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9 LYNN ST - BUILDING INSPECTION Of The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar ZOl1 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date pplied: r 44� i 3l Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION Lpert1. Pr y Address: ` 1.2 Assessors Map&Parcel Numbers h r S�-r 1.1a 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 O,wner of Record: =V m D +�' S alem Y`(��w O I9-70 Name(Print) City,State,ZIPS Lv r ee# a-7 9- -11-15-a-70% No.and S�trc t Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) W I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Descriptign of Proposed Work': OV 1 1_,) build rl + (%,Wmv � •io co SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ a ��, 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee -6-Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 21 bther Fees: $ 4.Mechanical (HVAC) $ Lt , 5.Mechanical (Fire $ ' Suppression) TAll Fees: $ n -k No. Check Amount: Cash Amount: 6. Total Project Cost: $ d 1 gL, Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) / o z l 2 )-07 zr+ " `V_ LSm� License Number J Expiration Dat Name of CSL Hold&r List CSL Type(see below) o.No.anndd Street . Type Description treet U Unrestricted Buildin s u to 35,000 cu.ft. R Famil Ciry off/' wn,State,ZIP �t Masonry tcted 1&2 Dwelling RC Coin WS Window andd Siding SF Solid Fuel Burning Appliances q�$ - 'v)a-1�►3a cherlbh.5m I Insulation Telephone Email address D Demolition $12^Registered Home Improvement Contractor(HIC) r aw� &C t `` �sm HIC Registration Number Expiration Date 4 C�panx j�Il P. oj�1IG Registrant Na�mye _No.and Street 1� ' ^*' CASr- . ©�qU(! q"' s�)O, 1.I1 Emaill addres r'M Ci /Town,State,ZIP Telephone ' 1 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 ..........P No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize hascnps to act on my behalf,in all matters relative to work authorized by this but ing permit application. Print Owner's Na a(Electro gnature) Date 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 an accurate to the best of my knowledge and understanding. / Dor c,rrY �L / � 0 Print Owner's or Authorized Agent's Na a(Electronic Signature) ate 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. oe v/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' c • � t Salem Historical Commission 120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970 (978)745-9595 EXT 311 FAX (978)740-0404 CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving ❑ Reconstruction 'A Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other work as described below will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property- 9 Lynn Street Name of Record Owner: Margaret& Timothy Doggett Description.of Work Proposed: Removal of chimney in rear addition to below roof line, board and shingle over to match existing. Dated: November 19.2009 S EM HISTOORRIICCAL CO/MMMISSION By: j The homeowner has the option not to commence the work(unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals)prior to commencing work. V A Masonry Doctor Inc. �t t 4 Leslie Road Ipswich, Ma. 01938 Cherith.smith@gmail.com www.masonrydoctor.com 978.312.1932 R CUSTOMER SERVICE AGREEMENT AND WORK CONTRACT This is an agreement between Tim Doggett(customer) and The Masonry Doctor Inc., 4 Leslie Road, Ipswich, Ma. 01938. 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$933.00 with a signed contract on or before the start date of the project. The customer will pay the Masonry Doctor Inc. the remaining balance of$1,867.00 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 of 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: Tim Doggett 9 Lynn Street Salem, Mass. Total: $2,800.00 Anticipated Completion Timeline: 1 week Project Start Date: Monday,July 25,2011 Project Description: Remove existing chimney to below roof line; Rebuild new chimney to code; Homeowner to provide bricks; Install new flashing; Wash chimney; Dispose of debris; Clean job site w PAYMENTS $933.00 retainer fee due on/or before Monday, July 25 ,2011 (with signed contract) $1,867.00 due upon Project Completion Make check payable to: //nnC `� Masonry Doctor Ak-( �M cu'" 4 J" /fro\ `J 4 Leslie Road Ipswich, Mass. 01938 This agreement shall be interpreted and enforced in accordance with the laws of the State of Massachusetts. Customer(Print) Date Customer(Signature)t/ Date Masonry Doctor Inc. July 5, 2011 The aso Doc Inc D to a�® CERTIFICATE OF LIABILITY INSURANCE °�'�";D6�) 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(ies) 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 endorsement's). PRODUCER CONTACT NAME: Circle Business Insurance Age PHONE (978) 777-5619 FAX Ne: (97e) 777-41398 247 Newbury Street ADDRESS: PaulaHalas@Circle2nsurance.net Danvers, MA 01923 PRODUCER 1357 INSURE R(S)AFFORDING COVERAGE NAICR INSURED INSURER A:Scottsdale Insurance Co. Masonry Doctor Inc. INSURERS:Travelers Insurance 4 Lesley Road INSURER C:Uti ca Ipswich, MA 01938 INSURER D: 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. NOTWITHSTANDMG 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 TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY UP LTR POLICY NUMBER MND/YYYY) (MNUDDYYYYI LIMITS GENERALUABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENE FAIL LIAR ILITY CLS1559325 1/24/11 1/24/12 DAMAGE TO RIF.ENTED $ 50,000 CLAIMS MADE FX7 OCCUR MED UP(Arty one person) $ 5 000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GENTAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OP AGG $ 1.000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMB INED SINGLE LIMIT $ B ANVAUTO BA1A069057 4/28/11 4/28/12 (Eaaccidert) ALLOWPED AUTOS BODILY INJURY(Per person) $ 250,000 X SCHEDULED AUTOS BODILY INJURY(Per accident) $ 500,000 PROPERTY DAMAGE $ 100,000 X HIREDAUTOS (Pereccidenl) X NONOWNEDAUTOS $ $ UMBRELL LIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ L. WORKERS COMPENSATION 4434225 6110TI1 6/10/1.2 X WC A,,TU- I I oTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTNE EL EACH ACCIDENT $ 100,000 OFFICERMIEMBER EXCLUDED'! N/A (Mandatory m NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICYLIMIT $ 500 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACach ACORD 101,Additional Renerks Schedule,if more space La mgui red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tim Doggett ACCORDANCE WITH THE POLICY PRO S 9 Lynn Street Salem, MA 01970 AUTHORIZED REPRESENTA 1) ©1988-20 9 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD CITY OF S�ULENI, i%AASSACHLSETTS BUILDING DEP{RT-.%MNT • 120 WASHINGTON STREET,axe FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KI,NIBERLF_Y DRISCOLL MAYORTHOMAS ST.P[ERRS DIRECTOR OF PCBLIC PROPERTY/BCILDLNG CO%MUSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� ^ g Please Print Leeibiv Name(BusinessOrganintioNlndividual): t 1 aso 1 r\i Doc. c Address: City/State/Zip: 1 hr IU• ���J b Phone H: a g 1 - 1 U 3 �- Are you an employer?Chec the appropriate box: Type of project(required): 1 1 am a employer with &L 4. 111 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 t 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me is 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 I LEI Plumbing repairs or additions myself.[No workers'comp. c. 152,§t(4),and we have no 12.❑Roof airs insurancerequired.J? employees. [No workers't comp. insurance required.] NZOt6er Any applicant that cheeks box NI must also all out the section below showing their worker'compensation policy infumtation 'I(omeownen who submit this affidavit indicting they are doing all work and then hire outside contractor;must submit a new affidavit indicating such =Comments that check this box most anached an additional short showing the name of rho subeomacton and their workers'comp.policy infamustion. l am an employer that b providing workers'compensation Insurance for my employees. Below Is the policy and fob site information Insurance Company Name:_��-)" c-�(I- / Jr I Policy b or Self-ins. .LLic.M I ��^-7` Expiration Date: (1�n- / (0 I Job Site Address: I L�n Yl `�'i d P City/State/Zip: 1t tiF�n q �� 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations or the DIA for insurance coverage verification. 1 do hereby certJ rider the pains and na t o perfa that the information provided above is true and correct Sian t ire• `` Date: P 1 0- Official use only. Do not write in this area,to be completed by city or town of iciaL City or Town: Permitit.ieense# Issuing Authority(circle one): I.Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other CITY OF &U.&M. N'WSACHUSEM • BU:MEWNG DEPART%I&NT 130 WASHINGTON STREET,3� FLOOR oT TEL. (978) 745-9595 FAX(978) 740-9846 lQJIgERLEY DRISCOLL MAYOR THows ST.PmRRz DIRECTOR OF PUBLIC PROPERTY/BU U-DING COMWSSIONER 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 1 11, S 150A. The debris will be transported by: CIS®�1 r.i 1 hoc-1�r- &utt1).P ru C-k- ( ame of hauler) The debris will be disposed of in : henA,c�u t,lhrre ,Irl (dame of facility) (addre s of facility) signature of permit applicant date Jcbti>rff.Joc RAM ! lt`- Ucp:trtmcut of Public 1:dclt S Bu:u'd ul'Buildin_ Rc_11L Iiun,and Squulard ` Construction Supervisor Specialty License License: cS SL,104227 Restricted to: JEFFREY SMITH �} 4 LESLIE RD ~ IPSWICH, MA 01938 ,nm Expiration; 12/20/2013 r— I�— b'-- Tr=: 104227 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement qontr ctor Registration Reqistration: 159704 Type: DBA Expiration: 5/1 912 0 1 2 Tr# 297563 n - MASONRY DOCTOR a JEFFREY SMITH , 4 LESLIE RD. / IPSWICH, MA 01938 r Update Address and return card.Mark reason for change. Address ❑ Renewal ❑ Employment ❑ Lost Card DPS-CA1 0 5OM-04104-G101216 s 0 Ir I _ ' I FT to .It _ e