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9 LOCUST STREET - BPA 10-670 REROOF �1-7 a The Commonwealth of Massachusetts 1 Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, T°edition OF SALEM Revised Juenury (�\\v Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 2008 \+ One-or Two-Family Dwelling This Sectip0or Official Use Only / Building Permit Number: I Date Ap",ie : Signature: I ` L V Building Commissio ect I spor of Bull Tgs t W SECTION 1:SI E N RMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers C Ll 'r- 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 11) Frontage(0) 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[3 Private❑ Check if es❑ y SECTION 2: PROPERTY OWNERSHIP' 2.1 Ow ' f Recor P E Dili cam_. 9 L o e vs S i Name(Print) Address for Service: 9-) 2 %A23 1 9 Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupie Repairs(s) Alleration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work-: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OHtcial Use Only Labor and Materials 1. Building S 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing 5 2. Other Fees: 5 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Total All Fees:S r6T( ression Check No. _Check Amount: Cash Amount:_ tal Project Cost: 5 5 t LA o © ° ❑Paid in Full ❑Outstanding Balance Due: i SECTION 3: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) D 9� `1 l03 5--14- ( D License Number Expiration Date Name ol'C'SL-IWider i�.Ar J ��.f nv�14�nY List C'SL"type(see below) .4JJre rvoc Description U I Unrestricted(up to 35.000 Cu.Ft. R Restricted 1&2 Family Dwelling 5ignaram M Masonry Onl J S , 8 Z 3 RC Residential Rootin Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 RegIsteredHo elmprovemeg(Contractor(HIC) —/ © g L...�P r b o177 C c�a✓'T� 111C Company Name r lIIC Registrant Name Registration Number ? ti9 ] 4 (.o ��'r P,>o bC,-y /�q--2 3- t P Expiration Date Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.1 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 71b:/O�WNERt OR AUTHORIZED AGENT DECLARATION Cr L-. eI- r C_ar2.T— ,as Owner o uthorized A ent ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. T�h�.-ter Print Name Signature ofOwner o ut ooze uen Date Signed under the pains and penalties of '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 ram(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 IO.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basement/anics,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" ' r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name(Business/Organ mtiodindividual): L Q N C=l J2,0 L1( C 1 Cp n i Q 4P 1 vv l+ Address: I Lk Cl H A f ,, Si- City/State/Zip: RE q jLIA Q I Phone#: g 9 g 53 l 8 a 3 Are you an employer?Check the appropriate boa: Type of project(required): . am a general contractor and I 1.�I am a employer with �'�_ 4 ❑ I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance Comp•insuranc;0 required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 L❑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' 13.0 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 subcontractors 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 polity and job site information. Insurance Company Name: /A N LIT'U AL r--4/ Ca — Policy#or Self-ins..Lic Expiration Dater L� Job Site Address: `I Lr3 Ctr Cam- Sr City/State/Zip: SALz .y,MA_D ( `n0 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 ofperjury that the information provided above is true and correct Sienature• k ��� Date: Phone#: S ( Z F.oard e only. Do not write in this area, to be completed by city or town officiaL own: Permit/License# uthority(circle one): of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector erson: Phone#: u3MAAA " ISS�B D.47E 07/3L?009 • RODi1cER - � .. 'divard F Sennotl In tmce THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE qgI Inc DOES NOT AMEND.EVEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 16 South Main Street Op..riel(L M.A 019S3 CONIPAI�S AFFORDING COVERAGE usuRED — -- 'n Glbely Contracting Company Inc - cOmPANY A ALM.Mutual Insurance Co w � E^ THIS IS TO CEATIFI'TH.gT THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANYISSUED REQUBIEMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WrTH RESPECT 70 L1'F{ICFI TI'BS CERTIFICATE MAY BE 1SSUID OR ALkY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBIECT TO ALL TIM TERMS,E%CLUSIONS.ItND CONDITIONS OF SUCH POLICIES,LUIITS SHOWN MAY I'IAVE BEEN REDUCED BY PAID CLAA'IS. CO nT1 Or ISLlOUNC[ POLICVETTE IPE POLIh'ELTIPdrIOb Llx roan NUMBER LATE INN/OExn'1 DAn11AMID1YTY1 LlNlri �L\IaAL LIABILITY 0EDEFx AcoA'liArz O LI'-L''N�NL.C'J.L Gf11LYAL LlAb1UT1 9P.OLl L'[}CV YFCI AGIi. IQ I�CL'JIAe MAC[QLCNR ➢Ex5(x0.L E AOV IIUYRY _J 0 W oz'.a 3 CONTUMIX S➢ROT. !FR UCCV:Jt LIK: — MAX DAMAC[Up AI IICD[:SFII.[I.'.niat.P-xi Aui W W BILE LIABIIIi\' COM9111ED'INlnr LINK ALL GWIS 4Y?(ki KXILY IIOVB I' I V.KC.L'40 AVTOE l%n Taol UCII.C4IELLITJ' ECDiII'ItUt'P.\' j I�cxucl_IAeeGT nM�„e,H i56itF.n'DAl1AT pCcs'LUB(LITY LACK Occm Ur! 'JROIPILLR pill Accalua �CriCF.P.uII uNYTSL'.i.rU1W "VORKY-M COa@ENSATION AND El@LOS2RS LLxLILITY ATLGITTS STATE T'HER IIC PR xYsnov x1A ,� APV[ESCncun'+C EL EACR ACCIDENT SO0,000 :1lIq L9S A1:f i I, n Ex" 6011197901_009 Og/03l1009 OV03R010 EL DISEASE-POLICS"LDtTr 500,000 -J EL DISEASE-EACH 500,000 I' HOULD'u"OF THE ABOVE DESCRIBED POLICIES BECANCFL I m BEFORE THE E PMATION DATE F,TEE ISSLR73 COA@AN1'1V LL ENDEIVOR TO a1A0,10 AWTTEN NOTICE TO THE CERrMCATE OLDER VANED TO THE LEFT,BUr FAnDRE TO DLUL SUCH NOnCE SHALL POSE NO OBLIGATION R LLIBRITY OFANY KIND UPON TIE CO\@ANY.RS a\OEM'OR P.FYRESENTArrM, IO WHOM IT MAY CONCERN _ t IrruORI2En REPRESENTATIVE 6169 wit Ne SCV5T4r.T-fine"ny l"ree ,bW ebtl4'Yc Me95.rnc.Wu.wr°yn,xrVOYse wen^u°r.c°ie � m,r � Page No. / of�PaOes C {, r LEN GIBELY CONTRACTING CO., INC. PROPOSAL C j J J 149 Main Street PEABODY,MASSACHUSETTS 01960 A0 home Improvement contractors and subcontractors L engaged in home improvement contracting, unless (978) 531-8234 specifically exempt from registration by Provisions of t Chapter 142A of the general laws, must be registered c FAX(978)53304 with the Commonwealth of Massachusetts. Inquiries k Submitted Nile n( �_�__ ./_. C�D about registration and status should be made to the 0 To: l' I Director, Home Improvement Contract Registration, �] /- ,� S-� One Ashburton Place, Room 1301, Boston, MA 02108 7 bcC's (617) 727-8598. Owners who secure their own Sa(tM n^fj^ 0 ig76 construction related permits or with unregistered I l'' •l contractors will be excluded fromm the the Guaranty Fund I Provision of MGL C.142A. GATE McMSTRATION NO. MA REG. 100811 e1�E78�4z3 hg9 / JOB LOCATION > slimal¢ for work to bap ormetl and materials to be used Weher/,, wee�atfoiWm�@ Q Q I(�fCn� 14-G.U-r PS 0 n-1 ( `f'� � 71� ( - �- ^^S /CQ y lk hCl�Gc� 0� LO Y m�� I A � / el v 1¢ y#7Qf� F 7�/ trait aI f 0.Il/a c*r �rr */V ' ''" /L �1�4 llYfM/�YJ GIW - LSc aC v �c/ r l let 1 / MOua1 r all 42 /ZI /-//."f � /� �' O Construction elated rtjO evr� /� („ J ,lh�l C �" f I �875,- A)J>�� ' M III begin Ihn work oe or WORK SCHEDUJ6 ' add 1e7.Tne Owner nmeby ComraeSC EO JU a in '/,;,'or Ortler ha "shiers before the In a tlay foil behind signing oI V,is Agreement,unless specifietl herein wr r greemenl. ab0u1 r al.Baiting tlalay couso0 by Ci¢umstan<as beyontl Gonlladoie control,lne work will ba Compleletl by co acknowlotlgos old agr as Ina1100 scM1etluli11 tlales are r pproximalo and Ibal sucn delays IM1aI era not avoidable by IM1e conlracl0!sit 1 ne<% ayingacOmple�n anOnsball contplY with WARRANTY Tne Conlmdor wartants @al Pe work lulnisM1atl nereuntle!snail be Lee Irom aelecre In malo,ial and wmxmanshe for a periotl rs tllamealea wilnm ame Ima,a,"places. the requibase,isnls OI antf�l Agreement.In Ina even)any select in w0lkmensniD or materials,or damage causatl by Ina Conlradoq his sunconlraclors.eaVlOco s Or a s, suconeh damage open defeclln ma etlals otlln manslpilp�The lo,atismghe Contractor swa r.hallbr.lp shall s earn survive any inspection pedormetl train connec0oo with the agreetl cousin d rape We Propose hereby to furnish material and labor—complete in accordance with above specifications,dollars(fo the Payment to be made as follows'. ?`�D ////////..j//g' 6 -,is )upon signing Contract: r name" o1r119"a'vh 114sham %l5 )upon cempletlOn ol/ slmet Ammss fg ,upon bempde fore Coime — l shall be made forewilh upon prone EeaeralZ �°($ complolion of work under this contract. _ puts, ,(adverse deposrbhof met.a than one third atlthe total contract price or�he shall j A r ea Silersure ,are amount of all deposits to payments which the contractor must make,in advance, u ° to order antllol otherwise obtain delivery of papers,order materials antl equipment, me:Traprepasens,tewiNemwn OY usll not av'cepletl willrin unders and Acceptance of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated.outlined above. that Youpthe Buyers froposal becomes a binding may cancel this transaction at any timeou are edtiooto midnighwork as specified lof the third business day yment will be Made as after the date of is transaction.no NOT SIGN THIS CONTRACT IF THERE ARon must be done in E ANY BLANK SPACES. LzZZ 7J�IC -- Hera nawre IMPORTANT NFOHMAIION ON BACK r $ I ✓/tE fJ/OflLlli6lLl[KICG��. (1� :L''QSX[C/LFnw.ctp _ ,, BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number CS 094763 Blrthdats: 05/14/1943 Expires:05/14/2010 Tr.no: 94763 Restricted: 00- THOMAS R DOBBINS 19 CEDAR HILL DRIVE - G� DANVERS, MA 01923 Commissioner r1� /re �iomneanevea o�✓ a�ruf�Q'o �\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registratlor" 100811 EXPiratlon:-6h3/2010 Tr# 268971 `( r Type: Pnva'te Corporation LEN GIBELY CONTRACTING::''INC. Brian Dobbins 149 Main Street Peabody, MA 01960 �---- Administrator