28 VALLEY ST - BUILDING INSPECTION (2) lyx l = 03 . c.tl Tyco
The Commonwealth of Massachusetts CITY OF
� Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
This Sectio"For Official Use Only ,
Budding Permit Number Date Applied
mldmg Official(Print Name), gnat Date
�l .. ,
B ..
SECTION: SITE INFORMATION
tBuildiang
ty Address: 1.2 Assessors Map& Parcel Numbers
ni I an accepted street?yes no_ Map Number Parcel Number
Information: 1.4 Property Dimensions:
ict Proposed Use Lot Area(sq ft) Frontage(ft)
g Setbacks(ft)
Front Yard Side Yards Rear Yard
Required ired Provided Required Provided Requ Provided
1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone; _ Outside Flood Zone? Municipal El On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[`
2.1 Owneri of Record: �� �
Name(Print) City,State,ZIP
'7 s7 VALL r 4� C1-72-P-A5 9 °3u
a
Telephone Emil Address
No. and Street
SECTION 3:•D$SCRIPTIONOF PROPOSED WORK(check'all that apply)
New Construction❑ Existing Building Owner-Occtipied� Repairs(s Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number at Units_ Other Cl Specify:
Brief Description of Proposed Work': S i fR c
4— IF KV 4 srL CS ¢-16d.T e'c
SECTION 4: ESTIMATED'CONSTRUCTION COSTS
71
Item Estimated Costs: Official Use Only .
Labor and Official
1. Building $ 1, 3 $ O 1 Building Permrf Fee $ Indicate how fee is determined.
❑ Standa d:City(Town Application Fee
2. Electrical $ ;❑Total Pio3ect Cosl',(Item.6)x multiplier e
3. Plumbing $ 2 Other
4. Mechanical (FIVAC) $
5. Mechanical (Fine Total All Fees: $
Su ression 1
Check Nb. Check Amount: Cash Amount..
6. 'Total Project Cost: $ 1 3 9 $DU ❑ Paid in Full ❑Outstanding Balance Due:
To cot )Tr2.a C,M
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
'�—r 9 ti --IL3 S—I�- ��
1 b b C'✓ng License Number Expiration Date
Name of CSL I folder
a 3 g List CSL Type(see below)
No. and Street Type Description
b t� P v�-�/"� D .( 1 ,6 o U Unrestricted Bui'din s u to 35,000 cu. ft.
City/Town, tu�State,ZIP R Restricted 1&2 Far,;',,Dwellin
�I Masonr
RC Roofin Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
L 6, L-- r 1 an8t (
HIC Company Name or HIC Registrant N;L_� IIIC Registration Number Expiration Date
I Le
No Street Email address
b M A 0 -i
Ci /Town, State, ZIP Tele hone
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 .......... ❑ 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 k=,,r , (;� & n) y- C �
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) 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 and accurate to the best of my knowledge and understanding.
Trutt Owners o �en game(Electronic Signature) Date
NOTES:
70kvnerr who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractorered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
r guaranty fund under M.G.L. c. 142A. Other important information on the IIIC Program can be found at
s.0ovioca Information on the Construction Supervisor License can be found at www.ntass.g�ovrdILstantial work is planned,provide the information below:
(sq. ft) (including garage, finished basement/artics,decks or parch)
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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
M'
... 600 Washington Street
`Ys „ Boston, MA 02111
air www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Leeibly .
Name (Business/Organizationgadividual): L ✓ lT t bo 4Y Cci v rzA r 7% , R Cp
Address: Q 3 �Z—
City/State/Zip: pPhone M 9 r l 8- 5 3 1 23 QL 3
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with Z 4. ❑ I am a general contractor and I
employees(full and/or part-time)." have hired the sub-contractors 6. ❑New construction
2.❑-I-ern a sole-proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in an capacity, employees and have workers'
Y aP tY• t 9. ❑ Building addition
[No workers' comp, insurance comp. insurance. 10. Electrical repairs or additions
required.] 5. ❑ We are a corporation and its ❑ P
officers have exercised their 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work P
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' 13.0 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.
:Contractors that check this box must attached an additional sheet showing the name of the subcmtractors and state whether or not those en4ties have
employees. if the sub-contractors have employees,they mustprovide their workers'comp.policy number.
I am an employer that Is providing workers'compensation insurance far my employees. Below is the policy and job site
information.
Insurance Company Name:e M_ M . N v iv A L C a
Policy#or Self-iris.Lic.#:_ D j O 9-7 Q O 1 .3 �_ Expiration Date: g 3 1
Job Site Address: '2— S VA L L.n S r City/State/Zip: S ALe en MA
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 cerptifyy under the pains andpenalties ofperjru'y that the information provided
i above is true and correct.
Signature: Date: 1 —
Phone#:
Official rise only. Do not write in this area, to be completed by city or town qfflkid..
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#:
,4��rrd CERTIFICATE OF LIABILITY INSURANCE 07 82013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONIFERS 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 endorsemenL A statement on this certficate does not confer rights to the
certificate holder in lieu of such endorsement(s). MA
PRODUCER 01634-001 M1pNNAELT
Edward F Sermon Insurance EnMICp.�LNo. _ �.No.
16 South Main Street ADDRESS:
Topsfield,NIA 01983
• INSURERISIAFFORDIMCOVERAGE
. A.I.M.Mutual Insurance Company 33768
INSURED
Lon Oibely Contraoting Company In*
INSURER C
23 Winter Street Rear
Peabody,MA 01000.6941
INSURER 0,
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 WTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEAMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWNI MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TV TYPE OF INSURANCE I POLICY NUMBER A&M AWMI I L ITS
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CLAIMSAUDE OCCUR I MED EXP(Any mMp n) Is
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ALL OWNED SCHEDULED BODILY INJURY(Pe,ecdd-A t
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EXCESS LIAR CWMSMADE AGGREGATE t
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AAlNNyU•ENPIAM W1&UTY X TORYLIINT9
A WS �V� NIA VWC4 00-60109 79-2013A 01312013 81312011E E.L.EACH ACCIDENT t 500,000.00
(I,MVaan�daeloq�InKHH,d))�� - ELDISEASE-FAEMPIAYEE $ 500,000.00
OCSCR1lON OFOPERATIONS aelov.• E.L.DISEASE-POLICY LIMT i fi0O,000.00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(A hACORD 101.Addrioml Remarks Schedule,H Moro space M mquhe0)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
• ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORG REPRESENTATIVE
®1988-2010�ACORD CORPORATION.All rights reserved.
ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD
FEB-04-2013 09:48 Sennott Insurance 998 887 2404 P.01
V c/V'Y/Av u
teDUCER 978.887.4900 FAX 978.387.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
.dward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
L6 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW-
/. 0. Boa 457
iopsfield, MA 01993 _ INSURERS AFFORDING COVERAGE NAIC0
LURED Len GT e y Contracting Co. , Inc. — INSURERA Catlin Specialty Insurance CID
2311 Winter Street INSURERS: Safety Insurance CDepany 39454
Peabody, MA 01960 INSURER C
INSURER D: -
INSURER E. .— •.—
OVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, CIpAA �
A H8a TYPE OFIMBVMNCS POLICY NUMBER :ATE MMI OATfi�IMRA4GDAMM -^- ULXTS �-
GENERAL LLMUTY 3700301537 01/29/2013 01/29/2014 EACNOCCURRmce 1 1,000 00
X COMMERCWLGENERALLIABILffY FRENBSES EAoeanEnee _E 100.0
CLAIMS MAOE L-- I OCCUR MEO EXP(Any om mrwn) F 5.000
PERSONAL S ADV INJURY S 1J 000.00
GENERAL AGGREGATE F 2,000,00 i
01
GENL ACOREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP ACID E 2.000.00
POLICY JE lOCi -'
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
ANr AUTO (Ea aeeleNX)
ALL OWNED AUTOS BODILY INJURY
_X SCHEDULED AUTOS (PerpMwnl I
X HIRED AUTOS
BODILY INJURY F
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PROPERTYDAMAGE
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OARADE UABIU" AUTO ONLY-EA ACCIDENT S
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RCB33/UMBRELLA LIABILITY EACH OCCURRENCE 1
OCCUR CLAIMS MADE AGGREGATE I
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RETENTION S yT 1 _••.•
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AND EMPLOTERS'LIABILITY TORY LIMITS ER _
ANY PROPRIETOWPARTNEILEXECUTIVF�u E.L.EACH ACCIDENT
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OTHER
'.SCRIFTIOH OF OPERATIONS I LOCATIONS/VEHICLES/DW6VBNPI8 ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING 04UMR WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
Evidence of Insurance NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,But FAILURE TO 0060 SHALL
IMPOSE NO OBLIO/1TION OR LABILITY OF ANY HIND UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AVTMORREO REPRESENTATIVE
Robert Sennott RP
CORD i8(2009101) 01968.2009 ACORD CORPORATION. All rights reserved.
The ACORD name and IDgO are registered marks of ACORD
v LEN GIBELY CONTRACTING CO., INC. Page No. ---Lot Pages
' S Street `25112 PROPOSAL
PEABODY, MAS MASSACACHUSETTS 01960
All home improvement contractors and subcontractors
(978)531.8234 Fax(978)531.9304 engaged In home Improvement contracting, unless
www.lengibelyeontraeting.eom specifically exempt from registration by Provisions of
pIChapter 142A of the general laws, must be registered
submitted �L'th Ul/ M ,ems ' with the Commonwealth of Massachusetts.Inquiries
To: I _/ "�`� .-.. �J / ." about registration and status should be made to the
o Director, Home Improvement Contract Registration,
U961 8 S� One Ashburton Place, Room 1301, Boston, MA 02108
(617) 727-8598. Owners who secure their own
C construction related permits or deal with unregistered
contractors wilt be excluded from the Guaranty Fund
Provision of MGL c.142A.
FH [ DATE REGISTRATION NO.
r7 YS 9 3 7 Z3 MA.REG. 100811
JOa al JOB LOCATION
C �",31D(\_V,(07 S� f as ose�s
We homey submit a,drafirdsh.m.Lard ea ial for work to be pt d.rmed and materials to be used:
-- i fill
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WORKS DUE �I/ � (//)
Canal I rANcvID N tl IM1e materiels before the thi d tl y follo ing the 'g g f Ih s Agreement unless spec I'atl here, t Copy a,n�r,29 n*' 'i
or
about \\\ ��_(d t ) B g delay caused by circumstances beyond Contractors control IM1e work will be comDlelotl by (y/Itl toacknor1 tly0 tl y 9e that the had I' g dates are appran m t nd Ih t such delay IM1 t t ha dable by the Contractor shell not b cons' etl 5 0 Ib 10 sWARHADI IYThe Comn¢Ior warrants that IM1e work loam hereunder shall be free from detects in materal antl workmansM1p for a perod of Iow ng complofpnantl sh
In.reyuimntonta of this Agreement.In the even)arty object In workmanship Oa materials,or damage caused Cy the contractor nls su CO a o`ors,amplcyees or ngeme,ie d,schwar�within
one year anor completion of any job,including clean up,the Cammctar shall,at his own expense,forthwith remedy,repair,correct,rapid cause to be rempdmd,repaired,or replaced
such duarr of s.In hear in malmmar or A nderm,.The foregoing war2n oe shell survive any hap colon pone rmotl in mnnedlon with the agere6upon work.
We Propose hereby to furnish material Labor-complete in accordance with above specifications,for the skin of:
A ^�3, FIX dollars
Payment Job m tlne5 a"/4folhVo.(w�sNy7 ry p��I --a
%(s 1`� )anstgntn9Y0yo tJra ` name of comranorrDestpneted Regauanl --
(5 A/ILd )upon camptakon of
$VBef AWrBA
%(8 )upon completion of
work Ci"State none
(8 )shaltbemadeeark uhupon L
cromplelion of under this contract. a a Fed cane Na. 1
Fill
Notice: NO agreement for home Improvement contracting work shell require a down N e -��
paymae amount
of all
deposit)of more than one-third of the trial must
make
price or the
total der a nl of ell deposits or payments which s the al order
materials
make,in advance, 70"1
d aw
to order and/or olM1arwiee obtain tleiivery of special order materiels and epuipment,
wh'cheyer aDlOunl'sg e(3atBr n yW wandrown bye Xnul abnormal all
Acceptance of Proposal I have read both sides of this document a d ace t e prices,specifications and conditions slated. undstsl;nd
Thal upon signing,this proposal becomes a binding contract.You are authorize to do he ork as specified. Payment will be made as outlined above.
You,the Buyer,may cancel this transaction at any time to midnight of the third business day after the
date of this transaction.Cancellation must be done in writing.
DO NOT SIGN THIS CONTRACT IFTHERE ARE ANY BLANK SPACES.
Cole sianeturo _ erne
IMPORTANT INFORMATION ON BACK 1"- t
7 'Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
('m.rrucu m Supcn i.ur }cww
License: CS-094763 -s
<x:r i S n..
THOMAS K DD&BINS rr
19 Cedar H01Arive ,
Danven MA-01923 ,��.
Expiration
Commissioner 05/14/2014
Otlice of Cu nsu nier Affairs 5 Business Regulation License or registration valid for individul use only
5;, =40ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
r�aa Registration: 100811 Type: Office of Consumer Affairs and Business Regulation
i!`r expiration: 6/23/2014 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
LEN GIBELY CONTRACTOG CO., INC.
Brian Dobbins _
23 R WINTER ST. `
PEABODY, MA 01960 Undersecretary Not valid w t ignature