31 MOONEY RD - BUILDING INSPECTION The Commonwealth of Massachusetts
it Board of Building Regulations and Standards FOR
V!�7 Massachusetts State Building Code, 780 CMR, 7"'edition NIUNICIP:�LIII"
Building Permit Application To Construct, Repair, Renovate Or Demolish a Rel iscdd✓emnal r
One- or Taco-Family Dicelling 2008
\ 'Phis Section For Official Use Only
u I yin Permit N e : Date Applied:
\� Yg tune: /� Z )• d w
Hui ding Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pro ert Address:
p y ` r7 L2 Assessors Map & Parcel Numbers
t] T u� R n
I.la 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(n)
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?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 nertof Record:
3 a J L K p L Lr i M o r3.-- nY Ro
Name(Print) Address for Service:
419 `7
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied pairs(s) Alteranon(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: .—
SECTION 4: ESTIMATED�I ONSTRUCTION COSTS
Item UEOfficial Use Onl Y
1. Building 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
_. Electrical ❑Total Project Cost" (Item 6) x multiplier x
3. Plumbing 2. OtherFees: $
4. Mechanical (HVAC) List:
5. Mechanical (FireSu ression) Total All Fees: SCheck No. Check Amount: Cash .-Amount:
6. Total Pruject Cost: ❑ Paid in Full ❑ Outstanding Balance Due:
Ova - AJII/A&�/V
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) O -7 b3 ��
' ' i\ 6b b ,A,J'S License Number Expiration Date
Name of CJSL- HolJcr List CSL Type (see below)
t u�t M,cl ,,•,�, ,-, p�a b�.�Y
T e Descri pion
�Address U Unrestricted to to 35.000 Cu. Ft.)
!'�-�[r1�'� R Restricted I&"_' t-arruly Dwelling
Signature M Masonr Onl
G`79 1 RC Residential Rooting Covering
"relephone ` WS Residential Window and Sidim,
SF Resldcntlul Solid Fad 13umme A tliancc Inst.dluu��n
D Rcs idential Demolition
5.2 RRered(Hotn�Imp77 mg�tt Contractor (HIC) ,
N ( t Registration Nwnber
HIC,C��--YYpnlpyeortHH�Rtt ,9AIDOF7��
(D- Z`3- D)C
AddR �� G O S �� Expiration Date
Signature OTelephone '
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed Lind 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
to act on my behalf, in all matters
authorize
relative to work authorized by this building permit application.
Signature of Owner - Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
- Lc t' ryrjL— as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf-. — jam,
I t C/gs2b(
Print Ne ���
Signatures oeef Lwner or Authorized Agent Dale
(Signed under the pains and penalties of erju ) 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. 142A. 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 basemendattics, 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" -
Sl
4
PUSUC PROPERTY DFFARTMCW
--•�`� //�/ /7 y 120 WASNINaToN VMXZT, 3KDFLOo11 .
SALXM. MA 01970
T[L (976)745-9599 EXV, 380
FAx (97®) 740-911"
STANLSY J. U90VICZ, Jae.
MAYOR
DISPOSAL OF DEBpa AFFIDAVIT
In accordance with the Provisions of M(X c 40 S334, I Acknowledge t ys a condition
of Building Permit 0 all debris r
wating governed by this Building Pcm*shaft be of in i c licensed� ,
a prs>perly l liceense soled-v,,nate
dusposal faci}ity, as defined by MGL c lj� SI_0A.
The debris will be disposed of at: q Fi o o t( M �
Locatton of Facl�lty
Signatu v of Pa mit Applies= Date
FULLY cotuplete dw following information:
(PLEASE PRINT CLEARLY)
'7� Z) 0b e ,
Name of Permit Applieant
F,,.m Naute, if any
1 y Oi ✓Ll A (z S-(
A& rrx, city $ SWc
The above statute requlm that debris from the demolition, rmovabon. rehab or Ether
alteration of building or structme be disposed in a li
fadispow
cility as defned by Mt,'1 cIII, S1SOA, sad the butt solid-waste
indicate the locatim of the fe ility. �� or ficexules sue to
i; The Conrnutmvealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington.Street
Boston, MA 02111
Ivlvmtrrass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/organintion,Indiiidual): L p
Address: I L4 9 M A i .
City/State/Zip: P, GI �r to✓ 1 "' �_ Phone#: 1 S 3
Are you an employer? Check the appropriate box: Type of project(required):
I I am a employer with _ a. El mu a general contractor and I 6. ❑New construction
employees(full and/or part-time).* bave hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. = 7. ❑Remodeling
slip and have no employees These sub-contractors have 8. ❑ Demolition
w orking for mein any capacity. workers' comp. insurance. 9, ❑Building addition
[No w'ori ers'couip. insurance 5. ❑ We are a corporation and its 10,❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself. [No workers corup. c. 152. §1(4).and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.❑ Other
*.Any applicant that checks box-1 must also till out the section below showing their workers'compensation policy-information. n
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy intormation
I am an employer that is providing tvorkcTs'compensation insurance for my employees. Belot,is the policy and job site
information. tn�
hrsumnce Company Name:
Policy#or Self-ins.Lic.#: L� 1 9 7 9,0 i - G rt Expiration Date:
Job Site Address: Q 13 A-1.e City/State/Zip: S qLo r, rIl o
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
fire up to$1,500.00 and/or one-year imprisonment,as well as civil lvmalties 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
Investigatious 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.
Signature Date: 2 2— 0 a
Phone#: `7 3
Official use only. Do not utTite in this area,to be completed by city or touts official
City or Town: Permit/License#
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#:
t
PRODUCER
THIS CERTIFICATE IS ISSUED.AS A%TATTER OF INFORMATION ONLY AND
Eduard F Sennort Insurancr CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
Aelatcr Ills DOES NOT AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
` POLICIES BELO%\'.
16 South Main Street
Top>;leld. N1.- 1.119N3 COMPANIES AFFORDING COVERAGE
INSURED
Len Gibel% Contracting Colnpam Inc
C'ONIPANY A A.I.M. Mutual Insurance Co
LETTER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED.NOTWiTHSTAN DING ANY REQU IRENI ENT.TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT
T(CI'.AHIC H THIS(ERTIFIC.\TE NJAU BE ISSUED OR MA)'PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TV ALL THE TERMS. EXC LESIONS.\ND CCCINDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
(v 11 Mk OF IPbl R:1NCE I.01-10 NVMIJLR POLICI'kFFECTICE POLICI'ECPIRAI'ION LI,11113 L1RI GATk INOt UUYYI UATEIMMIUU:IYI
I
GPLR%L LIAbILII l GENERAL WGREOATE
�`..
Ik:f'.1+1 J[NtY.iL LI+.pILtl1 1'R000CLSCOMPOPAGO.
^ PERSONAL 8 ADV.INJURY
k ACl l pCCI'RRLFCE
�.`V.C[i,j is.(O iPA•:hii:i^P"''
PINE UA\IiGE Nv,we(vu
IE7
--- — 'AtU [SPEUk1An.+as 1•nxal '
\11OV11911.L LI LtlIL11S
WAIT
U.51\Ott
I
KI
LiktILIT\
L�
1•V.C•14Ri1 D{SL{Gk
1:\CI:SS LI\tllllll LACI1 pick kkkNCk
UM9RkLLA FORM AGGREOATE
(1TIIhk TITAN UMURELLA FORM
II"ORKERS COMPENSATION AND STATUTORY LIMITS )THER
EMPLOYERS LIABILITY N
L .Ik-"r EL EnCH ACCIDENT SOp�000
A H:Sk:IL•. -1. i t
'At601097901'_007 08/03/2007 08/03/2008 EL DUE.ASE--POLICY LIMIT500
EL DISEASE--EACH
E\IPI.UI'EE 500,000
COMMENTS DESCRIPTION OF OPERA"rIONS OR LOCATIONS:
I
HOULD ANY OF THE ABOVE DLSCRIBED POUCI ES BE CANCELLED BEFORE THE EXPIRATION DATE
HEREOF,THE BSUINO COMPANY WILL ENDEAVOR TO MAIL aWRITTEN NOTICE TO THE CERTIFICA
OLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL.SUCH NOTICE SHALL IMPOSE NO OBLIGATION
Evidence Of Insurance IR LIABILITY OF AM'KIND UPON THECOMPAPAN),ITS AGENTS OR RREEPR✓SENNTTATTV/jES.
.- ���--cam„ l/!�'���✓J71.
_.-- - AUTIR I ZED RE PRESF.N'TnTIVE
u j
Yl,
4 D
1 :.:1*, '✓/t6 [0091N/10>1(['aQls� �✓N.ltWlt v "rf .iY! ^ ?:•
Board of Building Regulati6k4 and Standardl
't ••'^ '± HOME IMPROVEMENT CONTRACTOR' -'
Registration: 100811
;Expiration: ,6/23/2008
Type:- Private Corporation -
LEN GIBELY CONTRACTING CO.,INC.
Leonard Gibely
149 Main Street
Peabody,MA 01960 Deputy Administrator
07k �navrmonweald v1,W e4wa0
BOARD OF BUILDING REGULATIONS
License CONSTRUCTION SUPERVISOR
,_� i "r• I Nurnbe7 C9 '094763 _ -
s`>u B�rtNda�1 6/tAf�".3 r
)f�lre�►1u0ql0to10 Tr.no: 947.63 -
e '!'t 1•t t �S. I . ReatC�{I'S9Q Ef S$
:T THOMASR.DOB 19 CEDAR HILL DkZg .
' DANVERS, MA 01923 :
+ r Commlasloner
Y.
YS F I• P t.r l >
1 3
r
..
F
.Page No :_5. of Pages
LENGIBELYCONTRStreet CO., INC. PROPOSAL
149 Mam Street " �922�
�PEABODY, MASSACHUkTTS'01960
' ?� - ;^ ,-' � All home Improvement contractors antl subcontractors
%
"(978)531.8234 •`'' ✓ engaged Iry home Improvement contracting, unless
specificallyaxempt from.registration by Provisions of
FAX(976)531-9304
Submitted 1� � Chapter 1424%of;the general laws,'must,be.registered
with the Conimoriwealth of Massachusetts. Inquiries .
about registration and status should be made to the
Director, Home Improvement-Contract Registration,
1l7----- .-1 —' —V�� One Ashburton Place, Room 1301, Boston, MA 021011
(617):727-8588: .Owners.who secure their own
construction related permits or deal with unregistered
�''f contractors'will be excluded from the Guaranty Fund
D f fl Provision of MGL c.142A.
PHONE� - pATE REGISTRATION No. _.
MA.REG. 100811
JOS NAMEa1 - 1
JOB LOCATION -
��Q/gr0
We hereby submit apecigcatlons and estmetec for work to be performed and materials to be used.
-_ - -- - - 5
n, c
yZc.L�Ew_
v
/, t 2GG] Grl OJ
Ak
1 = � 'Anhh' l[ µlti alc TxJ•> Fl to tr SaI':i i� bra (1 /h °Ci•r^t Ry —
>—
.Construction related armits:
YJORKSCHEDULE+' "" �- � +• -
ConLecto/p. not pin Me wo&or orris Ne 'ate Isla bekre the th day klkrwl p Ne signing of iMa Agreement,uNe pacigetl herein wrXi actor win begin the wont on or
about_.{ r/l�Yldatel Ba p delay ceueetl by dreumatenc a beyond Contract rb.conirol,Ne work IX be completed by - ° C�C��pp.tJJrr..����'�dpaRR).The Owner hereby
adngM en egreS6E dw ccM1edNlrg dates eapproxlmate M1M1 lewhdelayi ihat'ar0 not avpldebk'by iM1O Nrector spell trot b0 wnsl yp6IID6Y'�,s othis Agreement.
.WARRANTY � -
TXe Conbackr warmnh N 1 N work NmleXed Xa4 uncle sh II b 1 s i am defects i materlat and workmanaXlp k e perb0 d /iQoilowin9 cbmpl tkn and Shall comply with
ins rep ma b of ml9 Ap e e t.In Ne are t y defect In km hip or malerkb r damage caused by Me Co ireclor NsaaebntraClbR,'employee garb b discovered within
one year eXercomplet on of ,y I e,inm d g clean up,me Conl actor shell,et hie own expense forlhwXM1 remedy spelt correct replace,ar cause to be remedied,repaired,or repot a
Such demape or sucM1 deled In malerlal6 or workmanship.The kregoing warrantlee shell curvhre my.Inspel.Son performed In mnnecllon wIN the agreedupon wwkl'
YVePrOF10Se hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
Payment to ba made as follows --
dollars($� may'm,
%S uponmgning Con
' ClrylSlate � ` P11
(sR I shalt be matle forewlN upon' �S > r f i�, ' '
1 i, q completion of work Under Ihle CgnireM. t v phone -- - T ereI ID No' —
Nolke No agreement for home improvement conlreMing work shell require a down;._ Nerve of Salesmen ,
.payment(advance tlepositl el.more then one-third of Na total contract price or the f-+ f� �2-_�-
.Iptal amount of ell depgslis or payments which Ne wntrecter must make In edveru:e 9vsnd�51p N
to bMer antl/or oNerwke obtain delivery of special order malerlels end aqulpme t �,,,7 r*
.Wh>�ig a amount is greater - ` -'" t °
)Nola till prapo691mryGe wlNdrewn by uv H,wl eccepled wMl days, ,
'ACCEptanCe Of PrOpOS81 1 have read both sides of this-document and accept the'prices specifications and conditions stated-I understand,
:ithafruporcisigningethis propgsal bsconi a'binding contract. You arg author(zetl to tlo ihe•wprk as specified. Payment will be made as outlined above..`;' ✓,
You,tft9 Buyer,may cancel,;hls transaction,at any tIfne.prior to;midnight of the third business day.after r'
the daje,of this transaction.Cancellation trust be done In writing:. A =,
t}k +` i 'DO'NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES L
:g f N�Cf' 6 1 ♦r, '� µ ,t .', ,3 ::: T G.r. t y { / I
siyww� w;i� Dery i sbnature _f Data i
X, .IMPORTANT INFORMATION ON BACK n< t ¢