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128 Federal St - C of NA application - reroof garage Date Stamp DEC 08 2017 Sale"' Historical Coal miSSlOjZ 120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970 For Office Use OWy (9M 619-5685 FAX(978)740-0404 APPLICATION FOR A CERTIFICATE OF APPROPRIATENESS Pursuant to the Historic District's Act (M.G.L. Chapter 40C) and the Salem Historical Commission Ordinance, application is hereby made for issuance of a Certificate of Appropriateness for: 0 New Construction ❑ Moving 0 Reconstruction ❑ Alteration 0 Demolition ❑ Painting ❑ Sign ❑ Other District: ❑Derby Street ❑Lafayette Street ❑McIntire ❑Washington Square Address of Property. I a ,� S T- Name of Record Owner(s): H rt b J-U V Owner Mailing Address: w •� b * ..Oy LA I Rkem-c .pc t` S.r- Descril2tion of Work Proposed Please tjpe orprvit clearly:Attacli additional slieets, as necessary Name of Applicant: L Y ❑Owner $'Contractor ❑Tenant ❑Other: Signature: - -- — Date: --Z Tel. #: E-mail Address: Le,,, &-t eLP L,YY, T—rr,a C?�;6 Certificate will be mailed to the owner unless otherwise indicated here: Certificate should be mailed to: Name tk-.'-Lr Mailing address: p: City: bP�Y'State Zi d i g� B ` . . ATTACHED DOCUMENTATION An application will not be considered complete unless all work items are thoroughly described and the application includes all information needed for the Commission to make a determination. Failure to submit a complete a>>t?lication ma - result in a continuation to a uture meetin . Recommended information includes: Photos-of conditions, taken from all public ways Site plan showing location of improvements Elevation drawings of the existing conditions and proposed improvements Drawings of details and other special conditions,including profiles Description,photographs, and/or catalog cuts of proposed materials(please bring to the meeting product samples, if appropriate) Dimensions(i.e.height of fence,size of pickets and posts, etc.) Paint color samples, if applicable(no less than 2"x2") Location and size of all mechanical equipment, such as transformers,HVAC equipment, electrical service and meters, and proposed screening The Commonwealth of Massachusetts OF Board of Building Regulations and Standards CITY M Massachusetts State BuildingCode,780 CMR SAMar ! Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling 1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers �T �.r aQ L l a Is this an accepted street?yes no Map Number Parcel Number 13 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? municipal❑ On site disposal system ❑ Public❑ Private❑ Checkifyes❑ SELTIOI�I 21 PR4],P1�RTY Q' �.".: 2.1 Owner'of Record: 1-4-e 1 b— .fir(Z-v 0 1, — J14 A Name(Print) City,State,ZIP _ 6w-- S C(�18g$'7r7� No.and Street Telephone Email Address TCTFON 3:UESCI�I'TION OF PR+DPO.=WO {0eck all that apply.) New Construction❑ Existing Build' er-Occupied ❑ Repairs Alterations) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work-2: 4 G d2 rt>® IL ene pL-0qfgg .P ES.TII IAT t ONSTRYIC3'I COSTS Item Estimated Costs: OfSel TJse , (Labor and Materials) 1.Building $ o �.�' Bung F F � Ii(dcate}iovi fee is dltern�iaedt t1 Standard City/Towu Appftcation gee 2.Electrical $ p Total Project Chose(heal 6)x multiplier x 3.Plumbing $ 2. Other Fe0X List 4.Mechanical (HVAC) $ 5.Mechanical (Fire $ Total All Fees:$ Su ression) Check No. Che©k Amount: Cash Ani 6.Total Project Cost: $7 0 flip- 0 laid in Full _ 13 Qutstand i r�dance Pue: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Business/Organization/Individual): I—e r1 j Uc. C0a4(6LCqin9 CO. Address: 'j Ll);iA-kf- City/State/Zip: h"dc M 14 U 1C PO Phone#: _61 Are ,you an employer?Check the appropriate box: Type of project(required): 1.ED 1 am a employer with�a 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ]New construction 2.❑ 1 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.1 g 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 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. $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 employees. 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 information. Insurance Company Name:_ 1- ! l�'I MGC�L(LLa //1,5 c,cran CQ C�y7L(,a LV T' - Policy#or Self-ins.Lic.M ✓W C 100(0 0 10 Id o/-4 A Expiration Date: 9- 3. c90 l g" Job Site Address: 1 a ISR ,.� se , -.,d City/State/Zip: SAL,n., h 7A-- 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 MUL 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: �_ — -� - Date: _ --- Phone#: C) 7 S Official use only. Do not write in this area,to be completed by city or town ofj"iciaL 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#• V® CERTIFICATE OF LIABILITY INSURANCE P31/23/2017 ATE(MlalDD/YYYIf) 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. I 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(si. PRODUCER 4 CONTA T Robert Poulin NAM : er Ou 1 Sennott Insurance Agency PHONE (978)887-4900 FArc Ne:t97e)ae7-zaoo — 16 South Main Street E-MAIL AkREss:robertpoulin@sennottinsurance.com P. O. Box 457 — '-.--------- , ------- - INSUR AFFORDING COVERAGE NAIL Y Topsfield MA 01983 INSURER AYyanston Insurance Company 35378 I INSURED I N+SURERB:Safety Indemni_t_ 33618 J Len Gibely Contracting Co. , Inc. iNSURERC: 1 23R Winter Street INSURERD: INSURER E. Peabody MA 01960 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1712398652 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADM SUBRI I NSRT-�-- ---- -- L rM 1 TYPE OF INSURANCE POLICY NUMBER POLIC EFF POLICY EXP LIMITS I X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A :—,!CLAIMS-MADE L^__I OCCUR PR MI E EaEx ourOnce E 100,000 1 3C41933- 1/29/2017 1/29/2018 MED EXP(AnX one person)- $ 5,000 PERSONAL&ADV INJURY E 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE i 2,000,000 r - l 1 1 X I POLICY'L JECT LOC PRODUCTS-COMPIOPAOG $ 2,000,000 OTHER: i AUTOMOBILE LIABILITY E OMBINED SINGLE UEA IT E 11000,000 6 !ANY AUTO + 8001LY INJURY(Per person) b ALL OWNED X,•• SCHEDULED 6221693 CCM OaAUTOS AUTOS 1/29/2017 1/29/2018 BODILY E X HIRED AUTOS X AUTOSWNED PROPERTY DAMAGE f --- 1poraccidom I UMBRELLA UAB PIP-Beak = 8,000 OCCUR EACH OCCURRENCE 3 EXCESS UAB CLAIMS-MADE AGGREGATE $ OED ' RETENTION E _ WORKERS COMPENSATION PER OTH- :AND EMPLOYERS'LIABILITY YIN TE ER !ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED?f N I A E.L.EACH ACCIDENT $ !II : `(Mandatory In NH) E.L.DISEASE-EA EMPLOYE S If yes,describe under 1 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S i I i DESCRWI ION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) i 1 i ' CERTIFICATE HOLDER CANCELLATION iSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I Robert Sennott/RP2 ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) CERTIFICATE OF LIABILITY INSURANCE m-rEv Yv&yY") 0810302017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R03M 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 INSURERjS), 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 WANED,subject to the terns and c andltiors of the policy,certain policies may require an endorsement A stdomsnt on this certificate does not confer rights to the certificate holder In lieu of such andorsem s). I PRODUCER •---•... -`� Frances McEvoy SENNOTT INSURANCE AGENCY PHONE97g 63-1614 a OIL ADDREM fran0sennodirmrancecom 1 16 SOUTH MAIN ST INsu AFFORDING COVERAGE r1AICS TOPSFIELD MA 01915 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER a: LEN GIBELY CONTRACTING COMPANY INC Il URERC; INSURER O 23 WINTER STREET REAR IrusuRERe: i PEABODY MA 0196MS41 W811RERF: COVERAGES CERTIFICATE NUMBER: 179481 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRuak LTR TYPE OF INSURANCE �'= POLICYNUMBER POLICY F.F'F POLICY EXP Lam COMMERCIAL GENERAL LIABUM - EACH OL'GIR� S CUUMSMADE OCCUR QAMAaETOPREMISES Me eWffVk&j ; MED EIS Ora $ -- WA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: T GENERAL.AGGREGATE S I POLICY❑JEC LOC PRODUCTS-COMP/OPAGG S OTHER: _ S AUTOMOBILE L IABUM $ ANY AUTO _ BODILY �0%►aN S ALL OWNED SCHEDULED AUTO$ AUTOS N/A BODILY INJURY(Per amMent) $ I HIRED AUTOS AUTOS PPERTYDMAAGE $ 1 $ UMBRELLA LAB OCCUR FACHOfxURRENCE _ -— ExcEss LIAR a�uMs�rAOE WA AGGREGATE $ E DID $WOMMSCOMPEIi"Um —AND EMPLOYERS'UAGUM Y 1 N X ANYPROPft1ETOR/PARTN£R!E](ECUTNE EL EACH ACCIDENT S 500000 A 0FFICERIMEMBERIXCLUDED7 WA NIA PUA VWC10060109792017A 08/0312017 08/03J201$ (Mandatory In NH) F-LDWEASE-EAEMPLUYEE i 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below _ E.L DISEASE-POLICY LIMIT S 500 ODO I NIA DESCRIPTION OF OPERATIONS 1 LOCATION81 VIIman(AOORD 101,Admonal Ramrka Se6adlYa,npgr Ha aeacdad M morasrgq is rapulfad) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay claims 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 certificate was Issued(unless the expiration date on the above the issue date of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Covepoky eg V�erifiation Search toot at www.mas&govAwdhvorkers-compensaftVsnvesdga6orts/. I _ _ CERTIFICATE HOLDER CANCELLATION --- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN iACCORDANCE WITH THE POLICY PROVISIONS. AU"ORIZEDREPREBBMfATNE -- MA 01945 R Danid M. y,CPCU,Vice President—Residual Market—WCRIBMA 01988,2M4 ACORD CORPORATION. AN r s rla mmL ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Dec 07 17 08:50a p.1 Herb Harvey ddshfh(o)Verizon.nebef December 7, G.7 7:55 AM (No Subject) 1 Attachn LEN GIBELY CONTRACTING CO,INC. 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'yvl vi1EwM0_ � I1 �Ai E/�,EEIfwrR l1010YVI1w,:R1,e�I1E r4k�1/,gjaa 1 ti 1`_- aoY,mnyar� — drwJl�nM Ew vrNw M A.YYI arwe TIE vka r ar Wr Mava d/lamb a arrr,lw rroi W aanmo.parr arw.M Earrrrta,>b vdv crib wtr.r.�n e�wrP/aprlJ Mr — 61 WEv�M�wi vren rWrrlEk uK w4rrOK 1Ai�IefgypA�, w~ rn aowaci ,�M MN��Yra,wwfkf.rn �T � Aeeeptarics or Proposal 111aa Eso oan E as of ns aom wmpl rr WiM.EPK*I)11 Id oandroro wars I rE aw whaa rHf6tddr9• papoEdaoyraw EtiElig ao,taft.!bu as EMradtwapdEwaoaAspciEa AptsEtEdlWllaosaa4laa El Ta You,the Buyer,m w carlf:tl thla teene n"W"at MW tiara PdVr to midAilOt od Rta tNrd bUal man dry&%w ma ante m lids aanaaet�pr►Canceuatbn mwta do"in rrWOW ,db N1U5 CONTRACT FTWOIE ARE ANY BLANK SPACES. - r.�-1z - - _ IYPORTAfE:n+FORwcrloh Oft eACit Massachusetts Department of Public Safety • j Board of IBuliding Regulations and Standards Licen: : C8.094763 Construe on Supervisor `r THOMAS R,DOBSINS I Co �I �/�— Expiration: sioner 00114/2018 I �T a �•aririrr.urrrr�rr/lI(►o��C�irwarl�ur /� OMcc of Consumer 40sirs do Business Rejulatim License or registration valid for individual use only ' HOME 1 P. Ei1W.CQAITRACTOR before tb#expit'stiop dsts, If found return to; Rsgistr i2c .00B11 .:;"`` Typr. dffiee of Consumer Amin gad 8usi;" Regulation F�cplro �8 Private Corpor don 10 Park Plaza-Suite 5170 r I Boston,MA 02116 ��=•r• ; • _EN GIBELY CONTRATItI� `CO:,INC. `.... r p i•i ; Arlan Dobbins I J R WINTER ST. FEi,BODY, MA 01860 Undenee � —-Not valid without sl sture t• r'