 26(2010105)
The ACORD name and logo are feghiligned marks of ACD
TAU/0S/2013/TUE 03:37 PM Financial Insurance FAX No. 6034323852
r. uu)iuul
DATEtLE1IDOP/YYY)
a`R� CERTIFICATE OF LIABILITY INSURANCE i/B/2013
THIS CERTIFICATE IS ISSUED AS A MATTER N INFORMATION�NDER. THIS
Y EXTEND OR A TER 7N AND CCONFERS No GE COUTS VERAGE E AFFORDED BY THE PON THE CgIMFICATE DPOLICIES
CERTIFICATE DOES NOT AFFIRMATIVELY
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUR6f(S), AUTHORIZED
REPRESFATATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER.
IMPORTANT. If the ceni0cate holder is an ADNTIONAI iNSUR®,the polietroes)must be Endorsed. H SUBROGATION IS WAIVED.sub)aet to
the terms and I the
of the polity.eenaln Polleles may require an endorsement A statsmerd on this caUticate does not carder dgMs to the
eenlBeate holder in Deu of such endDrsemen S• r` Patricia Blais
PROOUCER PHONE , (603)432-6414 .rsmtd3zaesz
Financial IDSUzance Services Inc blais@fisins.com
PO BOX 930 IN6TmEaeAFF0RDP1otbVERA� ''s"c•
Derry L� 03038 UHUREI tA:Peerless InSn7 anC® Co 419E
INSURERR.Peerless Ins
INSURED
IrsuRRBRc:
A J Wood Construction Ina uauRERD:
337 Haverhill FA
NN 03036 RaIIREtF:
Cheater REVISION NUMBER:
COVERAGES CERTIFICATE NUMBER:�172003T07
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED M THE INSURED NAMELI ABOVE FOR THE POLICY PERIOD
INDICATED.CERTIFICATE NAO Y BE T STANDING
SUED OR MAY PERTAPI,THE INSURANCE AF 0 OR CONDITION D BY THEANY WPOI.ACIESCT OR 01-HER DESCRII4E�MERF-W IS SUBJEUMENT WITH CT TO ALL OTHEI TERNS,
IXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYF(AVE BEHd REDUCED BY PAID OWNS. UMW
iNSR TTPEOFURSURANCE Pl=NUMBER EAOR O rE 1,000,000
Ca/RRER S
GENERALUABIury 6 100,000
X COMMERCIAL GENERAL LOB"" /16/2012 /16/2013 h1E5 a(p aIe n 6 15,000
A DAVdSM/d>E ®OCCUR P870668S pE250NN.aAOVW.URY S 1,000,000
GENERAL AGGREGATE 6 2,000,000
PR=Crs COMPA'W AGG 21000,000
GENL AGGREGATE LPAT APPLIES PER: $
X POLICY o- LOC 1 000 000
AUTOMOBILE LIABILITY BODAYINAIRYIPerW—) 6
ANY AUTO 693505 /a/2012 /e/2D13 BODILY WJURY IPwscdd N) 6
B �o,� X SCNO DLEDS® . 5
X HIREDAUmS X AUTOS ATM EACH O 6 3,000,000
CCURRD7� 6 3,000,000
X UM6RELIA UAB X ODa1R AGGREGATE
B E%CESSUAS CWMSNADE 8802098 /16/2012 /16/2013 6
N NC STATU- O 14
WORKERSCONPENSIATON ElEAOR A00GEIT 6
AND EMPLOYERV LIABILITY YIN S
AWPROPRIE nyE❑ NIA El OLSEP3E-EAEMPLO
pandMery in RDn _CEWMENM EXCLUDED? F1018FASE-POLCYLUff S
if yyeess,,��d SvibA.mdar
pEStiNIPTION OF 0PENTI0NsI
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Description: Gall"
CANCELLATION
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIB®POLICdEa BECANCD LIVERED in
THE EXPIRATON DATE THEREOF. NOTICE WILL BE DELIVERED W
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORI2l;o RrA7NE
. . Sam Fragala/DEBRA
®1808-2010 ACORD CORPORATION. All rights reamed.
ACORD 26(2D1010S) ThB Awn name and logo are registered marks of ACORD
INS025(2010MI01