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9 ABBOTT ST - BPA-10-876 ROOF a The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY �J Massachusetts State Building Code, 780 CMR, Th edition OF SALEM r9 Revived Janaary Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008 One-or Two-Family Dwelling r� This Section For Official Use Only Building Permit Number: Date Applied: y�[�" 1 V(� Signature: ' \ ' / 00 Building Commissioner/Inspecto#Uf Buildings Date SECTION I: SITE INFORMATION 1.1 QPro=ddress: 1.2 Assessors Map& Parcel Numbers 1.1 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 It) Frontage(tt) 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? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownert of Record: 9 Ab60 -iz-v S-c Name(Prim) Address for Service: 9-78 `2 `lS 4z.S &2 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Ow dRener-Occupiepairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.El Number of Units Z. Other ❑ Specify: Brief Description of Proposed Work': t SECTION J: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building S I. Building Permit Fee: S Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees: S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S l{ '^ S-- 0Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) O q (.i—1 c,3 License Number Expiration Date Name ol'CSL- I(older List CSL"type(see below) '�1 -i 4 M S-T- Ese )x-,�r'y t Description Address U Unrestricted(up to 35.000 Cu. Ft. R Restricted 1&2 Family Dwelling Sign ore llehy M Mason Only 5 d S 3 3 RC Residential Rooting Covering 1elephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 R If)e Home m rovetneot Contractor(HIC) D © g 1 �L.p..� �rP6 L(� (r HIC Company Name or HIC Registr t Nam Registration Number N 4YMAt�� � — p Add r�Q��-� it 823y Expiration Date Signature '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...........O 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION 1 L`P,✓ Q t ,fj 1- r G,-t, r,as Owner orIFuthorized Agent reby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Rwrier o Authorized A ent Dare Si ncd under the ams an nalties of r'u 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 Mol have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.115,respectively. 2 When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq. FL) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halt/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 600 Washington Street Boston, MA 02111 u,p www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 1 7 1 lN! Name(Business/Organiration/Individual): L Q ✓r 1 .Do L1( t r� 1 e. A e' /'1 Address: ( Lk 9 A t S< City/State/Zip: Phone #: g 9 9 S 3 l 8 a 3 [2. you an employer? Check the appropriate boa: Type of project(required): I am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling I am a sole proprietor or partner- These sub-contractors have g, ❑ Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. ❑ Building addition comp. insurance? [No workers' comp. insurance 10. Electrical re airs or additions required.] 5. ❑ We are a corporation and its ❑ p 3.❑ I am a homeowner doing all work officers have exercised their 11.❑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 I3 ❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homwwners who submit this affidavit indicating they are doing all work and then him outside contractors most submit a new affidavit indicating such. tCommictors that check this box most attached an additional sheet showing the time 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: 1-7 7 M 11 L A� 1 i S C r) — Policy#or Self-ins.Lic.#: 1(�(0 1 () 9 ? 9 D l O q Expiration Date: 4 Job Site Address: .k e, r i <;1'- City/State/Zip: Q Lem E:21- (47 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 ' a Date S- Z- l0 Phone#: 3 F[(t' only. Do not write in this area, to be completed by city o=5Plumbing n: Permit/Lihority(circle one):Health 2. Building Department 3. City/Town Clerk g Inspectorrson: ISS<-EDATE 07/31/1009 RODUCER 'di ald F Scnnott Inswancc T M CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE geancy Inc DOES NOT AMEND.EXTEND OR ALTER THE COVEFLAGE AFFORDED BY THE - POLICIES BELOW. I6 South Main Street up+ficl(L M.A 01983 CONTANIES AFFORDENG COVERAGE usLIRED —— --- =n Gllxly ContracdnR Company lnc COMPANY A ALNC Mutual Insurance Co THIS IS 70 CERTIFY'THAT THE POUCBiS OF WSURANCE LISTED HELOIV HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER10D PIDICATID.N07WITHSTAWING ANY REQII7AEWEIIT,TERM OR CONDCFION OF ANY CONTR.gCi OR OTHERDOCUMENT WITH RESPECT TC q'HICH THIS CERTIFICATE MAY BE ISSUED OR\1.41'PERTAPI,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUHIECT TO ALL TllC TERMS,EXCLUSIONS.AHD COW IT[ONS OF SUCH POWCtCS. LU11TS SHOIVN MAY Ii.4VE BEEN REDUCED BY PAID CLAMIS. CO TY9[OF LVR'RAAC[ POUR[SFERIv[ POUR ELPIPATIDM L5A 1'OLIR IIVMBFR pA)Z MY/D[YT\l C.ST[IIAMIDLVTYI LIMITS L[K[GAL LIA9ILITY G61[FAL wGGA!GATE iP.ODOLISygypPl AL:L. O L'I;NML".1::AL GLIILYJL tJAtlILIL1 I��CLAlIAS MAC:OcCR'S PC[:ip'IALG AUV IIIIUSY L4C!UR"V'Q i1Ki G W ILLS':i CO!4:ARC3'S TILT fIY2 DAYACE Imo- 11[['(:SFII':[liniaar l.r�.x;• aVl WI V bILE LIAtlILIiI' COMOIIIEII'INf.LC IIMR ! NIY AVIL` f LOW WAy?Cki =0LILV[NJUh,f X.EDL'UD FU705 I'N Pniio1 Hle_C'AVTOS II DCV CWIJWIMOS ECNL\'1IU01,1' i;�cN.ACE:uec5tr an xNzul — FEGFUn'DM4 M @CE[5 LIABILITY' LACY.OCCLRATIIC.. �UM¢i11u IJWI AGGRECLE [[n1All UUDPSLA U'ORISRS CODBENSATION A.YD LIADIL[TA' ATLLMTTS STATE THEY + GTIPLOST.AS LLA IIC ip.VIFJCIn:J —�i AI HCI W!I�II CNL: EL EACH ACCIDENT sort(too 3I OS/0 6010979012009 03/3010 EL DISEASE'POLICTLDVT 300,000 _ EL DISEASE-EACH 500,000 i I I - .�, HOULD M'Y OF THE ABOVE➢ESCRLBED POUCEES BE CAVCELLID BEFORE THE ECPRAT[ONDATE F,THE ISSLR.'G COMPANY'WILL ENDEAVOR TO LLAIL HO AW TEVNOTICE TO THE CERT CATE OLDERN NED TO THE LEFT,BUT FAILURE TO GLUL SUCH NOTICE SHALL BLpOSE NO OBLIGATION R LIABILITY OF ANS'KIND UPON TILE COV(pANY.ITS AGENTS OR RDRESFNTATTLU 0 WHOM IT NIAY CONCERN ' i VTHORI].ED RCPRESENT:LTIVE 6169 f - N . Pages Page No. �_oi�._ LEN GIBELY CONTRACTING CO., INC. 149 Main Street 20 571 PROPOSAL PEABODY, MASSACHUSETTS 01960 All home Improvement contractors and subcontractors engaged In home Improvement contracting, unless (978)531-8234 specifically exempt from registration by Provisions of FAX(978)531-9304 Chapter 142A of the general laws, must be registered Ed with the Commonwealth of Massachusetts. Inquiries To: c--/y)_t � _LV_ (J�5-'✓-r✓- -- about registration antl status should be made to the �/ Director, Home Improvement Contract Registration, ,t / b b p�' �T _ -__._ One Ashburton Place, Room 1301, Boston, MA 02108 rL -- (677) 727-8598. Owners who severe their own construction related Permits or deal with unregistered contractors will be excluded from the Guaranty Fund D .7� Provision of MGL or 142A. PHONE MTE REGISTRATION NO. MA REG. 100811 I��8 -?:l4s _ /o -ILA JOa LOCATION JOB NAMEMO. 1�11 ��NO� `/!/ 1 We hereby submit specillcalmns antl as,names Tor work to be perormed antl melenal bud t� _E-_ _6_, v`I ©� n_�_�--- T � ^ �/ N Li Fnz _ la.'-(� 'l'J�-.VC1Y I ! T/d'� .i(�N`l�l�-�'.L..�^�J 2.0 f.]� ✓ I..r1,G0 �L c. n2 t/vv i✓L �-L��•�,�/�YF-�Lc��/�1��'JS�p_'J��ci_- ._<6'�'7-I__ i�[ .� � �UJsf-- 1 a_cp-1 raSCc �<Con,nstruction related permits. r �- -1- WORN SCHEDULE greehe Owner hereby Contractor II not begin the o kle).aerr the ng delayrcaused bytcirclums circumstances beyond d contractors c Atml,the nw kl II reached o plat 0 by rt C a t II begin Ibe work...' About — a a kno on gas antl agrees t e scheduling dales are approurrate and that such delays that are not avoltlable by the convector shall net be cons or o this Agreement. WARRANTY lollowin completion and shall comply with The Convector warrants that lha work IurnisM1ed hereunder shalt be tree from detects In material and workmanship for I,period of 9 coo requirements of this Agreement.In the event any defect in workmanship or materials,or tlamagecaused by the convenor,M1is subconva rs,aetloyeesoragents,isdiscoveretlwithin oo hyear fter compldelec1 any job, including clean sn up, ilP he IDe�oragoin95warmnt eiftall,at lA shall sos a rry.any inspection perense forthwith formed in%onnactirrel oo with the a9aed upon work�'reDairetl.or rePlace4 - damage or suche We PrOpose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: ' p dollars ism Payment to be made as follows: / d �� COOJ 3 ra C C %($j 4 z u��ring coo mi/9 CNeNmeaotAcoulowtmr Desigrwwd lira is4en %(g��L)uPon completion of ���� seem Address upon completio - ciryrsute Ph/ shall b title forewith upon Phone _ Foderm ID No. $ )completion of work under this contract. Notice: No agreement for home improvement contracting work shall require a down Name of Susan,ay payment(advance deposit)Of more than one-third of the total contract price or Me /\F' total amount of all deposits or payments which the contractor must make,in advance, lwmorizad spnawre to order and/or anthems.obtain delivery of special order materials and equipment. Note:This proposal may as wimdevo,talus it-1 awemad afor day,. h'LE (11--ter ruponce of Proposal have read both sides of this document and accept the prices,specifications and conditions stated. I understand ning,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You,the of yer,thi transact el this transaction n att any time t be done prior in ritlrl9 idnight of the third business day after DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. /� �J 1 1� sigaewre Dam sigaawre Dale'J•�_.J-I-- IMPORTANT INFORMATION ON BACK I • BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 094763 Birthdate: 05/14/1943 Expires: 0 5/1 412 01 0 Tr. no: 94763 i • Restricted: 00 THOMAS R DOBBINS 19 CEDAR HILL DRIVE DANVERS, MA 01923 Commissioner ✓die iiommosruie¢(d �"yam✓rru�a�huaslla Board of Building Regulations and Standards HOME IMP ROVEMENTCONTRACTOR Registratiorj}, 100811 Expiration 6/P312010 Tr# 268971 ;Type: Priv r ate Corporation r P.d LEN GIBELY CONTRACTINGCO.,'INC. Brian Dobbins ` f 149 Main Street Peabody, MA 01960 Administrator