11 CHURCH ST - BUILDING INSPECTION (2) r^dNCf � /
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The Commonwealth of Massachusetts
® 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:
1 SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
11 Chu r6151rntk S() \-e nr, ()1470 line FSsex cAndofnin;%)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2.PROPOSED WORK
1 Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
}-� Existing Building❑ Repair Alteration ❑ Addition a Demolition ❑ (Please fill out and submit Appendix 1)
l Change of Use ❑ FChange of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes >1 No ❑ —Q
Is an Independent Structural Engineering Peer Review r uired? Yes ❑ No '}OS
Brief Description of Proposed or
' Xv1101.
AnInue, rr ^.
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(04 12°N si /; r- ,1 Ia 11'N crct .n is a y
S CTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR .t 1
CHANGE IN USE OR OCCUPANCY fAA.
�
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O
Existing Use Group(s): Proposed Use Group(s): - SCom'L.A
SECTION 4 BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.IL)
Total Area(sq.fL)and Total Height(fL)
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❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H11❑ H-5❑
1: Institutional 1-1❑ 1-2❑ 1-3❑ I4❑ M: Mercantile❑ : Resideuti R-1 11 R-2❑ R-3❑ R4❑ &v tCICXS
S: Storage Sl❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ HIA ❑ IHB ❑ I IV ❑ 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 muicipal❑ A trench will not be Licensed Disposal Site
n
f requiredX or trench or specify: S
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazazds to Air Navigation MA Historic Commission Review Process.
Not AppficableXIs Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Yes❑ No ❑
SECTION&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: p-
SECTION 9,. PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner (`()an
Cro, in&1,%cid (,wood 9- 1
Name(Print) o.and kreet 91 City/Town Zip
Property Owner Contact Information:
r000as JOh►ikal m
Title Telephone No. (business) Telephone No. (cell) J e-mail address
If applicable,the property owner hereby authorizes
9"6A('%4 hoc*- 1nC Zlie Rd. ISUA%dn MA. o Iq3@
Name �t 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)
f building is less than 35,000 co.ft of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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Name(Regis • t) Telephone No. e-mail address �• gistration Number
U I-P-5 R�_
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Street Address Zity/Town State Zip Discipline Expiration Date
10.2 General Contractor
M asi)A fg
Co any Name t_
Smi !(�Smi "1C - 1,5q-70q - 5 a 8
y -H,l rc. I I
Name of Person Responsible for Co traction License No. and Type if Applicable
4 Lt.slic- Rd > >psL4ck ". o q38
Street Address city/Town State Zip
a-18-3 12 -\43Z .s cu
Telephone No. business Telephone No. celle-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.9 25C 6
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents most be completed and
submitted with this application. Failure to Provide this affidavit will result in the denial of ftissuarice of the building permit.
Is a signed Affidavit submitted with this application? Yes No ❑
SECTION 12•CONSTRUCTION COSTS AND PERMIT AE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
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 $ 87 s. (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 the�yknowlge understanding.
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PI Tint n_d si a Title Tele hone Date
P � P
e 1
—rte CAI -
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval• ISI
Name Date
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where plicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(nuiy require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas(Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 S mifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Smve /hivestiation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance 1 E'
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other S
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
S o ']�312-143 N, �;
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Registration Number
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Name(Registrant) Telephone No. `dress 5��• �
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Street Address City/Town State Zip
Discipline Expiratio Date
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N e(Regis• ant) Telephone No. e-mail address egistration Number
)Wtie. ' Ina,;Jr 6►g3A SP? �o ,
Street Address �Ci /Town/Town State zipIhsnPlme Expira on ate
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci /Town State Zi Discipline Expiration Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location(Please indicate Block# and Lot#for locations for which a street address is not
available)
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No. and Street City/Town Zip Name of Building(if applicable)
For the above described propTrty the following action was taken:
Water Shut Off? Yes ❑ No)4 Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No A Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No)A Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
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Masonry Doctor Inc.
4 Leslie Road Ipswich, Ma. 01938
Cherith.smith@gmail.com
www.masonrydoctor.com
Phone: 978.312.1932 Fax: 978412-9403
JOB ESTIMATE #2016105
DATE: August 8, 2016 p
CONTACT. John Kadim \
Crowninshield Property Management
18 Crowninshield Street
Peabody, Mass. 01960
PHONE: 978-532-4800
EMAIL:jkadim@crowninshield.com
JOB SITE: The Essex Condominiums
I 1 Church Street
Salem, Mass. 01970
PROJECT DESCRIPTION: (courtyard) Remove brick ribbons in 6 different areas; Repair 6
substrates areas as needed; Reinstall existing brick in existing footprint in 6 areas; Install
polymeric sand in joints; Dispose of debris; Clean job site
PRICE ESTIMATE: (courtyard) $990.00
PROJECT DESCRIPTION: (sidewalk @ street) Remove 50 square feet of existing sidewalk;
Prep substrate as needed; Form new sidewalk in existing footprint; Pour new sidewalk @ 400
psi; Install sidewalk finish; Install control joints as needed; Remove forms; Dispose of debris;
Clean job site
PRICE ESTIMATE: (sidewalk @ street) $2,300.00
PROJECT DESCRIPTION: (ribbons @ street) Remove three brick ribbon areas; Repair
!''substrate areas as needed; Reinstall existing brick in existing footprint; Dispose of debris; Clean
job site
PRICE ESTIMATE: (ribbons @ street) $750.00
PROJECT DESCRIPTION: (Rear Law Office @ 15 Church Street) Remove 4" brick band at
threshold of door, Prep substrate as needed; Pour area with concrete in existing footprint;
Dispose of debris; Clean job site
PRICE ESTIMATE: (Rear Law Office @ 15 Church Street) $600.00
PROJECT DESCRIPTION: (West Alley/Entry Door) Remove existing knee wall on both sides;
Dispose of debris; Clean job site
PRICE ESTIMATE: (West Alley/Entry Door) $985.00
PROJECT DESCRIPTION: (West Alley/Crack Repair) Fill cracks in alley wall with
elastromeric sealant(2 cracks @ 11' I); Dispose of debris; Clean job site
PRICE ESTIMATE: (West Alley/Crack Repair) $250.00
PROJECT DESCRIPTION: (Driveway) Remove cow a in drive ay area (15'x12'); Prep
substrate as needed; 1 crushed stone lr as needed; Po new concrete @ 4000 psi in
existing footprint; Install co rete s ; Dispose of debri ; lean
PRICE ESTIMATE: (Driv a 4,545.00 / v
THANK YOU for your interest and have a wonderful week!
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i CITY OF S.U.E:NI, 2 ANSSACHUSETTS
• BuI DINGDEP\RTMENT
• 120 WASHINGTON STREET,3'o FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KlNfBFIU-EY DRISCOLL
MAYOR THONW ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BL'IIDING COMMSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information APlease Print Legibly
Name(Busim-&Organizatiorutndividual): I�'1Q50(1ry dJd&roc— kc,
`
Address:-4—lett I t� RA
City/State/Zip: ITwi[h, ft- Q 1 q-,J 3 Picone a: cn oo- 312-I q3 2
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 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 S. ❑ Demolition
workingfor me in an capacity. workers'comp.insurance.
Y9. ❑Building addition
[No workers•'comp. insurance 5.;4 We are a corporation and its 10.El Electrical repairs or additions
required.] officers have exercised then
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑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' 13.1A0 ther
comp.insurance required.]
•Any applicant that checks box 91 must also fill out the section below showing their worketa'compensation policy infunnuion.
'1 romeownen who submit this affidavit indicating they arc doing all work and then hire outside eommcmn must submit a new affidavit indicating such
::untm,ton that cheek this box most anachcd an additional sheet showing the tram:of the sutt.conttacton and their woken'comp.policy information.
I am an employer that Is providing workers'compensation Insurance jar my emplayeex Below Is the policy and Jab site
information. b le-Qx 5ep— ^Az-6,)-c, rw
em Insurance Company Name:
Policy Q�l
M or Self-itis.Lic.q: Expiration Date:
Job Site Address: City/State/Zip:
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 5250.00 it 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 files ojperrmy that the information provided above Is true and correct
SiLn /1 Darr I( �
Phoned
Oficial use only. Do not write in this area,to be cmnpleted by city or town agriaial,
City or Town: Permit/License H
Issuing Authority(circle one):
1. Board of stealth 2.Building Department 3.Cily/town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person• Phone R•
The Commonwealth of Massachusetts
-� Department of Industrial Accidents
Office of Investigations
r I Congress Street, Suite 100
Boston, MA 02114-2017
Masonry Doctor,Inc. May 14, 2013
Four (4) Lesley Road
Ipswich,MA 01938
Notice of Decision Regarding
Affidavit of Exemption for Certain Corporate Officers or Directors
Pursuant to the provisions of MGL 152, Section 1 (4)as the amended by Ch. 169 of the
Acts of 2002 your affidavit has been reviewed and the Office of Investigations has
determined the following:
NOTE: It is your obligation to submit an approved affidavit to your insurance carrier in
order to complete this process.
--K_The affidavit was approved on 5/14/2013 . Attached please find your approved
—affidavit.
The affidavit was rejected on .
Your affidavit was rejected for the following reason(s):
Related SWO Case ID#:
Affidavit ID#: 155738
ORM 153 The Commonwealth of Massachusetts DIA use only
Department of Industrial Accidents
Office of Investigations-Dept. 153
One Congress Street_10th Floor,Boston,Massachusetts 02114
httPWp vw.mass.gov/dia - \ 7�
AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPOIRATEwo ID a: 1b�✓
OFFICERS OR DIRECTORS
Chapter 169 of the Acts of 2002 amended M G.L. c. 152, f](4) by adding the following paragraph:
"This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of
the issued and outstanding stock of the corporation. Notwithstanding section 46, these provisions shall
apply only if the corporate officer provides the commissioner of industrial accidents with a written
waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the
purpose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set
forth in section 25C.—
Pursuant
.Pursuant to M.G.L. c. 152, §1(4)as amended, ItWe the undersigned officers of-
���11j R – — r
T–(NameofCorporatrooaad ddress)
each holding at least 25% of the issued and outstanding stock in said corporation do hereby "
right to be exempt from
> y invoke the
p the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a
workers' compensation policy covering the undersigned corporate officer(s) or director(s). I/We the
undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L. c. 152 for
any injuries that may be sustained while in the employ of the above-named corporation.
Further, I/we the undersigned do understand that, should the above-named corporation hire or have in
its employ any employee(s)in addition to the undersigned corporate officer(s) or director(s), said
corporation is required to obtain workers' compensation coverage for the employee(s)as prescribed by
M.G.L" c. 152, §25A"
I/We the undersigned have read and understand the statements and obligations as delineated above and
I/we have checked the appropriate box below my/our name(s)indicating my/our desire to be exempt or
not to be exempt from the provisions of M.G.L. c" 152.
Signed under the pains and penalties of perjury:
t -, -
�l 3
Ams
Print Name Date(mm/dd/yyyy)xercise my right of eLenuggnor El I wish NOT to exercise my right of exemption
GJ y t ff
\.Stgnature ��
Prmt Name&Titlele
�
Date(mm/dd/yyyyT—
I wish to exercise my right of exemption or � I wish NOT to exercise my right of exemption 4� a
Co
G7
Signature Print Name&Title
❑ 1 wish to exercise my right of exemption or E] I wish NOT to exercise my right of exemption Date(mm/dd/yyyy)
Sr
Signature
Punt Name&Title Date(mm/dd/yyyy)
❑ 1 wish to exercise my right of exemption or Q I wish NOT to exercise my right of exemption
Note:ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN.
on back THERE CAN BE NO MORE THAN 4 SIGNATURES. InSnUedons
Form 153-Revised 06-04-10
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
== Registration: 159704
TVpe: DBA
Expiration: 5/19/2018 Trtt 287858
MASONRY DOCTOR ti
JEFFREY SMITH IL
4 LESLIE RD. f^y1
IPSWICH, MA 01938
.;�
Update Address and return card.Mark reason for change.
SCAT G 20M-0.5711 "" ❑ Address [IRenewal E] Employment ❑ Lost Card
!? Massachusetts Department of Pu6lic Safety
Board of Building Regulations and Standards
License: CSSL-104227
Construction Supervisor Specialty
JEFFREY A
4 LESLIE RD Mflti
WMCX MA 01938 «f
i
L -xpiration:
Commissioner 12/20/2017
f
CITY OF S. .&Nl, TNLksSACHUSETTS
BummxG DEPARTMENT
130 W 1SHNGTON STREET, 3rD FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJIBERL.EY DRISCOLL
MAYOR T Hoetas ST.PmRRE
DIREG[OR OF PUBLIC PROPERTY/BUUMING COM%USSIONER
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:
Masm v
-dum -irur�k-
(name of hauler)
The debris will be disposed of in :
(lame of facility)
(addreis of facility)
signature of per*it_ppliciant
77/CX 11h
ua e
debriulLdm