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50 FREEDOM HOLLOW - BUILDING INSPECTION (3) The Commonwealth of Massachuset s 10NA! SERyi ES CITY OF Board of Building Regulations and Standards SALENI I. Massachusetts State Building Code, 731wap 18 Ay evised.Llor 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish as One-or Two-Family Dtvel ing This Section For Official Use Only Building Permit Number: Date Appl" d: Building 011icidl(Print Name). Signature- ate SECTION G SITE INFORNIATION I.I Property Address: 1.2 Assessors�Nlap&Parcel Numbers SD �( p-o "oLLow 20 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 R) Frontage(11) 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❑ SECTION2. PROPERTY OWNERSHIP`` 2.1 Owneru of Record: 12ti,i h �e wA2 Z C con 11AA jT�me(Print) City,S L e,Zip 50FA. 0-ebor 1 6211 S9Lr 1 9y4 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Buildin Owner-Occupie Repairs(s Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify Brief Description of Proposed Work : ,✓ UJFv Eh U4 LAJ, �r--vt SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ ptJ 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 3. Electrical S ❑Total Project Casty(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Total:111 Fees: $ Suppression) Check No, Check Amount: Cash Amount:_ 6. Total Project Cost: Ss80 0 & 0 ❑Paid in Full ❑Outstanding Balance Due: COA-it zZ r r SECTIONS: CONSTRUCTION SERVICES 5.1 CCmtstruction Supervisor License(CSC)' Q y �L 3 _ L-I— ) 1 , 51 tra Vic!,b o:g a License Number Expiration Date Name of CS17flolder. fz List CSL'rype(seebelow) io. ;md Street 'type Description A bd�� t 9 / U Unrestricted2 Fr(Buildings u toing w. It.) /-) 0 R Restricted IR:2 Family Dwelling Cayfrown,State,ZIP M Masot RC Rooting Covering WS Window and Siding S I Solid Fuel Burning Appliances 9-7 1 Insulation Telephone Email addr D Demolitio essn 5.2 Registered Home Improvement/Contractor(HIC) 'Q Q ` HIC Registration Number Expiration Date KIC Cump:my Nnnte or HIC Registrant Nnme No Street Email address C2.,, h� o� eMq Iarba Cit /Town,State,ZIP 'rele hone SECTION 6: WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(MIG.L.c.,152.g 2SC(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 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;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. L. R- 4- i � ,Print Owner's u aliorized Agee � ame(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 IM.G.L.c. 142A.Other important information on the HIC Program can be found at wVwW.mass.gov'oca Information on the Construction Supervisor License can be found at www.n:asss�,ov:'dps 2. When substantial work is planned,provide the information below: 'total floor area(sq. R.) (including garage, Finished basementlattics,decks or porch) Gross living area(sq. it.) Flabitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type orlieating system Number of decks/porches Type ofcooling system Enclosed Open 1. Total Project Square Footage"may be substituted for"Total Project Cost" 1 1 The Commor(weahh 60fassachusem Department oflndustria' 1ccidents rke of Investigations, I Congress'Stre4 Suite I00 Boston,MA 02114-2017 wwlumassgoy/din Workers',Compensation Insurance Affidavit.Builders/Contractors/Electrjcians/Plumbers A !leant Informs on Please Pri t'Le ibl Name (Business/OrgaI&ation/lndivjduaj): L:4.�v Cy, 'j,:e L Y, CJ -rJZ.A c Address: , \ �Q i.J ,� , -� >L St- Ci /State/Zi Phone#: . Are you an employer?Check thi'appropriate box. 1.® I am a employer with / o� 4 I am egeneral contractor and I p e'of project:(;equued);' employees (AM and/or part-time).+ have'hiried the sub-contractors fi. .[]New construction. 2.❑ I am a sole proprietor or partner- listed on the attached sheet,. 7• Remodel ship and have no employees Thesesub-contractors'have g : Demolition working for me in any capacity. employees and have workers' [No workers' comp•insurance comp insurance.: 9• ❑ Building addition re9 •) 5 ❑ We are"a corporation and its 10.0 Electrical repairs or additions 3. I am a homeowner doing all work officers bave exercised their 11, Plrmibin m self ❑ S repairs or additions y NO workers comp, right of exemption per MGL 12•❑Roofrepairs msurancerrquved•J?, c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. msurmce required.] •Any applicant that chakt box RI tnuat also fill out.the section below showing they workers'compensation pohcy information. t Homeowners who submit this affidavit radieati5g they are doing all work and than him outside conhactois must submit a new affidavit indicating such. 'Contractors that cheek this box must attached an additional sheet showing the'neme of the sub-comtactots'em state submit a n w not those entities have . employees. if the sub-eoniraetors have employees,they must.provide then workers comp,policy number: r am an employer that Is providing workers compensation Insurance for my information employees. Below Is the potty and job site Insurance Company Name: ,'r fiti v rt/A 4- y&c r b Policy#or Self-ins. Litt # [/(�C [ D O 6 C) I n 4'7 q ,D61 Expiration Date:_ Job Site Address: ac,��_t p 49��#aD ( City/StateMp �C[�p Attach a copy of the workers' rnmpensation poi➢cy declaratioq page shownn the policy LA Failure to'ecure coverage as Q g ( g.. . po Y number and expiration date). 8 required carder Section 25A of MGL c. 152 can lead to.the imposition of crmnnal penalties of a Site up to$1,500.00 and/or one-year,imprisonment, as well as:civil penalties, n 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;DlA for insurance;covemge;verification.,... I do hereby certify under the pains and pepp/ties.of perjury that the information rovlded above:+'true and correct p Q Suture �� P one#: Ojlrcial use ad/y. Do not write m this area,robe 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 in 5.Plumbing inspector 6.Other Contact Person: Phone#: ACORN, CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) 02/06/2014 F>sooucER 978.887.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 16 South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P. 0. Box 457 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC# ir1 1e1) Len GT e y Contracting Co. , Inc. ' INSURENA Catlin Specialty Insurance Co 23R Winter Street INSURERS: Safety Indemnity 33619 Peabody, MA 01960 INSURER C: INSURER D: INSURER E: COVERAGES 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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNSft DD ,TR NSR TYPE OF INSURANCE POLICY NUMBER DATE P605NBEMFD FEVTW DATE OONM LIMITS GENERAL LIABILITY 37003Q214S 01/29/2014 01/29/2015 EACH OCCURRENCE s _ 1,000,000 X COMMERCVLL GENERAL LIAR ILfry PREMISES Ea occurrence $ 100,000 CLAIMS MADE O OCCUR MED EXP(Any one person) $ 5 r OQ A PERSONAL SADV INJURY i 1,000.00 GENERAL AGGREGATE $ 2 QQQ OQ GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $ 2,000,00 POLICY PRO- . JECT LOG AUTOMOBILE LIABILITY 6221693 COM 01 01/29/2014 01/29/2015 ANYAUTO COMBINED SINGLE LIMIT $ (Ea ectAderll) 1,000,000 ALL OWNED AUTOS BODILY INJURY B X SCHEDULED AUTOS ((Per peson) $ X HIRED AUTOS --' X NON-OWNEDAUTOS (Per dent)INJU $ _ (Per eccioene — ----- PROPERTY DAMAGE (Per accident) 5 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANV AUTO OTHER THAN EAACC $ AUTO ONLY: AGG E EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ j OCCUR CLAIMS MADE AGGREGATE $ 5 DEDUCTIBLE ' 5 RETENTION E $ WORKERS COMPENSATION _ AND EMPLOYERS'LWBIUTY YIN TORV L S E ANY PROPRIETORIPARTNER/EXECUTIVF{'� EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED'! U _ (Nandalsoibe urger NH) E.L DISEASE-EA EMPLOYE $ If ee, noq I SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ''roof of insurances. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE / D� Robert Sennott RP c ACORD 25(2009101) 01988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A 08/0i12 � CERTIFICATE OF LIABILITY INSURANCE OA101YYYY) 0810014 Pcertificate RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE D CERTIFICAES NOT TE FOFININSURANCE DY OR OESATIVELY NOT CONSTITUTE A CONTORR ALTER ACT BETWEEN THE ISSUING INSURER(S),RAGE AFFORDED BY THE ENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. 11 SUBROGATION IS WAIVED,subject to te holder conditions ieu of such endorseemeijs)jaicles may require an endorsement. A statement on this certificate does not confer rights to the 01834.001 SenRon InsuranceMain Street ° 1 Ord R°,MA 01983 � INSURED jNwREg A. A.I.M.Mutual Insurance Company 26168 Lan Gibely Contracting Company Inc INSURER R 23 Winter$treat Rear INSURER C Peabody,MA 01$60.6941 T 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 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, �yEXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHIOWN MAY HAVE BEEN REDUCED BY PAIDCLAIMS. lTR TYPE DF INSURANCE I POLICY NUMBER GENERAL LIA&CITY - LIMITS EACH OCCURRENCE $ COI.MERCUL GENERAL UABILRY A�fO RENT $CLAIMSMADE OCCUR MEDEXP An mw( Y Fmson) E PERSONAL a ADV INJURY S GENERAL AGGREGATE $ EML AGGREGATE LIMIT APPLIES PFR. --.--._ PRCOUCTS-COMPYOPAGG S G ICY 0- OC AUTOMOBILE UABIUTY 1 ANY Auro s ALL OVMJFD"DV BODILY INJURY(Per person) S AUTOS N06 BODILY INJURY(PolawdenV f MIRfDAUTOS NON.OVr r— AUTOS G S 3 U MSRELLAUAB OCCUR EACH OCCURRENCE S EXCESS LAB CWMSMADE AGGREGATE S OED RETFMION S wpgNEgS��y�EIJSAi p� U- � i A— AHVGEMOP'LpOYEErRpBR'pLIpAgBI�RY v1Y� X IY IT 0 _ A 9�FI �R1'MEILI�R IXCItlERIF]cECUTIVE^ NIA VWC•,00-g010979-2014A 6i3I2Q14 g/3J2g16 E.L.EACH ACCIDENT $_ 600,000.00 IMandalery In NH) DED'1 u ffrrY2L !bbaa �I¢� E.LOISEASE-EAEMFLOYEE $ 500,000.00 okY.. IGN�1F pFERATIONS Eebw E.L.DISEASE-POLICY LIMIT $ 600,000.00 DESCRIPTIONOFOPERATIONS/LOCATIONSIVEHICLES(Anech ACORD011,Addhlonw Remarks Sclwdale,amWs specs Ism wree) 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 ACORD 26 2010)06 1988.2010 ACORD CORPORATION.All rights reserved, l 1 The ACORD name and logo are registered marks of ACORD LIBELY CONTRACTING CO., INC.ENfi r Page Np. _Lot _Pages 23R Winter Street C_O.)Jz 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.coin specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered SJbmiuea �,J rA2 with the Commonwealth of Massachusetts.Inquiries To: 12V� 75 1 / Z about registration and status should be made to the / / J Director, Home Improvement Contract Registration, 5 b I—ac 'CM `-j O// 0 W oL'O 1 One Ashburton Place,Room 1301, Boston,MA 02108 (617) 727-8598. Owners who secure their own Sg 1'7 4 0/ /j rzo construction related permits or deal with unregistered v / 1 contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. FMpNE ad es.'anemoN Ne. /rl, - �� S Y9 � �z,Z�� MA.REG.100811 wows NAMs,It ea �VVV sea ioenTlo Br uu�A K1 Sat b As' �a vc? we nordby summt spacltcanons om azrmums mr work to be performed and m tea is to be proud. e fq T 12 0 L'6 /D 04 W/who L,tr -6 v/ v/�o 1 NS'�14-u /D sltn, l,f�,l //YJL Gr J-1 ie,,6rLS TWIT _ / SJS�ES 1NSuI _. e4 4r / x Al! t pc2M- 7- 11 © 12 COIYOo WOHI(CIUr w+n II rk Or dul4rAno vtrrls IltirO tlay l.,,Owiag Ind signing of tills Agmement,unlawe specilietl M1erein wr fA' iel b O,M un ar vdow rrr fr/rwfr((( (Okla).Barring aolay cvused dy cveumelancvs beyond Convectors conll0l,Nv walk will oe completed bo lJ t.T IaT to(�nar hereby do wd noa aCAnowleJ slnal the scnodul ng tlklos 0,vapY Oalinalo add I'm such tlelbyc lM1¢Iera notkWitlkble Gymeconrrnclor snailnotbecn darednsviolulNnsof lni graomknl. HxYJOn rot or<mdli dsaen al lime ol¢sNiGle ttul are rrywrp]lO oo rcpairea in whet tO rdnplJ,a I'.—"adY.willbe"wheled al5 _ppr man nourtMANYOUR) WARRANTY and sllvll COm vriln lna COnt beerI nnls dial lna work lurnisliotl nkreunuer shall bd tree liom dalCc151n material antl worAn,dn'u hip fora periptl of �J��(following completion py mo recuii mo e.01 In Ad,oe morl.In the ovdll kny tletecl is workmknsnip or mon.he.or damvga causou by m¢Contractor,me s ecol/ffi[lOr9,emplOyxes o�agents,is discovamd wkhin ucndvmu"a, �SOC11 Itlolact I nnmo�ol Vials Oawo knOnehl hadtoe¢tor ired allow shell uNvo whipro Iactlron pddorm ad i n conectioniiwilh the vyr¢aLLupk�wodketl,repalNd.mreplaCod. V going w ham We y Propose hereby to furnish m Ix.._.com in accordance with above specifications,for the sum of. yn — dollars($'52L y ) Pa tent to sod es loll w e: C Remove Oil tram. All gup shadow on all produds from thermal mr. D�lue In,Conked Add permit co911 neetletlwe pull permit. Jpkn completion o1 Off✓/ — N lice. No Breemonl to me Irnpr lent Immledln0 work shall rOquire o d n paym nI(mil a pan of t e than one,hird of far mtm co ind,I lupon eomplotlOn of on Or the far amount t Il tlkppeis payments wblch lne rouetter, 1 ad an a,to O e outer otn e a obtain dell very of a viral shall be.do herewith up j on mat -else equipmen, rnevel q I godand tand,lion of work under his cpie 1. du.tii':pioWsal mLLy oo wilndkxn py ua ll not ed[uplotl vrldn days. 'A,khorra el aw Acceptance of Proposal I have read both sides of this document and a eel h fie specifications and conoifions stated.I understand that upon signing,this proposal becomes a binding contract.You are authorized to isthe s peofis J. Payment will be made as outlined above. You,the Buyer,may cancel this transaction at any time pri r to Idht of the third business day after the date of this transaction.Cancellation must be done in writi g. R E ANY BLANK SPACES. � t 4 1' - T DO NOT SIGN THISONTRA IMPORTANT INFOFMATION ON BACK fill Massachusetts - Department of Public Safety Board of Building Regulations and Standards t mstrurtiun $w1wrl I'm License: CS-094763 THOMAS[t. DOBBIN 19 Cedar Hill Dri M019 ` Danvers A 01923 r Expiration Commissioner 05114/2016 '�/�r �rm urnirrora�/�r�n,�(luJor�riJr//J . • ... . , ,\ 01lice of Consumer Affairs& Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: 100811 Type: Office of Consumer Affairs and Business Regulation fxplratiow 6123/2016 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 LEN GIBELY CONTRACTING CO., INC. Brian Dobbins -' - 23 R WINTER ST. � �,__ a— ___ ..___.__._._.._7utsignisture _._._._._.._.._'_..___._ PEABODY, MA 01960 Undersecretary Not valid wit r I Marcia Kirkpatrick From: Thomas St. Pierre Sent: Thursday, September 18, 2014 2:44 PM To: Marcia Kirkpatrick Subject: FW: Unit#201, 50 Freedom Hollow, Salem MA fyi From: Cyndy Anselmo [mailto:cyndyCalecpllc.net] Sent: Thursday, September 18, 2014 12:16 PM To: Thomas St. Pierre Subject: Unit #201, 50 Freedom Hollow, Salem MA Hi Tom Please be advised that the owners of Unit#201 at 50 Freedom Hollow,Salem, have received approval from the Board of Trustees to install new windows in their unit, which work is being done by Len Gibely Contracting Co., Inc. of Peabody. Thanks Cyndy Cyndy Anselmo East Coast Properties, LLC Real Estate and Property Management 400 Highland Avenue Suite 11 Salem,MA 01970 P: 978-741-2003 F: 978-745-9684 cyndy(4�)ecpllc.net - 1