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12 SUMMIT AVE - BUILDING INSPECTION (4) The Commonwealth of Massachusetts 'I Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This 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) I a Summ, ye,��r__1 ' fmr>t'5 nain No.and Street City/Town Zip Code Name of Building(if applicable) 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 Existing Building❑ RepairA, I Alteration ❑ 1 Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No-9 Is an Independent Structural Engineering Peer Review required? Yes ❑ No Bri Description of Proposed Work: ll i (` iUA t ' 2 V r SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ 1-3❑ 1-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit- Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-Way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: -7X 2 SECTION 9: PROPERTY OWNER AUTHORIZATION Nppte and Address of Property Owner �X` ✓I bLol1 Iv145G4'f c c��---i2 Sr�yuwtrfisAy� '�f—'--�Ai.1 t�; lt>—O)9.,7c7, Name(Print) —No:�Street—, City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) —e-mail address I applicable,the property owner hereby authorizes - N "'^`ah v - k�--,--1-2 guw.�..fi={�t/G ALF a _wk-•ti pi97z:�_ Nam 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 than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Ci r Compa ame C ( t ' LS S� {O xp. aoJ o►3 Name of Person Responsible for Construction License No. and Type if Applicable u Ie Ite, �TQS�Ich M _�. 8 Street Address City/Town State Zip - g3a M-tea-- _a_ r . Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 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❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor tl0 and Materials) Total Construction Cost(from Item 6)=$ q 00> 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.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 PERMIT APPLICANT 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 tt best of my know edge and understanding. edfre S i+L tmgson -3 - 1`13z 5' y Il Please print and sign name Title Telephone No. Date LI LeS\ie- Roo--J Ma, cm2 Street Address City/Town S Zip jn Municipal Inspector to fill out this section upon application approval: Name Date Masonry Doctor LLC M 4 Leslie Road Ipswich, Ma. 01938 Cherith.sm ith&8mail.com �r t� Liabilitv and Relinquish of Permission Release Form On this fourth day of May, 2011, intending to be legally bound hereby, the undersigned agrees and does hereby release,from liability and relinquishes permission in all choice making decisions associated with any and all contracted work with Masonry Doctor Inc., and any of its employees or agents representing or related to Masonry Doctor Inc. in regards to the current contracted masonry project on 12 Summit Ave, Salem, Mass. 01970 dating from May 2011 thru May 2011. The undersigned further agrees to abide all the rules and regulations promulgated by Masonry Doctor Inc. and/or its affiliated employees throughout the duration of the contracted masonry project (May 2011). Rules and Renulations 1. The home owner relinquishes all personal choice making decisions to a third party: Anthony and Sheryl Miniscalco. 2. All decisions made regarding any masonry work contracted on 12 Summit Ave., by Masonry Doctor Inc., will be conducted by said office and said third party only: Anthony and Sheryl Miniscalco, and will be conducted by both parties in a responsible and appropriate manner. Sionntnrea/Termc of Release Project Dates: May 2011 /1AR(L-i k j{DylrM 1, a)ztf Name L12 Summit Ave/Unit Owner) (date) Signature Masonry Doctor 5/4/11 Masonry Doctor Inc. (date) 1 t l �� `� .. . -.i .. � � .- �. Masonry Doctor LLC 4 Leslie Road Ipswich,Ma. 01938 Cherith.sm itha-m ail.com i,iahility And Relinnnish of Permicsirin RPleaae Form On this fourth day of May, 2011, intending to be legally bound hereby, the undersigned agrees and does hereby release from liability and relinquishes permission in all choice making decisions associated with an and all contracted work with Masonry Doctor Inc., and any Y mY of its employees or agents representing or related to Masonry Doctor Inc. in regards to the current contracted masonry project on 12 Summit Ave, Salem, Mass. 01970 dating from May 2011 thru May 2011. The undersigned further agrees to abide all the rules and regulations promulgated by Masonry Doctor Inc. and/or its affiliated employees throughout the duration of the contracted masonry project (May 2011). Rnles And Renudatinns 1. The home owner relinquishes all personal choice making decisions to a third party: Anthony and Sheryl Miniscalco. 2. All decisions made regarding any masonry work contracted on 12 Summit Ave., by Masonry Doctor Inc., will be conducted by said office and said third party only: Anthony and Sheryl Miniscalco, and will be conducted by both parties in a responsible and appropriate manner. Cianatnrvs/rPrme ofRplp%cp Project Dates: May 2011 Name (1 ummit Ave/[Tnitwner) ( ate) Signature Masonry Doctor 5/4/11 Masonry Doctor Inc. (date) l� Cr ' _ a . CITY OF &U.&NI, N'LkSSACHL'SETTS BL'ILDLNIG DEPARINM%4T • 120 WASHINGTON STREET,3'a FLOOR TEI_ (978) 745-9595 FAX(978) 740-98" KINIBERLEY DRISCOLL MAYOR THoNw ST.PIERRs DIRECTOR OF PCBLIC PROPERTY/BU .DLNG co%maSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(BusinewOrganizationiindividuDMA-orall):1 �1 nr\I �� Address: 4 r 2,1'le ' CZor 'Ji 7 City/State/zip:T(ML.e)iC-V-). Nb,- 01CiNdPhone #: Rsa Are you an employer?Check the appropriate box: Type of project(required): ..rr--��tt�� 1.1�1 l am a employer with 4. ❑ i am a general contractor and 1 6. ❑New construction / employees(full and/or part-time).* have hired the sub- contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 11. ❑Demolition working for me in any capacity workers'comp.insurance. 9, ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their l0.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I t.❑Plumbing repairs or additions myself[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees. [No workers' 13 O comp. insurance required.] ther fYY15Dl1(ln feDd� •Any applicant that checks box N I most also fill out the section below stowing their woken'compensation policy information. 'I Imteuwnen who submit this affidavit indicating they am doing all wok and they hire outside c,,tmero,moat submit a new affidavit indicting such =Comrxtors that chcek this box most anached an additional sheet showing the m one of the aub-contncton and their woken'comp,Polley infatmotion. I am on employer that is providing workers'compensation Insurance jar my emplayees. Below is the pollcy and job site information. 1 ` ' ' \. ' '. ` Insurance Company Name:_rl-A-��beJ(—r�t MIATI.n a 1 cr�[�l Policy#or Self-ins.Lic.M yy C --1 5-1,S 3-7 31-2 -1 0-1 Qpiration Date: ' Job Site Address: I;z SI,IIYlmi,+ N e, City/State zip: cC L f (Ylll ems, O Lei 7 t� 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 S 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 5250.00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby c5plo under arse pains and p ahies of perjury that the information provided above is true and correct. Sim iure:((��C 1 2,&1 1 (] Date• c 11 f I Phone# `f1� Official use only. Do not write in this area,to be completed by city or town ofJIcial City or Town: Permitil.1cense p Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person• __ _, Phone#• A alht� CERTIFICATE-OF LIABILITY INSURANCE �'E'5�4 ' /11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policypes) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsernenl(s). PRODUCER CONTACT NAME: Circle Business Insurance Age PHONE 978) 777-5619 FAX No: (97e) 777-4e9e 247 Newbury Street AODaREss: PaulaHalas@CircleInsurance.net Danvers, MA 01923 PRODucER 1357 INSURER(S)AFFORDING COVERAGE NAIL# INSURED INSURERA: Scottsdale Insurance Co. Masonry Doctor Inc. INSURERS:Travelers Insurance 4 Lesley Road INSURERc:Liberty Mutual Insurance Ipswich, MA 01938 INSURER°: INSURER E: INSURER F: +COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOLTYPEOFINSURANCE INSRIMn SUER POLICY NUMBER PM/DDNYYLICY MMDUYOn(IXY LIMITS LTR GENERALLIABLITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIPS ILITY CLS1559325- 1/24/11 1/24/12 DAMAGE TO RENTED $ 50,000 DLAIMSMADE 1XI OCCUR MED EXP(AM one person) $ 5,000 PERSONAL&ADV INJURY $ 1 000 000 GENERALAGGREGATE $ 2,000,000 GENTAGGREGATE LIMITAPPLIES PER PRODUCTS-COMPIOP AGG $ 1,000,000 X POLICY 7 PRO El LOC $ ,ECTAUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Eaacciders) 4/28/11 4/28/12 ' B ANVAUTO BA1A069057 BODILY INJURY(Per person) $ 250,000 ALLOWNEOAUTOS BODILY INJURY(Per accident) $ 500,000 X SCHEOULEDAUros PROPERTY DAMAGE $ 100,000 X HIRED AUTOS (Per accident) X NONOWNEDAUTOS $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ L. MARKERS COMPENSATION WC1315373181010 6/10/10 6/10/11 7{ `PVC STATU-T. OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTME Y/N NIA E.L.EAC H ACG DE NT $ 100,000 OFFICE MEMBER EXCLUDED? (Mandalory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UNIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Reredos Schedule,if nlure space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Salem ACCORDANCE WITH THE PO CV PROVISIONS. Salem, MA 01970 AUTHORIZED REPRESENTA © 988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD x Office of Consumer Affairs and Business Regulation� 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement C ntractor Registration Renistration: 159704 Type: DBA MASONRY DOCTOR _ r Expiration: 5/19/2012 Tr# 297563 JEFFREY SMITH m 4 LESLIE RD. a ' IPSWICH, MA 01938 y b li 7f V la q,1� e Update Address and return card.Mark reason for change. DPS-CA1 0 5OM-04104-G101216 Address Renewal Employment � Lost Card s:rchuscRo- Dcp:u'tmeur n1 ublic Sali•h of Kuildin� Rc�uL❑inn.: P Boa,(I - Construction Su urrl sland:rrd Pervisor Specialty License License: CS SL 104227 Restricted to: JEFFREY SMITH r! 4 LESLIE RD IPSWICH, MA 01938 t� Expiration: 12120/2013 nor Tr=: 104227 r CITY OF SM.&M, NLAiSSACHUSETTS • BUILDING DEPARTMENT 120 WASHIINGTON STREET,Yo FLOOR TEL. (978)745-9595 FA.r(978) 740-9846 (QNiBERLEY DRISCOLL MAYOR THOMAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUILDING CO3-MaSSIONER 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: ,T2 ev Smi+h - HGl o Do*j%---Fnc (name of hauler) U The debris will be disposed of in : (r aame of facility) (add ess of facility) signature of permit applicant date a�nd�atr.a�