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15 MAPLE ST - BUILDING INSPECTION (2) 3 2 ED C-r' qq- The Commonwealth of Mas TAAL CITY OF +, 1 Board of Building Regulations aiidStandards SALEM Massachusetts State Building Code,7800 CAFR A & uu v" t1� JC►' �8 Revised.Llnr 201 Reno / Building Permit Application To Construct, Repair, vate Or Demolish a One-or Tivo-Family Drivelling This Section For Official Use Only . Building Permit Number: Date Ap ied: Uuilding Oftictal(Print Name). - Signature, Date SECTION I':SITE INFORMATION I.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accep ed street?yes_ no Map Number Parcel Number 1.3 Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(It) 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❑ Check if yesO p y SECTION 2: PROPERTYOWNERSRIPr' 2.1 Owner[of Record: A~D rz-e+w.. 2 L A t S A.o L L /A L..0 .n. NlA erne(Print) City,State,ZIP iS /Vlab►_ � Sr _ �A 2- 5�a - s48� No. mid Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Buildin caner-Occupie Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specily: Brief Description of Proposed Work': 47 `r" CZ la ALA 1-1 0u J_e 1Zo0 Y:f cl SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and iN(aterials) I. Building S 6 V O O AP I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing .4 2. Other Fees: S d. Mechanical (FIVAC) S List: S. Mechanical (Fire S Total All Fees:3 Suppression) Check No._Check Amount: Cash Announn 6. Total Project Cost: S 14 o U 'vv ❑Paid in Full ❑Outstanding Balance Due: MA�L� C_oN`r �t Z2 §ECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor Liceitie(CS;L)39� �'1i �Q�(p t„ License Number Expiration Date Name of CSL Holder ' 1 YC dill List CSL'rype(see below) No. and Street 'type Description ®� n A U Unrestricted(Buildings u to 35,000 cu.11.) !`1 R Restricted 1&2 Family Dwelling Cltylfown,State,ZIP M Masonry RC RoofingCoverin WS Window and Siding SF Solid Fuel Burning Appliances Insrdation 'role hone Email address D Demolition on D O p ( ( 2 a E be.0W C en_h'-ri— Mt Registration Number Expiration Date HIC Compat Nante or IllC Registrant Name yu.�d Street Email address 1) 19L a ---53l �i3� City/Town,State,ZIP 'rele hone SECTION 6: WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c.,15Z.§ 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 Wmance of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION;TO BE COMPLETED W HEM OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERIIIIT' 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:OWNEW ORAUTHORIZED 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. Qj - 17— 1 Print Owner's or Nmn• 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 M.G.L.c. I42A.Other important information on the HIC Program can be found at www.nr1ss.11ov1oca Information on the Construction Supervisor License can be found at w�ew.nrus.^_ov:!Jns 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 ofcooling system Enclosed Open 3. Total Project Square Footage"may be substituted ror"Total project Cost" The Commorlwealth ofMasspehuseds Department oflndustrialAccidents Office oflnvestigadons 1 Congrest'Street;Suite I00 Boston,MA 02114-2017 wW,Km Workers'Compensation Insurance Affidavit BuRders/Contrmetors/Elec Applicant•Information tricians/Plumbers please Print Leeibly Name.(Business!Organization/Indivjaual): Cc Address: . Ci /StateM . 6o t Phone M, R"� $ Are you an employer?!Check the:a 3 P appropriate boa. Ishect. ®I am a employer with / 0'1 4. ❑ Y am a general conua e'of project,(regmred):employees(full and/opsrt=time).• have'hirea'dte subco 6• ❑New censhuction2.❑ I am a sole proprietor or partner- listed on the attached7. ❑Remodelingship and have'no employees These sub-contractorsworking for me in any capacity: employees and have worers S' ❑Demolition [No workers' comp. insurance comp.insurance.t 9. ❑ Building addition rend•] 5: ❑ We are a eofporation and,its 10:❑Electrical repairs or additions 3.[31 am a homeowner doing all work officers have exercised their11. pitunbin m self 0 g.repairs or additions y [No Workers comp. . right of'ezemption per MGL msurance regpired l t;; c. I k §I(4),and we have no` 12•0 Roof repairs . employees. NO workers'' 13.0 Other comp.insurance 3 hir ed.] •My applicant that checks box Ml-must also fill out the section below showng ftir workers'compensation pohcy iaforroahon Homeowners who submit this a&davrt mdica[ing they are doing all work end theo him outside eontmewis must submit a sew ffidavit indicating such. tContraetors that cfieckthrs box 'must attached an additional shed showing the name employ of the subcovhactors and state whettier or Out those eutifies have. .. em !f the subcontractors have employees,they mu"rpVide their workers comp:poficy number: Jam an employer that is providing workers'compensation insurance for my employees. Below is the polley and job'site information. �1 Insurance Company Name:_H ,'T. Policy#of Self ins. Lic. r��,/�wc-i Q D 6 b l n Q ry q �t514r YExpiiation Date: 1 ej Job Site Address: 1 S J 'A b i� City/State/Zip; q( o Attach a copy of the workers' compensation policy declaration page showin the Policy f .--.tA. Failure to secure covers a as P g, ( g P y number end expiration date). B required under.Section 25A of Ot c. 152 can lead to the imposition of criminal penryldes 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 ofthe,DlA for insurance;coverageiverification I do hereby ce?*,vneerghi!paimgndpenabtWe ofpm7+n'y fat the inform rovided above is sue and correct p Datesg !—7 1 A4 Rhone 5 -S 1 OJ) Ial use oWy. Do not write in this area,to be coLpleledby city or tow=ial, City or Town: ermit/hicenaIssuing Authority(circle one): 1.BoardofHealth 2.BuildingDepartment 3.CiClerk 4.Ele 6.OtherContact Person• Phone ACORQN CERTIFICATE OF LIABILITY INSURANCE t210MD2014 02/06/2014 T KODUCER 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 NAIL# iNSuREO Len Cl ely Contracting CO. , Inc. INSUREan Catlin Specialty Insurance Co 23R Winter Street INSURERS: Safety Indemnity 33618 Peabody, MA 01960 INSURER C: INSURER D: NSURER 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. INS R OD LTft NSR TYPE OF INSURANCE POLICY NUMBER PATE MIEd/FD TN OATS MW N DMRS GENERAL LIABILITY 3700302145 01/29/2014 01/29/201S EACH OCCURRENCE $ 1,000 00 X COMMERCIAL GENERAL LIABILITY PREMISES Ea=u"nce $ 100,000 CLAIMS MADE a OCCUR MED EXP tAnY ate perean) $ 5,000 A PERSONAL BADVINJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $ 2,000,00 - POLICY PRO- ._ JECT LOC _ AUTOMOBILE UABIUTV 6221693 COM 01 01/29/2014 01/29/2015 ANY AUTO - COMBINED SINGLE LIMIT $ (Ea aWdent) 11000,00 ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY $ B (Per Penan) X HIRED AUTOS -----� BODILY INJURY $ X NON-OWNEDAUTOS (Pet acadant) —'--- PROPERTY DAMAGE $ (Pera=dent) GARAGE LIABILITY AUTO ONLY ACCIDENT $ ANYAUTO OTHER THAN EAACC $ AUTO ONLY: AGO $ EXCESS UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR El CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION E $ WORXERS COMPENSATION _ AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANYPROPRIETOR/PARTNDED? CUTf✓F� E.L.EACH ACCIDENT $ OFFICEOPRIEBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ II Ya d Wilco under SPECIAL PROVISIONS Uabx E.L.DISEASE-POLICY LIMB $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT)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 WWRER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE A Robert Sennott RP `��^"° F ACORD 25(2009/01) 01988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD alcatzo�® CERTIFICATE OF LIABILITY INSURANCE DATE 112 0 14 "' o9/otl2ola 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 pollcy(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(s). PRODUCER 01634.001 CUNTACT Edward F Sennott Insurance16 South Main Stree M No Fxt AC�: Topsfield,MA 1983t �odEss: INSURED INSURER A. A.I.M.Mutual Insurance Company 26158 Lan Gibely Contracting Company Inc INSURER 5' - 23 Winter Sheet Rear Peabody,MA 01960.5941 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 1$ 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. tJSEXCLUSIONS AND CONDITONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPEOFINSURANCE Id POLICY NUMBER MOX, � CX,n. LIMITS GENERAL LIABILITY - EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY MBE TO RENYED f -71 11SE5(Eaa f CL S AIMMADE OCCUR PREMED EXP(Any one pelsrm) E PERSONAL&ADVINJURY E GENERAL AGGREGATE f EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTSCOMP/OP AGG E Dalcy r—rA OC AUTOMOBILE LIABIIJTY SINE SI 1 f ANY AUTO BODILY INJURY(Poe Femn) $ ALL OWNED SCHEDULED - AUTOS AUTOS BODILY INJURY IN,acdrlen0 E HIR®AUTOS NON-0WNED P AMAG --.- AUTOS t E UMBRELLA LIAR OCCUR EACH OCCURRENCE f FJtCESS LUIB CLAIMS MADE AGGREGATE f OEO RETENTION f - E �Yd� �iS�d&PER�TL4f+r X TVA LPMT4s OFR'- A a� I�� I ��Id�� cEcuTrvE,y- NIA VWC-100-610979.2014A 81312014 6/31216 E.L.EACHACCIDSNTT_ $ 600,000.00 '('fMa¢nstl��mory In NH), MN E.L.DISFASE.EA EMPLOYEE E $00,000.00 D SCRI ION OF OPERATIONS Oebw E.L.DISEASE-POLICY LIMIT $ 600,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES(Atkch ACORD 101,AeePoonal Remarks Scheeule,It mom space is repujawl 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. AUTHORRED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 2$(201010$) The ACORD name and logo are registered marks of ACORD a LEW-GIBELY CONTRACTING CO., INC. Page No.___L_of�_Pages ,MASSACHStreet 25844 PROPOSAL PEABCDV,MASSACHU�TT._yS��I,�1�yew • �µ1 930 All home Improvement contractors and subcontractors (978)531-8234 Fax(976)531-9304 engaged in home improvement contracting, unless www.lengibelycontracting.com specifically exempt from registration by Provisions of Chapter 142A of the general laws,must be registered Submitted \ 1 , with the Commonwealth of Massachusetts.Inquiries To.- n V W about registration and status should be made to the C �p Director, Home Improvement Contract Registration, ....... One Ashburton Place,Room 1301,Boston,MA 02108 (617) 727-8698, Owner. who secure their own 'J C�.A..[/1/s 1•I A v 1 �� construction related permits or deal with unregistered r -- -. contractors will be excluded from the Guaranty Fund Provision of MGL C.142A. PIo' 2) C,(� GATE ) REGISTRATION NO. )5�Z-51(J� �////ta MA.REG.100811 Jc1e NAmE/rvo. 1 / JOB LOCATION ' SAME tl entrainsor work to by pedomled and materam to be used sl ,So 1 I" o el)`r P S'r4 r r 7jo�7 //, F, - .. Pi_ Zxv �firly t, r�� ._cc G_9�5 /J �tnO-Stnn�pjli�.CCM ftillow / y� _ .. P COfAJJs_ ��juJ e2 o C7l C' �U A,t a q°�'`'p- (i. 14yP,s. / I; �rI 026 r3. 9 s1/LP- 41C) I vep it cR, _ P6I�)Tl �nl yS CI C �S T 4; CLqg . (J /, a.C✓�_(.vrl (f�-CG, Jv_ t. woRW6gHEo MGf - _ - Corlr legnt rk or ord IM1 t -I pl IndBtldo,l ll gIB gig IN qg I, p letlh - 'IgC I Ilp gn IM1e worx on or zCouw(tlataL ae B 0 y d by t bay d C I 1 In. k 'Il b pl I. d by (tl I L TM1 Owner perapy e know dUyro tllallpeschatll gb leaare approMmale antl let suchdly,Thal are not aw4able by the contractor shall not It ndomd vloletbns of this AbhorTnl. WA ( //JJ ih0 LOnlydmor warlanle teal IM1B work luindrni6hatl M1Braunder Shall pe I,Ba Iron dolecls In malarial and workman-'for s penM oILY/� lollowinp complotion and Shall comply wily I requirements of NI6 Agreamenl.ln IM1e event any tlelB[I In workmanship pl malenab,or tlamego caus¢d by IM1e Conlraclor,Ms nupconlmctors,empkryaes ar agents,Is di5c9veretl witpin ne year.,.r cons rion of my I.a,is ng clean up.'no Basin., n igungshall,m M1is mvn.Afhv a,lorlhwa remedy,repaid cons[resti or cause to ba remedied,rapeimtl,or replacetl, r Such tlamego or auto tlolocl in malerlala or workmanship.Trio braggnp warranties that survive any impaction padormed In o.-d ron wilh Ipe n1drid upon work. We Propose hereby to Ia ish malarial antl,labor-complete in accordance w' above apecif a/tiol]/;I that s m oC if Payment to be Baad/o�a�\s.1(jj TTlglw., aYe($ S/ 1, w l8.-J1LLI upon sing Lonct',� \� ) _L Nema of GunoecanOesignaled neg'rsna Isl upon c avast Aeem.6 t upon completion of i J _y $_L shellbamatlelmaw upon clryretale / ne ) 1 / I comPtmionolsAN unearths came, Rnone RMemllo No. Nolics NO so4mirm for home improvement contrecfmg werk shall radium a down 's. ymonl(advance o on-mind 01 the total contract price or Ih la1 amount of all deposits a,Par a a tr Ioini is,o IM1e contractor must make,In ativance, °Dame pn ! to order ana/or othenv a Obtain delivery of special order materials and eeuipmers of m re than pain " - wnchaver iemliscomialmav de col lawn by a6nnora¢epmo wilnm tlare. Acceptance of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated.I understand that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified. Payment will be made as outlined above. You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Cancellation must be done In writing. ///) D T IGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. vvnsny cow � �� slen•w,a cola IMPORTANT INFORMATION ON BACK 17�tUegYl4tlapi._.,.. .. ^._ ,:s...Iwr+aeaorsN�"'ai°W Massachusetts -Department of Public Safety Board of Building Regulations and Standards C�ni.u-urtion Supen i4w License: CS-094763 THO"R DOBOIN 19 Cedar HilMA A 01 O19292 ` Danvers 3 Vj i -- v c ,l �' "� Expiration Commissioner 05/14/2016 ons n r+Affairs&Business RegulatorUrlA License or registration valid for individul use only �'�\ OI'lice ol'Cunsume s Regulation g Y *15 ME IMPROVEMENT CONTRACTOR before the expiration dale. If found return to: gistration: 100611 Type: :Office of Consumer Affairs and BusinessRegulatio_n 10 Park Plaza-Suite 5170 plration:- 6/23/2016 Private Corporation Boston,MA 02116 LEN GIBELY CONTRACTING CO., INC. Brian Dobbins. 23 R WINTER ST. PEABODY, MA 01960 Undersecretary Not valid wit ut signature r