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B-19-1149 - 0027 BUFFUM STREET - Building Permit I ' The Commonwealth of Massachusetts �} Board of Building Regulations and Stand& &s CITY OF Massachusetts State Building Code, 780 CMR A 1s ICJ SALEM 5 Revised Mar 2011 Building Permit Application To Construct,Repair,Reno, a e Or Demolish a One-or Two-Family Dwelling This Section For Official Use:Only t Building Permit Number: Date Applied: y w� i✓ O l Building Official(PrmtName) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address:27 Buffum Street 1.2 Assessors Map&Pareel Numbers L l a Is this an accepted street?yes no Map Number Parcel Number 1.3 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2:, PROPERTY OWNERSHIP' 2.1 Owned of Record: Sal Pangallo Salem,MA 01970 Name(Print) City,State,ZIP 27 Buffum Street 978-744-8796 salpangallo@comcast.net No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Buildin Owner-Occupie Repairs(s Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑' Number of Units Other V Specify:Roof Brief Description of Proposed Workz:strip and replace main house upper roof with architectural shingles SECTION,4:,ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $9,175.00 1. Building Permit Fee:$ Indicate how,fee is determined: 2.Electrical $ ❑ Standard C.44own Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2 Other Fees: $ i, h 4.Mechanical (HVAC) $ List — ►``1' j (� ;: 5.Mechanical (Fire $ Suppression) Total.Afl Fees:$ Check No. Check Amount: Cash Amount. 6. Total Project Cost: $9,175.00 ❑Paid in FuII ❑Outstanding Balance Due: I .SECTION S: " `_CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 094763 5/14/20 Tom Dobbins License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 23 R Winter Street, No.and Street Type Description U Unrestricted(Buildings u to 35,000 cu.ft. Peabody, 01960 ZIP R Restricted 1&2 FamilyDwelling City/Town,own,,State,Z M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 978-531-8234 office@lengibely.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 100811 6/22/20 Len Gibely Contracting HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 23 R Winter Street, office@lengibely.com No.and Street Email address Peabody,MA 01960 978-531-8234 City/Town,State,ZIP Telephone 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...........❑ x SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN: OWNER'S'AGENT OR CONTRACTOR APPLIES FOR BUILDING•PERMIT 1,as Owner of the subject property,hereby authorize Len Gibely Contracting to act on my behalf,in all matters relative to work authorized by this building permit application. Sal Pangallo ,_-3 Z p Z� Print Owner's Name(Electronic Signature) Date SECTION?b:OWNER 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. Tom Dobbins Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: l. 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. 142A. Other important information on the HIC Program can be found at www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (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 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" 01 LEN GIBfLY CONTRACTING CO., INC. Page No. _-Lof Pages 23R Winter Street 29943 PEABODY, MASSACHUSETTS 01960 All home improvement contractors and subcontractors (978)531-8234 Fax(978)531-9304 engaged in home improvement contracting, unless www.lengibelycontracting.com specifically exempt from registration by Provisions of t Chapter 142A of the general laws,must be registered Submitted l with the Commonwealth of Massachusetts.Inquiries l/-__�_.-_..-_ about registration and status should be made to the ? Director, Home Improvement Contract Registration, y)1�✓/L? 5.�= One Ashburton Place,Room 1301,Boston,MA 02108 _-_ (617) 727-8598. Owners Who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund ,d A4 M j3l1®� Go j�,�, � «� t Provision of MGI_c.142A. PHONE DATE p REGISTRATION NO. 7 7 - (J ! I - , / MA.REG.100811 77 . .. . JOB NAMEINO. JOB LOCATION We hereby submit specifications and estimates for work to be performed and materials to Itil %A1-- as'cefZ -0 need v - j2 ✓tA 12 0t�i' 1 r,�-���r CCiz 1� �'Jvni�?L ry 7�r � v iv rr2./iI fir,6.4 7i L��s; f�N/1r� ANd Fie6A ,vt _1i�s . /J ,�"/Z �9iru�-��e<�_�i�7Vdrra�7C Zh�t 1 WORK SCHF.OULE %rf Contractor of b'egi th work 1,i3rSfe t rials before the third day following the signing of this Agreement,unless specified herein writing.Un o 'll begin the work on or about - (date. ar,ing-d y caused by circumstances beyond Contractors control,the work will be com feted-by te).The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the contractor sha I n e c idere� ions of this Agreement. 9 Hidden rot or conditions not seen at lime of estimate that are required to be repaired in order to complete this contract,will be completed at$ '� perm our(MAN HOUR). , WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in material and workmanship fora period of%_7 G-(:ZIlowing completion and shall comply with the requirements of this Agreement.In the event any defect in workmanship or materials,or damage caused by the Contractor,his subcontaaactors,employees or agents,is discovered within one year after completion of any job,including clean up,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied,repaired,or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor-complete in accordance with above specifications,for ItU4 sum o dollars($ 1'7 Payment to be made as follows: All guarantees on all products from manufacturer. r Clean Job Site And Remove All Job Trash. ' %($ )upon signing Contract ADD PERMIT COST IF NEEDED-WE PULL PERMIT. ($ )upon completion of Notice: agreement for h me improvement contracting work shall require a down pe �ent(advan de sit)of more than one-third of the total contract ($ )upon completion of \price or `t total amo t f fit eposils or payments which the contractor must make,ih Ivance,to or r andyor otherwise obtain delivery of special order % ($ )shall be made forewith upon materials d equip e ,w ichever amou t is realer. completion of work under this contract. Note:This proposal may be 61hdrawn by us it not accepted within days. } Aur tine g. tur Acceptance of Proposal I have read both sides of this document and ccg'pt h pr as,specifications and conditions stated.I understand that upon signing,this proposal becomes a binding contract.You are authorized t do fhe rk .specified. Payment will be made as outlined above. You,the Buyer,may cancel this transaction at any time pr r t id fight of the third business day after the date of this transaction.Cancellation must be done in alai ng. D SIGN THIS CONTRACT IFTHE E .RE ANY BLANK SPACES. / q�((/�(7�J'� Signature {�'� (,1, Date Signature - Date r IMPORTANT INFORMATION ON BACK 110- The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: LEN GIBELY CONTRACTING Address:23 R WINTER STREET City/State/Zip:PEABODY, MA 01960 Phone#:978-531-8234 Are you an employer?Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 10 employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑ Manufacturing no employees. [No workers'comp.insurance required]* 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp. insurance req.] 12.❑✓ Other CONTRACTING *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:AIM MUTUAL INSURANCE COMPANY Insurer's Address:27 Buffum Street City/State/Zip: Salem, MA 01970 Policy#or Self-ins.Lic.#VWC10060109792019A Expiration Date:8/3/20 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 certify,under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: go ` �? Phone#:978-531-8234 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia A�O® DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE. 07/1612019 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 terns 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(s). PRODUCER NANCT ME Marianne Ho sradt CROSS INSURANCE-WAKEFIELD INC PHONE 781 9141000 F"�N,; E-MAIL ADDRESS: mhoysradt@tgacross.COm 401 EDGEWATER,PLACE STE 220 INSURERS AFFORDING COVERAGE NAIL# WAKEFIELD MA 01880 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B LEN GIBELY CONTRACTING COMPANY INC INSURERC: INSURER D: 23 WINTER STREET REAR INSURERE: PEABODY MA 019605941 INSURERF: COVERAGES CERTIFICATE NUMBER: 426517 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: INSR ADOL SUBR - LTR TYPE OF INSURANCE POLICY EFF POLICY EXP POLICY NUMBER MMIDD MIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE. $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence). $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO- JECT LOG -PRODUCTS-COMP/OP AGG $. OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED .. - AUTOS AUTOS .N/A BODILY INJURY(Per.accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS er accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ RED XCESS LIAR CLAIMS-MADE N/A AGGREGATE $ I I RETENTION$ - $ WORKERS COMPENSATION PER OTH AND'EMPLOYERS'LIABILITY YIN X'I STATUTE ER ANYPROPRIETORlPARTNER/EXECUTIVE E.L EACH ACCIDENT $ SOO;000 A OFFICER/MEMBEREXCLUDED? WA NSA WA. VWC10060109792019A 08/03/2019 .08/03/2020 - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yyes,describe under DESCRIPTION OF OPERATIONS below I EL DISEASE-POLICY LIMIT .$ 500,000 NIA DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,Additional Remarks Schedule,may be attached if more space is required) 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 ceitificate.of insurance shows the policy in force on the date that this certificate 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 Search tool at www.mass.govAwd/workers-mmpensationrinvestigations/. 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. AUTHORIZEDREPRESENTATIVE C r �Y L,-, Daniel M.Cr4y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved: ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD DATE P M 13NYM CERTIFICATE OF LIABILITY INSURANCE 01/ 19 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 have..ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statemerrt on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME:ACT Stephen Gill Cross Insurance-Wakefield PHONE p�; (781)91-1000 F (781}22457T7 .401 Edgewater Place Suite 220 kAMIL ADDRESS: sglil@sennottinsurance.cem INSURER(S):AFFORDING COVERAGE NAIL S Wakefield MA 01880 INSURER A: United National Insurance Co. 13064 INSURED mSURER s. Safety lndemn)ty 33618 Len Giliely Contracting Co.,Inc. INSURER'C: 23R Winter Street INSURER D INSURER E; Peabody MA 01960 INSURER.F COVERAGES CERTIFICATE NUMBER: 19-20 Master 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. LTR TYPE OF INSD X. POUCYNUMBER WDD NllD P U?Arrs x comurRCdAL GENERAL UABIIM EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE II OCCUR 10.000 PREMISES Eaoocunence $ .. MED-EXP Any.one person) $ 5,000 A L7221167-A 01/29/2019 01/29/2020 PERSONAL aADVINJURY $ 1,000.000 MGENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,ODO;000 POLICY R�7 Lc PRODUCTS-COMP/OPAGG $ 2.000.000. OTHER: I $ AUTOMOBILE LIABILITY - .. . .COMBINED LIMIT MIT $ 1,,000,000 EaaiaSdent ANY AUTO BODILY INJURY(Per person) $ B OWNED x SCHEDULED 6221693. 01/29/2019 01/2W2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED x NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LJAS OCCUR EACH OCCURRENCE $ EXCESS UAB HCLAIMS-MADE AGGREGATE $ DEB I I RETENTION.$ $ WORKERS COMPENSATION i PER OTH-. AND EMPLOYERS'LJABILnY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $- OFFICERIMEMBER EXCLUDED? ❑ N I A .(Mandatory in NH) E.L DISEASE-.EAEMPLOYEE $ If yes,desmbe under DESCRIPTION OF OPERATIONS below _.. _ EL:DISEASE-POLICY LIMIT $. DESCRIPnON OF OPERATIONS ILOCATIONS/VEHICLES(ACORD:101,Additional Remarks Schedule,may be attached B more space Is required) 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. AUTHORIZED REPRESENTATIVE - ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD,25(2016M03) The ACORD name and logo are registered marks of ACORD • . Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards CS-0941549 Expires:03/08/2020 BRIAN d DOBBINS Commissioner r'%/rP`�aittit�rrff�ct/f�a�'(?:lla:�.:ic�fc�Ptl� � Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Comoration before the expiration date. If found return to: Reaistratfon Expiration Office of Consumer Affairsand Business Regulation t. 1008f 1._ D6/22/2020 One Ashburton Place-Suite 1301 LEN GIBELY CONTRACTING COMPANY,INC. Boston,MA 02108 BRIAN J.DOBBINS ; - 23R WINTER STREET U� PEABODY,MA o1960 Undersecretary Not valid 164thout signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards CS-094763 Expires: 05/1412020 THOMAS R DOBBINS Commissioner �-177P l��'RIl1JllGYtfiQ{f��t(s��11111111IYJffiR�t✓" Office of Consumer Affairs ti<Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suoolement Card before the expiration date. If found return to: Rwistration Expiration Office of Consumer Affairs and Business Regulation 100811- 06/22(2020 One Ashburton Place-Suite 1301 LEN GIBELY CONTRACTING COMPANY,INC. Boston,MA 02108 THOMAS DOBBINS 23R WINTER STREET PEABODY,MA 019W. Not valid without signature Undersecretary