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14 PALFREY CT - BUILDING INSPECTION (3) 13 �, I'he C'ununumveahh uF obi;usachuselts Board of Building Regulations ,and Standards CI'I'1' OF ' Massachusetts State Building Code, 780 C NIR ti,\LG.\I Building Permit Application To Construct, Repair. Renovate Or Demolish a One-ur rnvr-Fwnih Du'ellinkr This Section Fur Official Use Onl Budding Permit Number: Date) pled: It lluilding Olifcial(Print Mune) Signature )ate SECTION I: SITE INFORMATION I.1 Pro fray Address: 1.2 Assessors %Imp& Parcel Numbers 14 T09L 7dzoy � o uM%t- _ I.la Is this an accepted street?yes no \tap Number Purccl,Numher, 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Fronluge(11) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.c.40,§») 1.7 Flood Zone Information: 1.3 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es❑ SECTION2. PROPERTY OWNERSHIP' 2.1 QQwnert of Record: © CPA,-d, reao ti, 1 c Naune(Print) City,Slaw.ZIP Xie h/dl..vv (�L /I� SS.Av gt.4r- � Foe,.ysjy�, AL,, S16(,V�{ k(64 CilyvTlr' Y. GL> No.and Sueet telephone Flnail Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Buildi caner-Occupied ❑ Repairs( Iteratlon(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ .spe,ity: Brief Description of Proposed Work': ar_4 6 e S T 2:b 26 t_,/;-L�m R� e+ F 4— R2 .r Fsrx i L. Cry r11 q 4 nag SECTION 4: ESTINIATED CONSTRUCTION COSTS Item Estimated Costs: OMcial Use Only Labur;md \laterials) I, Building S O co'v I. Building Permit Fee: S Indicate how fee is determined: ❑Standard CityTuwn Application Fee 2. lilearical 5 ' ❑Total Project('ust'I Item 6)x multiplier x 1. Plumbing S ?• Other Fees: S_ a. \Icch.ulical III\ \('1 S List:._ -- � rotas \It Fccs: S_,-___—___ Check . 6° No. -. .__ hck \nhunun: _ C.hh \mmmt: o 1'mall'rnjcctCovt: 0 Cl Paid in Full ❑Instanding 1a.1..u1ce Doc: 1 SE(' ION S: ('ONSl'RIIC'f1ON SERVICFS 5.1 ('unstructiun Supervisor License(C'SL1 _- Luu,3- )iF_ t I ieen,c Nunlher F,pintoou Dutc --- - \.nnc ul l'til. I InlJer G I ut l'SI. I)tk Isea below!.__,____ _ Nu old Vreet ���-/) 141restriacJ I Du11Jin�x tin l0 1/,UIIO n1. IL1 \_e�✓✓QRcaricleJ L�� P.lmil Dttcllin l'ilsi I'uwn.Sauc./II' .�I Aluxnn ILC' Roolin C'u�erin ..._. R'ti nJuw'.mJ SiJin SF tiul"Fuel I)urning Appliances I Inxulmiun lblc bona Itmail aJJn'x+ D Dcnutlition S.2 Registered Home Improvement Contractor(IIIC) , D R 1 If _ "i t 4w L -r— ee-,Li, — IIIC Reghtraliun Nunlhur ligliruliun Dale I IIC Company Name nr I11C' Registmm N ma �� t� w, , r L S� r—T �'�+(uHY Stn:el Email address _ 6sw,I/MAI'Q12L--> 9�k �31R'a3�F Ci !Town,State ZIP 'rcle hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. I52. 1 21C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this atlidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... O No........... O SECTION In:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property, hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Otmcr's Narne(Electronic.Signulum-) Date SECTION 7b: OWNERI 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. Prim O,utct's ur \ulhariteJ Aganf Nonty ll!lactrunic.Signauln) Dale NOTES: I. An Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor (nut registered in the Hume Improvement Contractor(HIC) Program). will no have access to the arbitration program or guaranly fund under M.G.L. c. I12A.Other important information on the HIC Program can be hound at N N,% .',.1 Information an the Construction Supervisor License can be round at ,,,t„ �;o\ '!P` ll hen substantial work is planned, provide the infurmatiun below-. final Iloor area I sy. 11.1 - ____.._1 including garage° lmishcd basement attics, Jccks or porch! Gr+ii It%ing area 154. 11,1 ,- ... .... _... . .. habitable roues count ._ .. ... . _ 1 \umber o(lircplac¢s \'tmthcr of hedruonl6 \umhcrol'halhmmut _ .. ._ . . . -_ \unlbcrofhalfhalhi I)pc of hc.uing sy stem \umhcr of Jecks porches i I��pcl'anlingsyslel❑ I'nclo,cd t)pen ) "I mLIl I'ri,ieCl S,I II:IrC I'oU614a"Ill;ly be,Ilb i11I111CJ IUr I JL11 I'rllj CCl Cost- s � e , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 klyi wwwanass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organiz tionandividuap: Len Gibely Contracting Company Address: 23R Winter Street City/State/Zip: Peabody, MA 01960 Phone.#: 978 531 -8234 Are you an employer? Check the appropriate box: Type of project(required): 1.® 1 am a employer with 12 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors ' 2.[1 I am a sole proprietor or partner- listed on the attached sheet.. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l 1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no, employees. [No workers' 13.❑ Other comp. insurance required.]., 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractbrs that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance jar my employees. Below is the policy and job site information. Insurance Company Name: A. I .M. Mutual Insurance Company Policy#or Self-ins. Lic. #: 6010979012012 Expiration Date: 0 8/0 3/2M01 3 Job Site Address: QA L f=9-,-Y t�__�1 r 0— " " t City/State/Zip: Eft PM ! A ok!y?o 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification - --- I do hereby certifyp under the pains and penalties of perjury that the information provided above is true and/correct. Signature Phone#: ����'c ' Official use only. Do not write irr this-area, be completed by clly or town official City or Town: Permit(License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: iu:4c 5ennott Insurur',ce CERTIFICATE OF LIABILITY INSURANCE r l"�itc CLRTIrlC lrx Ia rBOVRD AE A E xm. DI wrom O.TI00 ONLY AND ONISM H0 RIBNT$ VIOR TNr ""I! ROLDiR. TMIa CIATIIIG'L•r Wr6 WVP A/IIAWATLVLLY OR BEOATIVILY AIeaRD, xxEshD OR ALTSA THL Cr GMZ Alramsp By RRI DMICIrA BELOW. THIS C[RTIVXC O.' _:reuDl.lTCy Wks LOT COHSTSTUTa A CONTRACT BBTMW I" laeuTNa ISa ORrRts) , AVEHOB zw RLPRNS-N TIVI OR MMVCLR, OrD THE it nxlrtGT■ ROLDER. U4d RTANV If Lh0 aertlfiaate Colder is un AMITIONAL IV3VRya, the pollvy(iee) wet Ise endorsed. If SUBBODATION LB WAIVYD, sublet[ to t� tc• and conditlaws of the polloy, certain yO1101sE aay requite an snare.-e.t. A et.tentant on this Rertifloato do.. nut a I,fbr righta to the OertLSJOAta holder In lids of soon eadorleoent(q '—ire tcaF DDrtKt ' Edward S SennOtt Insurance I.. Agency Inc r/V roe .0 1./r. Yr,IL 16 9oeth Main Street •OP""'D' .mar.n Tops Yield, MA 01983- cveoa. 4DI. IKKUPIfl ....Go.'.eWl _ it L,"enn c] I..vu..: - 33156 1 � Libo ly contracting Company Inc A.I.N. Mutual Insurance CO 1 23 Winter Street Rear ,..¢kI•� --1 n.vw c: Poltbody, MA 01960-5961 1 --I.------,----— owns r C'OVKRC Ed C TIPICATH NVHEIR: REVISION NLadHISR: ll(:". itl T4 C7KTIFY ..I THE MKI" OF CD W55kpm L15Tw RrLw ttnvr T' III= To TBr MaOam I "on rm TID: mi.. rUT= tBDxGTm. Y':IT LTHi'TAlLL1IN0 ARY PLDV IPEIm1T, TERS OR 00,I)MON OT PNf CONTBKR OR OTHER COGVEMf WITH RESPECT To "lw THIS cOT"ICATE INT I, I... OIl WtS PXWTAIN. T#• IN:OPANLZ Lr(ORDLD BY THE POLMES MCRIBm HEREIN 18 SUBJECT TO ALL THE T0R18, LILGLVIIOMS AND COMMONS Or SVCH Po1ICIr8, LIMITS SHOW bl.Y ILLVL UI:YY FIC,VCW BY YinG ClAitlr. _ POLTCT WAVES VOLwICT Err POLLCT CIO? LM[TB ° TYFH Or INBIANNCC wa/me I UEVXI.tL LIABILITY EAw omvuo LNbI L1IY DYaQ TD tD 4 ❑�<t6:ra scut �O¢M ass"I. Y.W sf ieW Qm1�V.1 JrW IiERi I Qk.l.l,- i �i AUT(WAN:tt LI?831 TT n'IaIY.D ..I6i iae 5 nn, n 1..watdn0l . Ir�r11n.. �a:E4 n.,er„ EDOIir .Y>l IDw Miwnl - ��f'iCIVN,144 NCO] DDOI tr [Y1110.r.ea.W fial . �IricN at.0. PAO .¢ 6,,.•11 ^� i Q�'�l�]+c•4..a tw (_ R:n,A r.a Oecwuatet r _� 1. r�1pelN:f lSl.{- 1 '� 1wltFllY CNSATI ear aVYa �� 46l/iYRS LIABILITY 1.2 TXP 4ficY%I:TOP/Y�N'fAOR:I/ RL. Iaa, 1 ,DO 1000 1 &YPanvS oYY3Ca0.9 ARE urt :nc 1. i� tuci 6 010 97 9012OL2 {. v..w .Duo wHn I 500,000 08/03/2012 08/0.3/2013 .---{ 500,000 it J CEATIBICATH HOLDrR CAJCELIa+PION _ _ SHOUIn ANY Or EMIT "M DESCRIBED W1ICIrd RE GANCLLLED 8EJ%)RV ITT E;V 1C'1211C2 Of Insurance ri9IRfIlow OATr TIYA201. N%'Td'WILL BE DELN61pJ IN ACCtlYlYJk1 VliH TNr MLICY D.W'Ia IONS. aYww+am v.u...r¢r.,e TOTAL P.01 JPN-24-2012 14:35 _ _ _ _ Senn_o_tt Insurance _ 970 Be'? 2404 P.J1 VI \rP • • • • _. �� � _ �_ _. . \V Ul/l4/2012 ^,. PRODUCER g78.'887.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 16 South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 4S7 Topsfield, MA 01933 INSURERS AFFORDING COVERAGE N IC # _INSURED _-- Len Gibe] ContracEing Co. , Inc. INSURERA Catlin Specialty Insurance Co 23R Winter Street INSURER e. 19038 Pea o y, MA 01960 wsuREaO: .. NSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTYVITHSrANDIING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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 Sucil POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. W9R Ov P IDYEFFECTIVE PODCYEXPIRATION LTR NSA TYPE OF INBUPANCE POLICY NUMBER p TE MWODMYY DATE MMGMYYY LIMITS GENERAL UA8ILTTY 3700301015 01/29/2012 01/29/2013 EACH OCCURRENCE S 1.000,00 X COMMENCIAL GENERAL LIABILRY PRCMIA9EB�a�aewrrence 7 Goo CLAIMS MADE rx-1 OCCUR MEO EXP(Any a pOr ) S 5.OO A PERSONAL S AOV INJURY i 1 GOD,O GENERALAGGREGATE S 2.666,OO GEN'LAGGREGATE LIMITAPPLIES PER: PRODUCTS•COFAP/OPAGG S Zz0001G0- POLICY '0 LOC ' AUTOMOBILE LIABILITY COMBINED _ ANYAUTO Ed Mderj BINDLE LIMn S ALL OWNED AUTOS BODILY INJURY s B 1 X SCHEDULEDAUTOS (Pv Pelson) X HIRED AUTOS BODILY INJURY S X NON-0WNED AUTOS (Per=1deW) _..._..._ FROPERTY OAMAGE (Per ecddenll - -- _-- - GARAGE LABILITY AUTOONLY EAACCIOENI ANY AUTO — OTHER THAN EA ACG OF AUTO ONLY: AGO S EXCESS/UMBRELLAUABILITY EACH OCCURRENCE _ L _ OCCUR UCLAIMS MADE AGGREGATE — _ S TIBLE : .. . .._ i ._ — _ DEOUC I f ---I _--_.._ AND EMPLOYERS'LIABILITY YIN TOgY LIITM ER •.� _- ANr PROPMETOROPARML111EXECUTIVEE:1 _ C OFFICER/MEMBER EXCLUDED? E.L.EAGN AGCIOEN7 8 IM\MWrF In NH) E.L DISEASE-EA EMPLOYEE i II)es.dull"urAer -- 6 ECIAL PROVISIONS beIW EL.DISEASE•POLICY LIMIT i OTHER JI PESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS VIDENCE OF 2012 RENEWAL COVERAGES. + I CERTIFICATE HOLDER CANCELLATION , SNOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIHATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRII Itik NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO W SO SHALL IMPOSE NO OBLIGATION OR LAUILrTY OF ANY KIND UPON THE INSURER.ITS ADEN TO OR REPRESENTATIVES. AUTHORQED REPRESENTATIVE Sennott Ins. Agency ACORD 2S(2009101) 01989.2009 ACORD CORPORATION. All rights reserved. The ACORD name and 1090 are mgislamd marks of ACORD - Iv do Page No. _Lof_ .Pages Et LEtV GIBELY CONTRACTING CO., INC. ^^O ^OC A L '� zsR winter Street 239.3 5 r K r OS AL �r PEABODY, MASSACHUSETTS 01960 ' 4 ' � : wi - All llo 19 improvement contractors and subcontractors ' (978)537-8234 Fax(978)531-9304 ' � r • ' ep g.e ge p In home Improvement contracting, unless www.lengibelycontracting.com 1 speollically axompt from registrationby Provisions of a> r r tr Chaptarl142A ol,the.general;laws, must rbe registered L,r C Submitted WltpA a ommonwealth of Massachusetts. Inquiries oD TO' 1.J_•Q �_A .� about registration and status should be made to the s-t Director Home at Contract Registration, a yS� Fna f� q4� Onej Ashburton:Place;Room 1301, Boston, MA 02108 ( i 7x7t`95g8:I.Ow there who secure. their own construetionl related permits,or deal with unregistered cdn Ira ctora will be excluded from the Guaranty Fund Proviso d of MGL c.142A. PHONE QaE -��'• p R8018TIR notN NO L- ke '-,t+•) 1 L Q 1^Z I•�. "O MA.REGi 100811 JOB rvAMFJNO. CATION s � J0 A , 9 LOa NPR L.lEa.a Y C> WC hobo,submit speeificadone and aetimed,I,,work to be pedormad and meterlaus to 00 used _ y;� a C 1 Tn Lta Ycr R-` 2D�=c _----- -- L.jp 4J.. - __��CSa��T� -� LS -. '✓gal..—i.a`�-'.-` ( I r+ �N.{ » �ijl I �- , 1 ...i .-._q :�i r.ieLa=�:nJ.T• T� �? YFY I+ hrl ���IL�A�� ..,,. .,.= _. . k, y J _ a e i -�y + I • rll IS1{t , it t{1Ur L: srt :+sdi I;gf- _ �C_n uctionrelatedpormits: WORN SCHEDULE C Iraclo II the begin the wgrk or order 0e mewrlale bolore the IM1ird tley to Ing fine al gg of Ole Agreement unless peal heroin writing 1 act III bopin m o k Dn m about (date).Barring delay caused by dreumstences boyyOOp Conlrepl0(e Control tM1fr work will be c.d letetl by date) T a O e hereby acknow es an agree t me echetlullnp dates are epproxlmew and that 6uc11 gelayathat u0 not awWabb Oy,the wntrector shell not be consider. ae lolauone onhre Agra nl. WARRAN +•. • Tho Contractor warrants tract the work lumlehetl hBieundar eM1ell be Tree Vom delecp In Idelsrlal end welYJ110nlhpr'10 a petlodol' lollowing compl011on and shop comply w N the raqu romans of 1M1le AQreamenL In the event any tlelecl In workmaneM1lp or mslerlala Or tlemeQe Caused by the Gent atlor.Ms BD oneaclOre employaec er eggGnu 's dscowrgd w li,n ,n ynnr she,vro�nplatlon of any pb,InGutling olDan up,th0 Convector shad,at bw arm erpanae foghwkM1 remedy repair cortecl,replace or 4euee to be romodled raps roc or mplacou ucl,bamoeo or such tlelocl In matetlal6 or worWneneMp.Tho loragoing werrpnllaY aM1a118DrvIVe an%InipOMlon DeaormeE In wnneCllon vIN the egr6e0-upon work. We Propose hereby to furnish material and labor—complete In accordance with above specifications,for the sum of: ... ,dollars($) Payment to be made as fQllows. 10 ig a 'i f c N �,p°" ,y,,�p�. . rr✓ t t/. , , tf yu Yf t I :� m ,Oe„ Ct nruN l �l fin( Irh t ° ilS S�+' T - .. ' %ls,L.(JSupon signing Contract: `Wn . � y, i .` ,•� Nms al ciousctapaingnate Rogslram %is�..LG—LNpcn completion of 81 eat Adbraee of IS OlyrSwle vnone _v �Lh a fo( upon compledonolworkundarthiscontract r f I M phone—"' 1 "�L �, '—Faderefiche, Y Notice: No agreement for home Improvement contracting work shall require a down Name of sswembn payment(advance depeslu of more than one-third of the total conman price or the —_ lclal amount of all deposits or payments which the contractor most make In advance, Acheloos season to order and/or otherwlse obtain delivery of special order materials and equipment, , M orenler Note',Tba proposal may be wlmtlrawn by uc if nor nKeplar wilM1in days ilk. Acceptance of Proposal I have read both side Q+of this document anafaccept'ir Op ices Sspeoi gallons end conditions stated.I understand that upon signing,this proposal becomes a binding contrabVNou are @uthodzed to do the work ae specified. Payment will be made as outlined above. You,the Buyer,may'cencel this transactiorl any time prior to midlrlght of the third business day after the date of this transaction:Cancellation must be done'ln writing DO NO SIGNTHIS CONTRACT IFTHERE ARE ANY BLANK SPACES. r Signalgro Q. 3 'Z- soruba, ' Dare — rZ re k IMPORTANT INFORMATION ON BACK ,• 1_pl Massachusetts - Department of Public Safety \� Board of Building Regulations and Standards Mi< m.u'uaiun .Sup.r�iwr License: CS-094763 t THOMAS IL DO BINS r r. r 19 Cedar HBWrivo,. r_= Danvers MA-01923 i r Expiration Commissioner 0 511 412 01 4 Office of Consumer Affairs& Business Regulation License or registration valid for individul use only as— DME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 100811 Type: Office of Consumer Affairs and Business Regulation a 10 Park Plaza-Suite 5170 expiration: 6/23/2014 Private Corporation Boston,MA 02116 LEN GIBELY CONTRACTING CO., INC. Brian Dobbins _ 7ut 23 R WINTER ST. ; < �PEABODY, MA 01960 Undersecretary Not validature 1