16 READ ST - BUILDING INSPECTION (2) "PUMA TGEflRM4ND "MVED 6Y THE
,elsP=a PWQR TDA.PEBWT WMG GRANTED
CITY OF_SALEM
5
is Pmwv Locwmtl in L,entim ofA
I D FYalo11C Dillow Yet No_ aoLidlna f� � A n S,
Is P'""L"aw to
h Cw1M1Wapn AIY9 Ys�_No__
BUILDING PERMIT APPLICATION FOR:
PertnR to:
(Circle whW*ver apply) Root. Reroof Install Siding. ContW Deck. Shed, Pool,
Other:
PLEASE tall OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The w4maigned hereby applies for a permit to build according to the f0WW9
Owners Nome I �•�' C�`C'
Address 6 Phone jai 78) Y-to S C,3 G
Amhiteds Name
Address & Phan S I
Mechanics Name . , �' , » jv
Address 6 Phon (9781 S 3 8-L 3 ti
No is to p qmo if oWlarp4
moloom ai tlirldrlp4 I a dre".for how many Wool"?
vm kdom W"m to iaw7 Asbeaos4
EaiYarw o0 5 $ 0"� CYy u mw o N A atata LIcMw• -7t 'z,
Sigrwtum of Applicant
SW WED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
NO.
APPLICATION FOR
PERM TO
S . tz
LOCATION
PERMIT GRANTED
20
77�
OF BUILDINGS
r
PUB UC PROPERTY DEPAR EN TMT
120 WAiHINOTDp1 6TRXWr. 3aDFLooa1
SALE:M,MA O 1970
TaL (970)746-9889 EXr. 360 i
FAX (R76) 740-96"
SYANL.a:Y J. USOVKZ, JR.
MAYOR
c
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with die proviaions ofM($,c 40. S34. I acknowledge that as a caladoas
of Building Permit IV all debris resulting from tha coastmCtim acbvity
governed by this Building Permit shah be disposed of in a property licensed solid.waste
�Posal facility, as defxW by MOL c M S 130A.
The debris will be disposed of _ tom' cab t M
Locanon or ramuty
Signature of Permit Applicant p 7
Date
FULLY camplcw the followiaS information;
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
f
Firm Name, if aay
t Li `' MA
Addreas, City & Stste
The above statute requires that debris from the crldemolition, renovation, rrbab or other
alteration of buildnug or structum be disposed in a prop
facility as defined by MGL cIII, S130A, and the b y-liceased solid-waste disposal
indicate location of the facility. eaWts of he are to
dicate th
y
i
h x, ,Ya + � u,�ff.
Fk t i .�'ar,wy�yy �'
>r k "; + x The Commonwealth of Massachusetts
Department of Industrial Accidents
3
Off ce of InvestlggtlonS, i
Y f MJ
t500`.Washington Street` .""
t�t
1 � r '` ` • Boston,"MA 02111
www mass.gov0q
Worl g#�s;,Ct tpfl sptto>� I{tsurance Affidavit. Builders/Contractors/Ejectriei ns/Elut bers
A licant Information TM � • Please�Print1
5 >r..:
\•tj! f SJi{r: i {,�'i/...'1 t
Name(Business/ rganizahon/indrvtduaq L ( r L�`�o �g
Address: 'A I,J,- I11-
City/State/Zip s a the n ftA D 1 9 t, O Phone #: ot _YR- S 3 'l S 34
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employerwith 4• ❑ I am a general contractor and I 6. ❑New construction
employees-(hill and/or part.time).' have hired the sub-contractors
2.0 I anti a sole'p opnetor or'partner. listed on the attached sheet t 7• ❑ Remodeling-'.,
ship apd have no employees ' These sub-contractors have 8. ❑ Demolition
working;for me' in any .capacity. workers' comp. insurance.
•� 9. ❑ Building at:wG,.n
[No workers' comp. insurance 5. ❑ We are a corporation and its
r required,] :' officers have exercised their I0.❑ Electrical repairs or additions
3.❑ I am a homeowner'doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself [Ng4wor ers' cQmp, c. 152,§1(4),and we have no 12.0 Roof repairs,:-
insurance reggiied]t employees. (No workers'
z"u;;a , , comp. insurance required.], 13.0 Other
'Any applicantlhfl checkebox#I must also fill out the section below showing their workers'compensation policy information.
t Nomeowngrs�porayptnitthis affidavit indicating they are doing all work and then.l»re outside contractors roust submit a new affidavit indicating such.
tConiractors that eiieck thiebox must attached an additional sheet showing the name_of the sub<onaacton'andiheir workers'comp.policy information. '.-.
I am err employer 11at tsprpvlding workers{compensation rnsurance for my employees Below is the policy and job site c t'
information,
Insurance CompgnyName s
Policy#or Self iris. Lic #-� 0 � O' Q '7 R O I O O Expiration Date:
Job Site Address t \Gv''f1 r� `j, r' City/State/Zip: S-A ly vt M A 0 ] rt 7(�
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 OQ'and/or one•year'imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250 00 a;day igainst the violator..Be.advised that a copy of this statement may be forwarded to,the Office of ;t
Invesngatio gfl[e DMA fqr insurance coverage verification..,,. x '< ;
I do hereby,'ce�t6,Under ifie pains god penalties of perjury that the infar,mra' on pr-ovided above!s true and correca
Sienature . e�C_ -- Date 3
Phone# ] 7 3`'i
Official ` only po not,WrI hi this area,to be'compleied by.arty or town offs0a
City.or Town a� Permit/License#
Issuing Authority(circle one):
{
I. Boarl It 'Ithv.i Building Department 3 City/Town Clerk 4 Electrical Inspector 5 Plumbing Inspector
ContactiPerson Phone#
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s !C e%!VI....a,
-. - - Board of Building Regulations and Standard
HOME IMPROVEMENT CONTRACTOR
Registration .:100811
Expiration `}6123/2008 '
,.
" - TYPe 'Private Corporation
1 �
G � '. e • - r, � fir....
LEN GIBELY CONTRACTING'CO., INC.
Mi
Leonard Gibely
149 Main Street --
Peabody,
MA 01960 � � Deputy Atlministrator.
ii .��ie 70o9lNxan(Vetut/t o� uWe�d f'.., fs��.
f -` BOARD OF BUILDING REGULATIONS ' -
alLicense: CONSTRUCTION SUPERVISOR -
IN mbe[t.CS� 094763 ' v
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!1 k �Ir�;,0�141010 Tr.no: 94763 {
P THOMASR DOWN$N -'sjf
19 CEDAR HILL DRIVE / ,
DANVERS, MA 01923 �^"'^ +"
Commission . .
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CERTIFICATE
CC ,r�F w g �+t ' /� DATE IMN/DDmYYJ
PRODUCER87 a9 RTIFIC 9 8)F 04„B'LIfY S CERTIFICATE 15 INSURANIC�OASAMATTE�i OF INFORMATION
7
Edward F. Sennott. Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE III
�4OLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR-
16 South Main Street ALTER THE COVERAGE AFFORD DRY THE POLICIES BELOW.
P. 0. Box 457
Topsfield, MA 01'983 INSURERS AFFORDING COVERAGE NAICtl
INSURED Len Gt e Y Contracting CO., Inc. INSURERA- Penn America Insurance CO.
INSURER B: _
INSURER C.
INSURER D. _
INSURER E'
GF
THE POLICIES OF IN5URANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMFO ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDIN
ANY REQUIREMENT.TERM OR CONDITION Of ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSVED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CCNOITION.`.OF SVCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MSR OD' POUCYEFFEO➢VE POLJC EYPIRATIOH l—J-- LIMITS
TYPE OF INSURANCE POLICY NYMBER
JIM GENERAL LABILITY PAC66S49116 01/29/2007 OL/29/2008 EAcH occuRRENcE—� 1,000,00
X COM.MERCAL GENERAL LABILITY DAMAGE To RENTED SD 00
c
CLAIMS MADE D OCCUR
MED E%P(AAY w�pareenl f . 1.,_000
A PERSONAL 6AOv INJURY _ f 1,000,00
GENERAL AGGREGATE _2.000100(
GEN'I.AGGRECA7E LIMITAPPLIE5 PER. — PRODUCTS-COMPIOP AGG t 21000,00
POLICY��PACT LOC 1 _�-----
AUTOMOBILE LIAUIUTY COMBINED SINGLE.La.IIT 5 I
' Y ALI O IEa ecGOCn(
ALL OWNEO AUTOS BODILY INJURY f
X SCHEDULED AUTOS IPena1 —.Jlf
B X HIRED AUTOS 90CI:Y INJUFY e
IIOOILYINJU 5
X NON-0WNEI AUTOS ---
PROPERTY OMIAGE S
--- IPar amaanu
GARAGE LIADIu7Y AUTOONLY-EA ACGOEHT ,S
ANY AU TO OTHER THAN EAACCOTHER THAN EAACC 5C AUTO ONLY: AGG f
• EXCESSUMOftILA LRBIUTY EACH OCCURRENCE
OCCUR LlCLAWS MADE AGGREGATE 5
DEDUCTIBLE. �--
RETENTION f t
WC STATU- 0 H-
woR RS COMPENSk DON AND ---
EMPLOYEAS'LIABILITV E.L EACHACCIDENT i
ANY PROPRIETONPARTNE"XECUTNE
OFFICERMEMBER EXCLUDEO'J E.L.01SfA$_E•FAEMPLOYEh Y_
v Yq ft u,bb u ar
SPECIAL�PROVISIONS Ualow E.L.DISEASE-FOLIf,V LIMIT f
OTHER
DESCPJPTION Of OPERATIONS I LOCATIONS/VEMCLES I EXCLUSIONS ADDEO BY ENDOR$EMENT I SPBCOL PROMMNS
C
SHOULD ANY Or THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE.
EXNRATIQV GATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TOMAIL f.
OAYS WRITTEN NOTICE TO THE CERTIFICATE HOLOER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF MYXUND UPON THE INSURER,ITS AGENTS OR RFPPrSENTGTWES, -
EVIDENCE OF INSURANCE AUTHDRaED REPRESENTATIVE
ACORD 26(2001108) wACORD CORPORATION 1988
•
A CERTIFICATE OF INSURANCE DkTS&"DD'"''
O
C N CHYs t�rONTFRAX(ArMj C&pTi/iCAT& LDRc TSII9 CAT2
Edward F $cltnOn lnsutiaa to N XL EXTEND EXTEND OR AL TC1 TlR CO 09 AFIQ D BY TR&
Agency Inc - .
16 South Main Strew COMPANIES AFFORDING COVERAGE
TopsAeld. MA 01983
Lrn Gibcly Commiing Compaoy Inc COMPANY A.1.M. Mutual Iruunce Co
LETTER A n
TWIS TO -197 HAT THE POLICItSOF WSVR LIM0111toW RAVE BEEV H 0 T RFD NANFiD AB FOR TH POLICT' Lot)INDICATED.NOTYTTNSTANDINO ANY UQQUMUENT,TERN OR CONDITION OF A.rY CONTRACC OR OTHER DOCUMINTYI[TH RESPECTTO WWCH THIS
CFRT[P[CATE MAY BE ISSUED 01 NAY PERTAIN.THE VOURANCE APFORDW BY THE POI Imc OESCEtt O N91LEM 19 SUBJECT TO ALL TSCE TEtats,
EXCLVSION3 AND CONDR[ONS OF SUCH POLICIES. LD1RS SHOWN)lAY HAVE RREN REDUCED BY PAID CLADLT.
Co TM OT fX[DEANYS PWCY MDdlaf V%JCY OPSKTIYE WULY LXM.TI LDEIT[
L t[+TCINN/00/YYI D.T%M.NMDa Y)
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EHxmw'Vw�ILm � ?` L .
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ftY3hltt(aV(f!O>tl.TfON TTGI(A'�CLTL[1CC'Li TTDIf
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CERTTFIC ATV. HOLDER CANCELLATION
SI[OULD ANY Of T[[E ASOVE DESC=XD POLICSES BE CANCELLED BEFORE THE -
E"MAT.ON DATE TIU[EROP. THE ISSUING CO?RANT WILL ENDEAVOR TO
EV1deRCe Of Insurance NAIL !0 DAYS WRlrTBNN=CETOTHECERTDICATEHOLtnNAMDTOnM _
LEFT. BUT PNLURE TO MAIL SUCH NOVCE SMALL UPOSE NO OBLIGATION W.
LIAEILITY OF ANY XD"D UPON THi COVPANY. a5 AGENTS OR
REPRESENTATIVES.
AVTHORILTD REPRESENTAI'(L'E
I
Page No. / of / i paBev
LEN.GIBELY CONTRACTING CO., INC.
.„149 Mom Street "
1754'2 'PROPOSAL" Ir..;.
PEABODY,.MASSACHUSETTS01960 -All home improvement contractors and subcontractors - -
(978)531-8234 engaged in home improvement contracting,unless
FAX(978)531-9304 specifically exempt from registration by provisions of -
submitted I- Chapter 142A of the general taws,must be registered
To: with the Commonwealth of Massachusetts. Inquiries
about registration and statue should be made to the
16/ Re \Ci0 Director,Home Improvement Contract Registration,
/G One Ashburton Place,Room 1301,Boston,MA 02108
� (617) 727-8598. Owners who secure their own
S k6M IW 9 ag70 construction related permits or deal with unregistered
/ contractors will be excluded from the Guaranty Fund
- Provision of MGL c.142A.
PHONE MrE UGamiboN NO.
MA.REG.100811
JOe NAMFrtA JOB LOGATIQY -
We Mraw eubmB epsdicaUve, estlmereefar nwkbbe peMmetl erW mebdW N be uses:
of—-arov/I r
T'9V
,
l:enatmcBon related permits: / --
a..
C>
(Jcr,ni f oa ioJS, ,H y
WOflK SGHEOOLE - ,
Canir¢¢lo II aeBl a xqF a arNr Ne metmleb seise Ma NIN aey kUuxinp Ne elBnlre d Ni9 Ppresment unle55 srreyc Ilea M1ereln w,l aaziy WI beBln N¢woA M w
'� abpm — leers) aemlN tleler�aucetl M dmumsmxec beyvna commcmu comrel Ne Nam w ll ea com^imetl vy onv rite Owner berets - '
wgnanrvn¢'�eBrem Netwed,etldlnB dares ere epprodmare Bna Net¢I,m mien Nal ere nptewmadeq Ne ronvearer aM1ell mae wit ae .wlau dNle nareemem.
e TI,o Canae¢Ior we,renb Net Me xo,k NmWMig,euMer Wll Ce free lmm aelxle In mebrvel ens wYMynsM1lp bra pBr�.^dal �G/rJ fylpwl,IB¢amplatlon ens Mell romply wlN
� NB reyulramrenp of Nb PB,aemBnL In Ne awm aM aekcl In voMmarWlpameleMLq paemsg¢¢ausea Ey Ne ConoeCNr,M1bw�Gro treaty—rB,emplcyma orepenb balecmerBtl wlViln '
�. year ether aon,plalbn a eM lab.Irv9lmlrp dean up.Ne Conb for dull,al N¢Own mpenaa bMwiN remedy,raper wrtecl replace or rouse b ae remeaiep,repelrea,or replacoa,
- eam aBmeBe aucM1 tlalecl In meUMUawbrendJR TTe NreOpinB xarrenlba Nell eu,vNe eM NaPetlkn peawmea In con,vcuan MN Ne eB,eeSuron vmrk
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
Payment to DB matle es tollowe:
dollars($ ).
?e %(E ) lapon dBNnB Conlrecl:'
%IE )up on roMplew of
�i1•' %lEluPan
' clry/sbu mon.
ee - xis ¢neB sa mme mrews,peon _—__ __
I o>mWetundwrKUMer tlua convect I'M FM,eI iDNu
_ po No agreement fro M1 Improvement condectM.work sr all require a dawn Namq pI gapy,ImF -
•� _ payment(ioveUrt 0 ro eerouU of more Nan are.Nira al Ne btal t Make price or N,
total r rtc/ ellr.pies otendelnbwbbb Me 0dat ida dad acid NeWa.M
y,41, N k antl/a nt 1, w oMeln tlelhury of¢peNel oNa maledab antl e4ulpment sbnawn '
1 fMka,ever emu t seremer
t,: . wa:rw pmpwd mayawlwmwngwmm�a®pba wdm aB,s
ere. Acceptance Of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated.I understand
that upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. -
' - You,the Buyer,may Cancel this transaction at any time prior to midnight of the third business day after.
the date of this transaction.Cancellation must be done In writing.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. - -
aw
SIBn. m "lTi � ' OanL � avrewre 'Dais
r - - - IMPORTANT INFORMATION ON BACK op-
p
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