10 MOULTON AVE - BUILDING INSPECTION (2) ,
The Cummonwealth of Massachusetts Town of
aL Board of Building Regulations and Standards
!I Massachusetts State Building Code, 780 CMR, 71"edition Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a
e- or Tit o-Faindy Duelling
This Section For OlTicial Use Only
Building Permit Number: Datt pplied:
Signature: Date
Budding Cornmtssto r or o
SECT N 1. SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
/ 0 irylCI a LToAi Av{
Ma Number Parcel Number
I.la Is this an accepted street''yes_ no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Air,(sq R) Frontage(11)
1.5 Building Setbacks(R) !,
Front Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
Ti-Water Supply:(M.(J.L C.40,954) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: + 0 /q ou LZ, V ce A16e
Name(Print) Address for Service:
Q � 9 S9 D '7
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildi Owner-Occupie Repairs(s) O Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units �_ Other ❑ Specify:
Brief Description of Proposed Wor': ,—�T_ 5---,a cl
SECTION 4: ESTIMATED CONSTRUCTION COSTS
RE�stimated Official Use Only
(tern I. Building 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 2. Other Fees: S
4. Mechanical IHVAC)
List:
t .Mechanical (Fire S Total All Fees: S
Suppression)
i Check No. _Check Amount: Cash Amount:_
6, Total Project Cost: S 1 Q/ d 0 0 ! 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ri =Djtc
License Number ExpLut CSL Type lsce heluwl
T' DU Unrestricted u to 35.
R Resmcted I&2 Familv Dwelhn
$i nalUre
M Mason Only
RC Residential Roofing Covering
Telephone IF
Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 legistered Home Improvement Contractor(HIC) ry'�
HIC c mpan Name or HIC Re trmfW Registration Number
Add ssyM�1�J ioa62rs (/
� s� Expiration Date
gn Siatur� Telephone 1
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 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 .......... O No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Si nature of Owner Date
J SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
Gr b y L r C,T c>! , as Owner o Autho 'zed 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.
Print Name
Signature of Owner o tit onzc Anent Date
(Signed under the aina an nalties ofPerjury)
NOTES:
f. 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 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 l0.R6 and 110.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces V umber of bedrooms
Number of bathrooms Number of halfbaihs
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage'may he substituted for 'Total Project Cost"
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
Print LegiblyA licant Information
. Please
Name (Btuiness/Organimtion/Individual): L Q R/ Gi be n et, t e— A - s • "•�� ^
Address: 14 Ck
City/State/Zip: q Phone #: Ct 9 g S 3 l 8 3
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have hired the sub contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner- These sub-contractors have g. ❑ Demolition
ship and have no employees employees and have workers'
working for me in any capacity. 9. 0,
Building addition
comp.insurance?
[No workers' comp.insurance 10. Electrical re airs or additions
required.] 5. ❑ We are a corporation and its p
3.❑ I required.]
a homeowner doing all work officers have exercised their I LE] 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 13.❑ Other
employees. [No workers'
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 most submit a new affidavit indicating such.
:Contractors that check this box most attached an additional sheet showing the name of the sub-contractors 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 policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: �, t7 1 0 9 7 9 D (� 0 D q Expiration Date: �I '
Job Site Address: M O U L-r-O a Y�ALP City/State/Zip:{ C n rn J 1 fl (�
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penaties of perjury that the information provided above is[rue and correct.
Signature: 1—
,v,,,� Date-
Phone
e only. Do not write in this area, to be completed by city or town official
wn: Permit/License#
uthority(circle one):
f Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
erson: Phone#:
a i
l ISSL�DATE 0713IM09
KODUCER
THIS CERTIFICATE IS'dilaid F Sennott Inbunincc CONFERS NO RIGHTS UPON THECERTIFICATE HOLDER.AS A MATTER OF INTOATION THIIS CERTIFIONLY CATE
ARenCV Inc DOES NOT AMEND.E%TEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
16 South Main Street
opsfid(l. NI.A 0)9S3 COMPAINES AFFORDING COVERAGE
NSURED
an Glbely Contracting Company Inc
COMPANY AAI.M. Mutual Insurance Co
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PERIOD WDICATID.NOTWFTHSTAWBJO ANY REQUTALI•[ENT,TERM OR COWfT10N OF ANY CONTRACT OA OTHER DOCUMENT WITH RESPECT
70\\'RICH THIS CER7ffICATE MAY BE ISSUID OR\1.41'PERTAPI,THE WSURANCE AFFORDt�BY THE POLICIES DESCRIBED HEREIN IS SUBTECT
TO LLLL TIBd TERMS,ECCLUSIOFLS.AND COW IT10N5 OF SUCH POLICES. LGIITS SHOIVN MAY'I'l.4bLE BEEN REDUCED BY PAID CLAIMS.
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OLDER MNCED TO THE LEFT,BUr FAILURE TO aLUL RCH HOTiCT:'$HAIL R\POSE NO OBDOATION
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6169
-_ - -- 149 Main Street �(� )All'
PEABODY, MASSACHUSETTS 01960 5
All home ImF aora
"'- (978) 531-8234 \ engaged in I lose
speciFAX(978)531-9304 Chapter 14lly e. i of
Chapter 142A .. - .a:.r.;ti,....red
Submitted /// with the Commonwealth of Massachusetts. Inquiries
To: about registration and status should be made to the . b.
�In Director, Home Improvement Contract Registration, li
One Ashburton Place, Room 1301, Boston,MA 02108 114
(617) 727-8596., Owners who secure their own
Sal ,�/ M 0 � 7Q construction related permits or deal with unregistered
W contractors will be excluded from the Guaranty Fund
- - - Provision of MGL c.142A.
PRONE GATE, REGISTRATION NO.
� s 3 ba v i MA.REG. 100811
JOB NAMEMO. f-� JOB LOCATION
s9M�
We by submit sp 1 fans and estimates far work to be performed and materials lobo used '
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WORK SCHEDULE
C t II eg n the work or order the materials before the third day following thesigning of the Agro nterm unless specretl M1 B t Ct II b g n IM1 k or
on 1—,jylj-w rr(���ll(4 (dale) Barr ng delay caused by circumstances beyond Contractors control the work will be comp in d by — o d 1 1 TM1e O M1 eby
EMrr6 cirlee ror ofgree flbut the schoduing dates are approzmate and that such delays that are not awease by the contractor shall not b¢ ens or one afonsiamis Agreement.
WARRANTY
The Cin-Vacor warrants that the walk furnished tangential,shall be free Item defects in malerlal and workmanship for a period of foeowing completion and shall comply with
the reondo able of this Agreement.In the evenl any defect In workmanship or materials,or damage Caused by the Contractor,his subcontecend employees or agents.Is discovered within
one year after completion of any lob.including clean up,the Contractor shall,at his own expense,forthwith remedy,repair Correct replace,or cause to be remedied repaired or replaced.
each damage or such dated in materials or workmanship.The foregoing warranties shall survive any Inspection peNormad in a' place,
will the agreed upon work.
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
dollars($ ).
Payment to be made as follows:
%(8I 3 )upon signing Contract; �(f �✓ a-'k�' J� `
1yy1--)) Nome oI Con raccalln signed Repairer
^/o(Y )upon completion of
Street Address
($ )upon Completion of
Ctly/Bole Plane
($ )shall be made lorawith upon `
completion of work under this Contract 'ei Eederm Ip No.
c
Notice: No agreement for home improvement contracting work shall require a down a
payment(advance deposit)of more than one-third of the total contract price or the
total amount of all deposits or payments which the contractor must make,in advance.
to order and/or otherwise obtain delivery of special order materials and equipment,
whisbover afflati is ORNINiC Nola:This prep all may be withdrawn by us k act accepted within days.
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 dat7th' ransaction.Cancellation must be done in writing.
DO NOT SIGN THIS CONTRACT IF THEREARE ANY BLANK SPACES.
Sera Jr. Balim / signawre Data
IMPORTANT INFORMATION ON BACK
1�
�..-- -- o/e 'go,x ueu,urvrel� c.' Cla.uael,ufeCG -.
I `-r BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
r - Number: CS 094763
Birthdate: 05/14/1943
- Expires: 0 5/1 412 01 0 Tr.no: 94763
Restricted: 00
THOMAS R DOBBINS
19 CEDAR HILL DRIVE
DANVERS, MA 01923 /�
Commissioner
L
�lse {i �-yp�it/au�r�eu�(I
Board of Building egul2tions and Stand
HOME IMPROVEMENT CONTRACTOR
Registration;, 100811
E%P,Iration:;;6/23/2010 Tr# 268971
;Type: Private Corporation
LEN GIBELY CONTRACTING-Cb'.,;INC.
Brian Dobbins
149 Main Street
Peabody,MA 01960 - - -----
Administrator