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12 HAYES RD - BUILDING INSPECTION C119ck IIZ3 Che Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR Revised.Nur 2011 e Building Permit Application To Construct, Repair, Renovate Or Demolish 3 One-or Two-Family Dwelling ` This Section For Official Use Only Building Perit Number: Date ppliede I Building Official(Print Nmne). Signature- Dat SECTION 1:SITE INFORMATION CD LI Property Address: 1.2 Assessors Map&Parcel Numbers Z A4Parcel Number 1.1 a Is this an accepted street?yes_ no Map Number cps D 1.3 Coning Information: lA Property Dimensions: .� •�+ Zoning District Proposed Use Lot Arca(sq It) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yank Rear Yard Require) Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L e.40,§54) 1.7 Flood Zone Information: I.tl Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal E3 On site disposal system ❑ Public[3 Private E3 Zone: iF es❑ SECTIONZ: PROPERTY OWNERSHIP! 2.1 Owner or Record: If- cel , O l g La (r A�S/D D✓-01r f/ i Lr R r• t, ,,�¢ � �ASkn � � me(Print) City,State,ZIP (A7 S I- N e S24�1 Z O T' C T'ov J a.r-� °1-7�' No.and Strect Telephone Bmail Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ t Addition ❑emolition ❑ ry Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work=: o — C -c—` scrl tltea[.! M.o�. �+p C n i, �•sLt`r RsE�L�r (.cJi...n:.cv SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and 1,laterials) I. Building S i �O n� I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2'a Other Fees: S t. %lech;mird (FIVAQ S List: 5. Mechanical (Fire 5 Total All Fees:S Su ressiun) Check No._Check \mount: Cash Amount: 6. Total Project Cost: m ❑Paid in Full ❑Outstanding Balance Due: tb6, 10 t D C7 G ��T2r2�sQV v� �t..sYLt�N�NPa� i r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 4 W-1 L2 License Number] Expiration Date- Name of CSL Holder List CSL'rype(see below) yp 1 3 0- uw v t.n S'r` -Te - Description No. and Street � r U Unrestricted(Buildings tip to 35,000 cu. It.) ` p � A (�,n {� .4 R Restricted 1&2 Family Dwelling City/fawn,Slate"ZIP iN Masonry RC Roofing Covering WS Window and Siding r, SF Solid Fuel Burning Appliances 9.°7 8 3 ` 8 Z3 1 Insulation 'role hone Enmil address D Demolition 5.2 Registered Home Improvement Contractor(HIC) L-. c. vr✓ Cl(� 2-�[ "�,yt�% HIC Registration Number Expiration Date IIIc Company Name or HIC Registrant Name 5',- No. and Street Email address Cit /Town,State ZIP Telephone SECTION 6:WORKERS'CONIPENSATION 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 AUTHORIZAITION:TO BE COPLETED WHEN. OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUMILDING PERMIT I, as Owner of the subject property,hereby authorize t9 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. C?- Print Owner's or it ionze ! gent ;line(Electronic Signature) Date NOTES: I. 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. I42A.Other important information on the HIC Program can be found at www.nnass..,•ovorn Information on the Construction Supervisor License can be found at www.mass.eov'd3rs 2. When substantial work is planned, provide the information below: 'rota) floor area(sq. It.) .(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 'rype of heating system Number of decks/porches Type of cooling system Enclosed Open_ 3. "'notal Project Square Footiige">tnwy-b`e substinited fur"'fatal Project Cost" Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Le(i /bel a Con�raCY%/I A l 0• Address: City/State/Zi : 6 AN d/ &96 Phone #: Are you an employer?Check t e appropriate box: Type of project(required): ! I am a employer with /01 4• E] I am a general contractor and I employees (full and/or part-time).' have hired the sub-contractors 6.,,❑New construction 2. ❑ 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' [No workers' comp. insurance comp. insurance.: 9. Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs;or.additions 3. ❑ I am a homeowner doing all work officers have exercised their I I,[] Plumbing repairs or additions myself [No workers' comp: right of exemption per MGL IQ repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13,ED Other _ comn. insurance requ¢ed.J Anv applicant that checks box#I must also till out the section below showing their workers'compensation policy information. 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 sub-contractors and state whether or not those entities have <mployees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and job site inj' rmation. i insurance Company Name: A. L M. Mulua/ Asuranee Co. Policy H or Self=ins. Lic. k: Expiration Date: 3' Job Site Address: / ;) 1-14 fi`'.P1' (2�o City/State/Zip: !� A L� 4yz MA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration"date). Fall 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties ofperjury that the informadon provided above Is true and correct. >i^nature: DateS L> Phone 4 9 1 5 3- 1 -S -f Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector t 6. Other 1 Contact Person: Phone#: DATE INWDDNYYY) CERTIFICATE OF LIABILITY INSURANCE _....... . .__._. ., 0&03/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les)must be endorsed. N SUBROGATION IS WAIVED, subject to - the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confor rights to the certificate holder in lieu of such endorsement(s). Y•aooucea C01rTACT _Lisa Curcio HONSENNOTT INSURANCE AGENCY ea oErDc (g78)g53-1813 _FAx _ TEs$,. Iisa@sennotOnsurarlce.com IB SOUTH MAIN ST. INSURERIS)AFFORONG COVERAGE NANCY 70PSFIELU— _ _ MA 01975 INSURER A: FUM_ MUTUAL INS CO - 33758 INSUNED W SURER e LEN GBELY CONTRACTING COMPANY INC INSURER C. W SURER D 23 WINTER STREET REAR Wsu;;E: PFAHODY MA 019605941 INSURFA F: COVERAGES CERTIFICATE NUMBER: 74371 REVISION NUMBER: IVIS 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 CER FFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, FACLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. UBR-- POLICY EFF POLICY E%P ___ LIHI TYPE OF INSURANCEM. POLICY NUMBER LWITa COMMERCNLGENERALL"RJFY EACHOCCURRENCE 3 _ CLAIMJ MADE 0OCCUR rJ�,e;_WSE91EA ott nrrcel t _-_- MED EXP(ABY om ynrmn) _{ ._.------- .._ WA PERSONAL B ADV INJURY_ 3 QEN'I.A cREGAI E UMI I APPLIES PER, _GENERAL AGGREGATE 3 I (�I I 1 Plillfv _._j JECI LOC PRODUCTS-COMP/OPAGG_ $ ...,__ QMEH[ 3 I AUTOMOSILEU WTY O WEDS LIW { I ANY AUTO BODILY INJURY(Pa paean) S C"- AIL 0 EO SCHEDULED BOOBY INJURY IPa NaciJaH { _ AUIOS AUTOS NIA ) NON-OWNED P OPERIYUAMhGE { HIkEDAUtOS AUTOS 1_ ! U311IRELLA LIAR OCCUR CWMSNADE) WA � RR HOGGUENCE EXCESS LS AGGREGATE Y RcTENTIONS 3 IORNEH5 OOMPENSATgN X STAT ANO -_ NO EMPLOVERS'LWDG fTY YON in-HOMwNRiOWAIII NER, ECUTIVf EL EACH ACCIDENT 3 500,000 A I a I�C:WMENDEHEACLUOED? N/w Na NIA VWC10080109792.016A 08/03/2018 0&03/2017 - (Mumemryu,NH) El.DISEASE-EA EMPLOYEE { 500,000 Jf Uf SC F SCRIP 11ON OF URna6 O PEI4111ON$Winn' OE.L.DISEASE-POLICY LIMIT $ 500,000 . WA UEYCRIPTION Of OPERATIONS/LOCAl10N9/VBWCLFA (ACORD 101,AaYlUontl Ranula 9UwYVM.nuY Yn n1M[MYema�APas NrpWrN) WorkersCompensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay clam%for benefits to employees in states other than Massachusetts if the Insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this eerttfleals was issued(unless the expiration date on the above policy precedes the issue date of this certificate of Insurance). The status of this Coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Sua,cfi tool at wvw.mass.govAwd/workers-wnipensatloNlnvestiga0ons/. 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. I AUTHUNQED REPRESENTATIVE ( 01930 Daniel M.Cro,-*y,CPCU.Vice President—Residual Market—WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserved. - ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DA1/le/zTE18/2o16 `-� 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 endorsemenl(s . PRODUCER NAPE; Robert Poulin___ __ Sennett Insurance Agency PHONE _� _.(978)887-4900 __. .__......_.,.F ..__...- . 16 South Main Street: MJIQ.EAU:_._._...._.__._.... .._...__-.. _.. _........_.LIA_�,.NoR(978)987-2404 robertpoullnesennottinsurance.com . .DREss ..... . .... .. .. .. . _... . ..____....----..._. P. O. Box 457 ..INSURER(SIAFFORDING COVERAGE_ "Co "ousf field MP. 01983 wsuRERp FArst Mezoury_Insurance Company ,rIJUXED INSURERe Sa£aty Indemnity _33_618 Lan Gibely Contracting Co. , Inc. INS 23R Winter Street wsuRER D: : INS,URERE . ._...._. ..._. ._. Peabody MA 01960 IN UflERF COVERAGES CERTIFICATE NUMBER:CL1611860930 REVISION NUMBER: [HIS 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 WiIICH THIS CEH 7IPICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE 'PERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR OADM SUGRf.___.._... .. ._ ... ___.-_. ._- LTR TYPE OF INSURANCE POLICYEFF POLIGYEXP IMMAKi I LIMITS POLICY NUMBER VY ?( CODYFACIAL GENERAL LAOILITY I I EACH OC TO S 1,000 000 j DAMA01 TO REN IED A I '.I. 'vsa.l t E I X C OCCUR 100,000 I I ENI§ES tE0.OCgJI!@RCB) -f__ _ !NJ-CGL-0000060987-01 1/29/2016 1/29/2017 uEO E%P(AT�meE6taon) �i._ 5,000 -. ..._ PERSONAL BAOV INJURY GS 1,000,000 iGCPl,-,LGREGATE IUAT APPLIES PER GENERAL AGGREGATE I S2,000,000 .. .I JESTCOMPrtJP AUG- S 2,OOU.000 AUIOUODILE UAUIU iY I I OYi11N: SWGLEuMR S 1,000,000 ',+ AUTC 1 BODILY INJURY IPm Pena;) 1 '_..._ L O1W. D XSCHEOOLEO j 6221693 CCH 03 i 1/29/2016 11/29/2017 eOUILYINJURYIPar WAcsotl S JTC6 AUTOS 1 ' PROPLRIV OAIV+GC -- F RCO A;:TOS X AUTOS .LbI. S'4@4IL S .. PIP Gave . UAIUREU-A LAtl i..._.I OCCUR EACH OCCURRENCE 9 EXCESS WAD GGREGATE GLA N -MADEI _ ..._I L ��n RFIF IT VNI I WORKERS COMPENSATION AND EMPLOYERS'LIAINM YIN I _ >TATV-TE.I ERI A!I( WAUPHIEtORAPARTNEWEXF.CUi'VE r — iEL AGM ACCID IT �S ---. iFlfkL ViiEXCLUDE°'/ NIA ... ' llalle tory In Ni i EI DISEASE-E EUP CYE 5 OF::PERAiCJNS pave E.L. DISEASE-POLICY LIMIT I S I I 1 I 1 I DESCRIPTION OF OPERATIONS 1 LOCATIONS VEHICLES IACORD 101,Aeoifional RBmAMa SeNdu10,may G aUxNee U mom space is mgWroe) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I ACCORDANCE WITH THE POLICY PROVISIONS. I AUTHORIZED REPRESENTATIVE Robert 3cnNott/RP2 _ 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 L:ucp Page No. ift of Pages -\ LEN GYBELYCONTRACiCO., NC. 23R Winter Streetreet28072 PROPOSAL PEABODY, MASSACHUSETTS 01960 All home Improvement contractors and Subcontractors (978)531-8234 Fax(978)531-9304 engaged In home Improvement contracting, unless www.lengibelycontracting.gom specifically exempt from registration by Provisions of Chapter 142A of the general laws, must'lie registered _ Submitted (/� I Q \y \}' with the Commonwealth of Massachusetts. Inquiries To:—_IL ICN- _-1._O.5_$-O(A s Ny' about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108 r"/�rr/-I © (617) 727-8598. Owners who secure their own n V M1_7_O 18 I O- construction related permits or deal with unregistered --f-I--`''�' ��---- -- -- contractors will be excluded from the Guaranty Fund Provision of MGl c.142A. P RNE !(� DATE REGISTRATION NO. _ MA.REG. 100811 JOB NAME/NO JOB LOCATION by s mit speciff on antl estimates br work t be ppoormed and materials b be used n �`���� ��, .o_ , —1 JCa �1.($ C11A1 C ._b)0,(�5 W r S II C aCr) 74 �p / --C -- �•— U QIU.M//IU—M.—.._-.(QSLIr Ck CA P �c ray, :- _rl a�2__S_ui� i _SGc7� on f5�: s_�_2\+ouln\ __- � ��� Z_c�/n�.jl}__w_ dP u�� � � `�--Ui(�M�--��t. -0 Cr09 WORK SCH ULE GONrac a the work or order Me materials before Ina IhiN day following Ina signing of this Agreement,unless specified M1arein car r call egin Me work on or about (Gere).Barring delay caused by circurrources beyond Cc control,the work win be completetl byy n� The Owner hereby ecknowl gas Gr g .... at Ina echetluling Gates are epprml ale antl Nat such tlaleys Incl ere not avoidable by the conbedor sM1 n ba cans ed as vblat pl this Agreement HitlGat rel orcinQa�aa]noorrthernnt�nJ�/D�I esth`nelyyMla�t ay�I�(i to be In oder to compbb Ms cnuect ll ba completaxetS per men hour(MAN HOUR). WARRANTY "Y� `�rJI WI✓`I�Y Lne_S� The Contractor wanenM Met Me work furnished hereunder II be Iree fro detects In material and workmanship for a pariah of /1l following completion and shall comply with the requlremenla of Mla Agreemanr.In Me erent any Mail In workmanship or remonels,or damage caused by the Contragor,his subs nt.ao.,emplbyaes.,agents Is discovered within one year aXer complagon of arty IoE,InclapIn clean up,Me Contractor shall,at his own expense,bdhMM remedy,repair,correct,replace,or cause to be remedied,repaired,or replaced such damage or such defect In materials or workmanshlPThe foregoing warranties shall survive any Inspection performed In connection with the agreed-upon work. We Propose ereby to furnish met rial and lappor-co tete in acco ance It ove specifications,for the sum of: C�faPn rC 11144 //10- a�� nsaaXila'rs1�°°f Payment to be made as toll we: Ir Re a all job trash. _ 26G)l eg2i 9/',lila All guarantees on all products from manufacturer. ($ )upon signing Contract; Atltl permit cost 11 nestled-we pull permit. ($ )upon completion o1 Notice: No agreement for home improvement contracting work shall require a down payment(advance deposit)of more than one-third of the total contract is )upon completion of price or the tom tal aount of ell deposits or ayments which the contractor must make,Ina ance,to order and/or oM Ise obtain delivery of special order a($ )shall be do forawiM upon ma ea.il ment. t pfa raster completion of work under this contract. Nota:I no popual may W witldmAn by us It not ancepla]w MM days. Autno' preture 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. DON SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Signe,.. r Oelae sianew,e Dam Uy IMPORTANT INFORMATION ON BACK Massachusetts Department of Public Safety i, ll� Board of Building Regulations and Standards License: CS-094763 Construction Supervisor _ THOMAS R DOBBINS 19 CEDAR HILL DR _P DANVERS MA 01923 ( JZU CA-- Expiration: '` Commissioner 05/14/2018 . (-Ile 1(i�uar�ennu�Col(�n��%GirJJl�cJ[ude((J License or registration valid for individual use only Office of Consumer Attain&Business Regulation before the expiration date. If found return to: i' HOME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation Registration:_..100811 Tye' 10 Park Plaza-Suite 5170 elf Expiration 16/231018 Private Corporation Boston,MA 02116 i LEN GIBELY CONTRACTI G QPi INC. �fZl I Brian Dobbins 23 R WINTER ST. PEABODY,MA 01960 Undersecretary of valid without 8462ture _ r 1, i