78 MEMORIAL DRIVE - BUILDING INSPECTION q f RECEIVED G
The Commonwealth of Massac t
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,71014l$gp 18 A 8; 4 SALEM
Revised.blar•2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date.App ''e:
Building Official(Print Name). Signature- U t
SECTION I-SITE INFORMATION
I.1 Property Address: 1.2 Assessors Map& Parcel Numbers
'7R M� oki-AL Dfr..W e
L I a Is this an accepted street?yes_ no I Iap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zane: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
I ublic❑ Private❑ Check if yes❑ p p y
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
LL_ e JML i a... 34lir1 MA
4me(Print) City,Slate,ZIP
No.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Buildin&cacaner-Occupie epairs(s Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-: c L Od,Lv '> c�F
SECTION 4: ESTIMATED CONSTRUCTION COSTS
em Estimated Costs: Official Use Only
Labor and Materials)
I. Building S �7 LAV f) o¢r I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical .S
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
C>. Total Project Cult: Sri L( � n ❑Paid in Full ❑Outstanding Balance Due:
01
J V+SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Liccnse(CSL) rl' �+ LA 1(-., 5- ( 4 _(`
T t b(O (,4- A n t License Number Expiration Date
Name of CSL Holder - ' :"'
List CSL'fype(see below)
q-?,, e W � S-r P,o.
No.and Street Type'- Description
U Unrestricted(Buildings Lip to 35,000 cu. ft.)
-PA R Restricted Ig2 Family Dwelling
Citylrown,State,ZIP M Nlasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
t Insulation
Tee hone Email address D Demolition
5.2 Registered Home Improvement Contractor(II IC) � pC) 8 �
1 J.0)_V -3_v�— HIC Registration Number —Expiration Date
fIIC Compan Nmne or HIC Regtstmnl Nnme
7 � LLl t ✓e'�.c S 7__
Rr street Email address
( f►�ja S31B�
Ci /Town,State,ZIP 'rele hone
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...........❑
SECTION lac OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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.
-Print Owner's o Aut xinzc r gents Name(Electromc5umture)
NOTES:
I. An Owner who obtains a building permit to do Iris/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 tile arbitration
program or guaranty fund under ib1.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass.euv'oca Information on the Construction Supervisor License can be found at w�o%v.ntass.eov/dps
?. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Typeorcoolingsystem Enclosed Open
J. "Total Project Square Footage"may be Substituted for"Yogi Project Cost"
The CoMmo4wlqafth.of A a4F pc#ul
Department oflndustrialAccidents
Office ofInvesdgadons-
" ' I Congress Street;suite 100
Boston,MA 02I14-2017
www. mas&gov/dia
Workers'.Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers
Asalicant Information -
Please Print Le blv
Name(BusinesslOrgaaizatioa/Iaaiviausl): �:4. �, G, �j.Q 1 y u A,i Cn
Address: 'a
Ci /state/zi . o Phone#: q
Are You an a 3
y employer?Check the'appropriate box
1.19 I am a employer with 4 4. 1 am a Type of)rroject(required
general contractor and I )
employees(full and/or part time).' have hired the sub-contractors 6• ❑New construction
2. I am a sole proprietor or partner- listed oil the attached sheet.. 7. Remodeling
" shi0'and haver no employees These.sub-contractors,have
working for me in any capacity. employees and have workers' 8' Demolition
.71
fNo workers' comp. insurance comp. insurance.: 9• ❑ Building addition
required.) 5:Q We are a corporation and its 10:Q Elechical repairs'or additions
3. Jam
a homeowner doing all work officl.ers have exercised their 11. Plumbir
m self. S repairs or additions
Y [No workers wmp. right of exemption per MGL 12.(]Roof repairs .
insurance regnired j t . a 152, I(4),and we have no
employees. [No workers' 13•0 Other
comp insurance required)
,!I rY applicant that checks box A'1 must also'fill out the section below showing,their wodters'compeusation policy i�aromtetron t OntracwnEth t ch6eobmd this affidevrt la t, they are doing all work and then hire outside contractors must subadt a new affidavit indicating such.
=Contractors that check this box must attached an additional shed showing the name of the sub-conbactois'and state whetfier or not those entities have:...
employees. If the sub-contrectors have employees,they must provide their workers'comp:pokey ntunticr.
l ant an employer that is providing workers compensation insurance for my emp
information loyees. Below is the policy and Job site Insurance Company Name: L/T V A L, 1+v c t o a, c .o
t7
Policy#or Self-ins. Iac. M. Z-wc-1 0 D- 6 d 1 t7 1,7.q
1G14pEzpiration Date:
Job Site Addrel R „ n P , city/state/zip: M M A
Attach a copy of the workers' compensation policy declaration page(showin the Policy �~
Failure to secure covers a as 6 p y number,and expiration date).
g required under Section 25A ofl4GL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.60 and/or one-year imprisonment,as well.es.civil penalties mi the form of g 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 tbe,DIA for insurance coverage;verification
I do hereby cerdfy pnder,the pgins and pengkks.o
fPerj+uY dial the inf¢nrratlon provtlied above is dwe..and correct
Date QI. . Ot t
hoe :
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other
Contact Person: Phone#:
AGORga CERTIFICATE OF LIABILITY INSURANCE DATE(MWOD/YYYY)
02/06/2014
PRODUCER 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#
INSURED Len Gl e y Contracting Co. , Inc. INSUeERA: Catlin Specialty Insurance Co
23R Winter Street INSURERS: Safety Indemnity 33618
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.
INSR DO' LIC EFFE TN PO YEXPI TION
Lift)NSR1 TYPE OF INSURANCE POLICY NUMBER DATE MM/D DATE MWDD UMRS
GENERAL LIABILITY 3700302145 01/29/2014 01/29/201S EACH OCCURRENCE $ 1,000,00
X COMMERCIAL GENERAL LIABILITY DAMA
PREMISES Ea oo o,nme $ 100,00
A CLAIMS MADE a OCCUR MED EXP(Any one peraon) $ S,QQQ
PERSONAL BADV INJURY i 1,000,00
GENERAL AGGREGATE $ 2,000,00
GEVL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $ 2,000,00
POLICY PRO-
.. JECT LOC
AUTOMOBILE LIABILITY 6221693 COM 01 01/29/2014 01/29/2013
COMBINED LE LIMIT
ANY AUTO (Ea anddent)
1,000,00
ALL OWNED AUTOS
X SCHEDULED AUTOS BODILY INJURY $
B (Per pereon)
X HIRED AUTOS ----
E X NON-OWNED INJURYWNED AUTOS (Per acddWA)
--- PROPERTY DAMAGE $
.. (Per aomdent)
GARAGE UABIUTY AUTO ONLY-EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGO -;—
EXCESS/UMBRELLA UASILITIr EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE E
tOPRIETORIPARTNESUFXECUTIVEr—I
EDUCTIBLE
RETENTION E $
PH
COMPENSATION
OYERS'LL41UUTY YIN TORY OMITS ER
MEMBREXCLUDR/EXECUTN�Er'-1 E.L.EACH ACCIDENT $
y In NH) E%CIUDED7 onn NH) E.L.DISEASE-EA EMPLO $
tnbe underPROVISIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
:goof of insurances.
CERTIFI
CATE 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 OBLIGAnON OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Robert Sennott RP F
ACORD 25(2009101) 01988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ac 13i` CERTIFICATE OF LIABILITY INSURANCE DATWO V2014 v)
L—� oelovzol4
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:It the certificate holder Is an ADDITIONAL INSURED,the pOIICY(ies)must be endorsed. II 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 C NNTACT
Edward F Sennott Insurance 7o. I: A .N 16 South Main Street
Topsheld,MA 01983
. A.I.M.Mulual
JINl AFFORDING COVERAGE NAG 9
INSURED Insurance Company 26166
Len Gibely Contracting Company Inc INSURER B
23 Winters treat Rear INSURER C
---- -----
Peabody,MA 01960.6941 —..__.___._----_ _
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,
SERXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IITR TYPE OFINSURANCE 1 POLICY NUMBER POII��ICyyE
LMMIGOM LIMITS
GENERAL —'
EACH OCCURRENCE S
COMMERCIAL GENERAL LIABILITY AMAGE TO RENTED'-- f
�CWMSMADE OCCUR MEO EXP(AnY one peiwn) E
PERSONAL IT ADV INJURY S
—.
_ GENERAL AGGREGATE S
EMI AGGREGATE LIMIT APPIJES PER: PRODUCTE-COMWOPAGG S
O ICY 0' OC
FET_.
AUTOMOBILE UAWLITY 17E6SIRCTE-OMIT S
ANY UTO
OWNED
BODILY INJURY(%,person) S
ALLOWivEO SCHEDULED
AUTOS AUTOS BODILY INJURY(Per acciden0 S
HIRED AUTOS NON-OWNED Rd-PER-fPD�GE—' _
AUTOS
S
UMBRELLA LIMB OCCUR EACH OCCURRENCE S
EXCESS LIMB CLNMSMADE AGGREGATE $
DELI RETENTIONS S
�I mPD EMPLTJYERa-LIABAITY .x TS�tPTIV.,
A B�FIC�ft/MEMBEAIGnRINEWF,)tECUTIVE E.L.EACH ACCIDENT
600,000.00
(ManeWery In NH) UDED N NIA VWC-100-6010979.2014A 813/2014 BIW2015
1111Y ddyy�lbWa A E.L.DISEASE-EA EMPLOYEE. S 500,000.00
Ok RIGTION�F OPERATIONS bobv ELDISE W-POUI UMR S 600,000.00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Aeditional Rwar6S ScheduM.IT eon cpece Iv regebad)
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
®1968-2010 ACORD CORPORATION.All rlghis reserved.
ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD
Page No._of Pages
LENG�Y CONTRACTING CO., INC. 25607 PROPOSAL
23R Winter Street ,� ,
PEABODY, MASSACHUSETTS 01960
All home Improvement improvement
and subcontractors N'
(978)531.8234 Fax(978)631.9304 engaged In home Improvement i contracting,Provisions
unless
specifically exempt from registration by Provisions of
www.lengibelycontracting.com Chapter 142A of the general laws,must be registered
with the Commonwealth of Massachusetts.Inquiries
Submitted (�� r v--�� ____ about re letratlon entl statue should be made to the _
To:.._/_ _(_C-�'.-�L/O�—L�--+--✓-p'L-��" Director,Home Improvement Contract Registration,
One 08
617) 727u rton la a59s. owners m lwho secure their own
construction related permits or deal with unregistered
_A contractors will be excluded from the Guaranty Fund
Provision of MGL C.142A.
VNONE 74
ATE RWISTRAnON NO. -
q�2 5y4Q
Joe NAMFMO. 1 ��12 ,V MA.REG.300811
•T JOB IOCATIpY
�.lJ dl2lJ Ch�
Wp heresy submit epedlicellpnc ere esdm.to.Is,work a b0 warormw and lrltlenah to be uaed;
2_L,4YRec2
z zc -k.00__�'t,�e ��'C�- r ._ ate— T✓�a t
-�L��L..aJ4w6SJ�l✓.:yv-_$f1C.�9F7r7.o��1.���1 cnTb AL2:�9G��_
�/,� k7 Sc=Z Qc�w �-P•-1-•J 7 A�-�la�s=J�w
L,,q,,.aM�a.� Sht.,rt�,_7'�Z_F_I�G �-�=�--
__L7
��ap-Ec ¢.�
�
Consorucllon nlategp rml - /�J O V' _t 2�
WORK SCHEDULE 1tleI, The Owner Ile,eoy
Conl,ecl r n01 In Iho tlela).0 BrinBit.
tleloy'ceueotl Cy lclrclumelences bapntl ConBlreCBolelM1conl,ol,I�enwolrN w611 be CClmplela0nby r111nB C Ire for wAI beBln IM1e wo, on or
boYl
ucNnawl Bes enU areas eNse).Barris,ing ogles etootedoalmel an0lnel eudl0dlays lost are nolewNade by Ne mn11ac1or aM1ell ml becNal r Baewv Op Ilona of lM1lf A9reempBy lw
ho
WARRANTY
'he reeulmmtor war Na ABst In.Work eawonl any0eled lnwobefree firer Wlerialt,or Ovnape causetl by the Conlreclpr,Ns au Veolon,employeewrepenu,orolsWverperease.
The ohrl we nd greee .d work Nmisllatl M1ereuntler shall be Irea Imm Oel%te in metebel entl worNmanallW or a perW of bllowin lotion and ones com
mpershe
my bar Boro m"ofer0s11rc11nmebrla601nvm oM1manaM1lp TheLlarepolnp weriraneesselwll ben urv�iv anse ynspecellpn pe0ormetli connnxtimbwhM1 IM1e epreeou%n wOA�npeheo,or related.
such
We Propose hereby to furnish material and labor-complete in accordance with above specifications,far the sum of:
dollars($ S ,
Payment to be made at follows: r (�
v -
Y.IE��OQ upon elpnlnBCommcl; TT1�, rose Mccm,uclaObEslpnmee Ropu�m^�
o(SS.1{44.�Nr,n wmpl¢I on of • (� a' s AM xa
% neom IIon of C"S
alb�,,'/'qe' owlN re upon ______ _feoemllb No. - ---_--
lr coinpiBl�on.l.MMer N UIlsconlect ono —
Tn -
Notice: No agreement for hems lmprpernmen scrabbling worn shall require a down Noma of sakaman
payment(.do.—deposit)pl more Nan one-third of ih,to,comncl price or the wmonzeo slpnm
need amount of all doposile or payments which Pe comm-1 must make,Inge pma e
to order set pastures.obtain deir m edg
y of special order ev e and a nt oawwkbeen by Ire ricsepletlxiNln days'
�nIL oraemr rldaama paw Imey
Acceptance of Proposal I have read both aides of this document and accept the prices,'speclfi attars end conditions state171, darstsnd
that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified. Payment will be made ae tl 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.
00n NOT SIGN THIS CONTRACT IFTHERE ARE ANY BLANK SPACES.
/ X dam 8 Z/ slenawra o®a
siv^°wr IMPORTANT INFORMATION ON BACK
_.............._.___._ ._..........................
.,....
}�f Massachusetts •Department of Public Safety
Board of Building Regulations and Standards
(1,mtructilut Supert isur
License: CS-094763 g
THOMAS R DOBBIN
19 Cedar Hill Dride `
Danvers MA 01923 -
Expiration
n n,
Commissioner 06/14/2016
,L_\ Office of Consumer Affairs& Business Regulation License or registration valid for individul use only
ems ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
-- glstration: 100811 Type: ! Office of Consumer Affairs and Business Regulation
j," ,, zplratlon: 5/23/2016 Private Corporation 10 Park Plaza-Suite 5170
�::,., Boston,MA 02116
LEN GIBELY CONTRACTING CO., INC.
Brian Dobbins '
23 R WINTER ST,
PEABODY, MA 01960 Undersecretary Not valid wit ut signature
r