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1 LAFAYETTE PL - BUILDING INSPECTION (3) 4�1 The Commonwealth of Massachusetts. Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM vlVA1 1 ��O Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: )) Date Applied: f4rr".&4&t _71 Building -Z Building Official(Print Name) Si re Date SECTION 1:SITE INFORMATION 1.1 ProperpAddress: 1.2 Assessors Map&Parcel Numbers I LcktaNe.iie 1P\ ace.' LI 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 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: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 caner'of Record: bill G�IhQt+ 5akem+ Mass. clicno Name(Print) City,State,ZIP 1 1.a�a.�Q H¢ 'el ace q-11-IL4 0367 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) )1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': e?XMrgnel ll.')C?771 ccryifrut- 1) am 4tX t r „2 K 4"6 SECTION 4:ESTIMATED CONSTRUCTION COSTS i Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard CityiTown Application Fee 2.Electrical $ ❑Total Project Costa(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: $ 91-1014 .00 ❑Paid in Full 13 Outstanding Balance Due: , SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) (o { c-fl I^—an 30`2 �ef4'' �M 14) LicenseNuumber xntonDate Name of CSL froMer 1S1 i �O� List CSL Type(see below) No.and Street C C Type Description rpsw 1 C�L,Hat>s Q�Q 3$ U Unrestricted2 Far(Buildings u el ing cu.ft. O R Restricted 1&2 Family Dwelling Cityown,State,ZIP M Masonry Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances q�g-3 )2_�g3 ,� (Y)QI I Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement ImprovemenntContractor(HIC) I �q -7 O ` Ma nfV T)e)c+rl / T'—ff44� HIC Registration Number q r1 a Ex imtio Dotate HIG Co Name r C tegistrant Name ' sme 8(ni4h@Qmaib o&) No.and Street Email address SI >;ch, W)cL&S n)CUS c0;?-,3)2- )C62- City/Town, ?g-.3)2- )a32.- Ci /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 issuance of the building permit. Signed Affidavit Attached? Yes ..........PC 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 MASON-RI rVCiT0 9-- to act on my behalf,in all matters relative to work authorized by this building permit application. F>1LL GIL13F2T -312(2 Print Owner's Name(Electronic Signature) a[_ � SECTION 7b: OWNEW 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 in this application is true and accurate to the best of my knowledge and understanding. tri i i^�h C a 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.gov/dps 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"may be substituted for"Total Project Cost" Office of Consumer Affairs and Efusiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration --- Registration: 159704 Type: DBA 77 Expiration: 5/19/2012 Tr# 297563 MASONRY DOCTOR _ ` JEFFREY SMITH 4 LESLIE RD. IPSWICH, MA 01938 Update Address and return card.Mark reason for change. E] Address [:] Renewal Ej Employment E] Lost Card JPSCAI a'S 50M-0d/04G101218 ! Nlassachusctti- Depar-tncot of Public Safch Boau'd of Building Regulations and Standard Construction Supervisor Specialty License License: CS SL 104227 Restricted to: JEFFREY SMITHIiiita. / 4 LESLIE RD IPSWICH, MA 01938 Expiration: 12/20/2013 ('ennuis%inner Tr#: 104227 i CITY OF S.U.F.M. NIASSACHLSETTS BUILDNG DEPAR' .W.NT + a• 120 WASHCVGTON STREET,Sao FLOOR -0j TEL (978) 7+5-9595 FAX(978) 740-9846 KI\1BERLF-Y DRISCOLL MAYOR TrIOatAS ST.PtERRE DIRECCOR OF PUBLIC PROPERTY/BUMDLVG CO\mBSSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �Y1 _ Please Print Leeibly Name (BusitxsiOrganizatioN .S tndividual): hAaO_f�l^ .\ � 4Jl/h.TOr Address: Leslie {Encu& City/State/Zip: ie lr, ,M& k 0)96$bone #: 91�- 31 a - I93a Af.eyou an employer?Chec appropriate box: Type of project(required): I t am a employer with the 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑ 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 10.❑ Electrical repairs or additions 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 cmployces. [No workers' comp. insurance required.] 13,� Other M Q S� f2.�A.t r •Any applicant that chssks box e1 most also fill out the section below showing their workers'compensation policy infummution. t I Inm.:owtaa who submit this affidavit indicating they an:doing all work and than hire outside contractors must submit a new affidavit indicating such. Tontractors that check this box must attached an additional shoes showing the name of the sub< ntmctors and their workm'comp.policy infarmatioo. 1 um an employer that is providing workers'compensation insurance jar my employees. Below Is the polley and Jab site injormruion. ' ' 1 Insurance Company Name: l A-A Ctrl/� . , 1�U ^� Policy#or Self-ins. Lic. #:_ (�� I(N114 `-1—. Lia �7Y 215 Expiration Date: 10 /y /� Job Site Address: I LQi (ATQITc. �(�� City/State/zip: �dl em, 5, 019-70 Attach a copy of the workers'compensation policy declaration page(showing the policy number and e:piradon 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 be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under fire pains and penahies of perJury/ythat the informatlo t pr vided above Is true and correct. Sienature -7p�Qr�1�/Ey Phone#:9 / OffirAd use only. Do net write in this area,to be completed by city or town ofciaL City or Town: Permit7.lccnse# Issuing Authority(circle one): 1. Board of Ilealth 2.Building Department 3.Cily/town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: _ Phone#: I / ' ® DAIE IMId/DD'YYYY) ^�o CERTIFICATE OF LIABILITY INSURANCE 3/2,/12 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 policy(les) 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 endorsemen s. PRODUCER CONTACT NAME: Circle Business Insurance Age PHONE FAx 247 Newbury Street ApDRESS: Danvers, MA 01923 INSURER(S)AFFORDING COVERAGE NAICk INSURERA:Scottsdale Insurance Co. INSURED INSURER B:Utica Masonry Doctor Inc. INSURERc:XS Brokers Insurance Agency 4 Lesley Road INSURERD:Utica Mutual Ipswich, MA 01938 INSURER E: Travelers Insurance INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 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 CONDTIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDU SUER POLICY NUMBER PM=NYY MADDD'YYYYY LIMITS C GENERALLMBILRY CPS1477980 1/24/12 1/24/13 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000 CUIIMSWADE OCCUR MED EXP(Ary one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERALAGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PE R PRODUCTS-OOMP/OP AGG $ 1,000,000 X POLICY PRO- LOC $ E AUTOMOBILE LIABILITY ElAIA069057 4/28/12 4/28/13 COMBINEDIN LE LIMIT $ ANYAUTO BODILY INJURY(Per person) S 250,000 ALLOWPED X SCHEDULED BODILY INJURY(Per eociderd) $AUTOS 500,000 X AUTOS X NON-OWNED PeOactldn DAMAGE $ 100,000 HIREDAUTOS AUTOS 8 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ IT D WORKERS COMPENSATION 4434225 6/10/11 6/10/12 X WC STATU- DTH- AND EMPLOYERS LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE YIN NIA E.LEACHACOCENT $ 100,000 OFFICE MEMBER EXCLUDED? (MaWabry In NH) E.L.DISEASE-EA EMPLOY EE $ 100,000 U ea,dwaibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPnONOFOPEMMONSILOCATIONSIVEMCLES (A1fac0 ACORD 101,Additional Rermrlm Schedule,"mora Space b reRJred) Job: 1 Lafayette Place Salem, MA 01970 Certificate holder is listed as additional insured CERTIFICATE HOLDER CANCELLATION City Of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem, MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Shelli Graves/Commercial Account Rep. ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 531-0063 E-Mail: ,< CITY OF S.0 EM. UxsSACHUSETTS BUMJUNG DEP{R-MEET 120 WASHNGTON STREET, 3" FLOOR TEL (978) 745-9595 Fn.-C(978) 740-9846 1CI%,BERLF-Y DRISCOLL MAYOR THoaus ST.PIERRB DIRECTOR OF PL:BLIC PROPERTY/BUUMLNG COMMSSIONER 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: MaSn nt L�oc,-�z�-- durnT-}ruck. (name of hauler) The debris will be disposed of in 1 + (n a of facility)r� io5 Turn ni�e Rd , rocll,ich OlR3� (address of facility) signature of permit applicant - a'7—l date •Jcbrivlr.Jnc A. , 1 r Masonry Doctor LLC 4 Leslie Road Ipswich,Ma. 01938 Cherith.smith@gnail.com www.masonrydoctor.com ' 978.312.1932 '.racy JOB DESCRIPTION/PRICE ESTIMATE DATE: Thursday, March 15, 2012 CONTACT: Bill Gilbert \�V JOB SITE: 1 Lafayette Place Salem, Mass. 01970 PHONE: 978-239-3382 EMAIL: gilbert_b@comcast.net JOB DESCRIPTION #1: Remove existing driveway; Adjust grade; Form new driveway (16'x27'x6"); Install rewire; Install crushed stone; Pour concrete; Sidewalk fmish; Dispose of debris; Clean job site PRICE ESTIMATE #1: $61995.00 JOB DESCRIPTION #2: Remove existing brick sidewalk (approx. 4'x2'0 ; Dispose of debris; Clean job site PRICE ESTIMATE #2: $500.00 JOB DESCRIPTION #3: Remove existing hot top (between house and garage); Adjust grade; Form new 203 square foot area; Install rewirpt Install crushed stone; Pour concrete @ 4"; Sidewalk broom finish; Dispose of debris; Clean job site PRICE ESTIMATE #3: $21999.00 • Please note that a $700.00 discount will be given if all of the work is scheduled together during the 2012 masonry season. • All work is completed to the highest standards and under full warranty: • Insurance certificate,workers'comp. and references are available upon request. THANK YOU for your interest and have a wonderful weekend! r 1;p Masonry Doctor Inc: : 4 Leslie Road Ipswich, Ma. 01938 Cherith.smith@gmail.com www.masonrydoctor.com f� 978.312.1932 roti CUSTOMER SERVICE AGREEMENT AND WORK CONTRACT This is an agreement between the Bill Gilbert(customer)-arid The Masonry Doctor Inc., 4 Leslie Road, Ipswich, Ma. 0 193 8. Under the terms set forth below, Customer agrees to purchase the services of The Masonry Doctor Inc., in preparing and constructing the project as set forth in the Project Description, and The Masonry Doctor Inc. agrees to render such services. As consideration, Customer agrees to pay The Masonry Doctor Inc., the amount shown as `Total' in the Project Description(`Contract Price') in exchange for performing the services described in the Contract Description. The parties further agree as follows: PAYMENTS Customer will pay the Masonry Doctor Inc. a retainer fee of$3,265.00 with a signed contract on or before the start date of the project. The customer will pay the Masonry Doctor Inc. the remaining balance ($6,529.00)upon completion of the project. CHANGES The Masonry Doctor Inc., will make reasonable efforts to complete the contract as designed. Circumstances may arise beyond the control of The Masonry Doctor Inc.,that may prevent construction of the Contract exactly as planned.' The Masonry Doctor Inc., will make reasonable efforts to minimize this impact on the design and construction. Customer acknowledges this possibility and accepts the action The Masonry Doctor Inc., will take to minimize the potential change in design. If Customer wishes to change any part of the instillation after this agreement is signed, but"prior to the commencement of installation,which results in additional material or labor costs for The Masonry Doctor Inc., or results in delays of the completion of the Contract, said costs will be added to the remaining balance of the Contract and billed as part of the original Contract. Any changes in the design or Contract, whether the changes result in additional time, cost or neither, must be made in writing and signed by both parties, using a Change Order Form. LIABILITY The Masonry Doctor Inc., is not liable for injuries of Customer or others on the Customer's property injured by or on machinery, supplies or work area constructed and used by The Masonry Doctor Inc. The Customer is not liable for injuries of Masons while working and completing the Project Description. PROJECT START AND COMPLETION An estimate of the number of days to complete the contracted work and expect start date are provided as a courtesy. There may be delays in the start date and completion date due to poor weather or other circumstances beyond the control, f the Masonry Doctor Inc. Those delays will not alter or invalidate any part of this Contract,nor will they entitle the Costumer to additional rights under the contract. TERMINATION This agreement may be canceled by the Customer by mailing written notice to the Masonry Doctor Inc., 3 business days prior to the Start Date of the Project, as stated in the Contract. JOB DESCRIPTION Job Site: Bill Gilbert 1 Lafayette Place Salem,Mass. 01970 1��---Totalr$9,794.00 Anticipated Completion Timeline: 1 -1 %weeks Project Start Date: Monday,March 26,2012 at 9:00 am 4 Project Description: Remove existing driveway; Adjust grade; Form new driveway (16'x27'x6'): Install rewire; Install crushed stone; Pour concrete; Sidewalk finish; Remove existing brick sidewalk(approx. 4'x20'); Remove existing hot top (between house and garage); Adjust grade; Form new 203 square foot area; Install rewire; Install crushed stone; Pour concrete @ 4"; Sidewalk broom finish; Clean job site; Dispose of debris PAYMENTS ✓ $3,265.00 retainer fee due on/or before Monday, March 26, 2012 (with signed contract) $6,529.00 due upon Project Completion Make check payable to: Masonry Doctor 4 Leslie Road Ipswich,Mass. 01938 This agreement shall be interpreted and enforced in accordance with the laws of the State of Massachusetts. R Gi t"tmles �1Zel�Z. Customer(Print) Date ��Q9aatp 3�Z(A�GZ Cust mer(Signature) Date Masonry Doctor Inc. March 19, 2012. The Masonry Docto Inc. Date ic; C/o � J c p nGY2�e �a..G� Thickness "T„ a� l� Length cam. llwll Width s Thickness „T, ao - f Length CC, - i dt h „ ,l i Li