14 NEW DERBY ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY
O
� Board of Building Regulations and Standards
m OF SALEM
I E State Building Code 780 CMR 7 edition
Massachusetts e
Revised Junaur
e )
Building Permit Application To Construct, Repair, Renovate Or Demolish a ). ?008
One-or Two-Family Dwelling
This Sect' For O tcial U Only
Building Permit Numb pp ed:
Signature:
Building Commissioner/I torof Buildin Date
SECTION 1:41# INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
IlyT'
L 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(tt)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne/L' f Record:
Name(Print) Address for Service:
G ') S -7v S '71
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupie Repairs( Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': t2.
rs.. rj02� 'T'2t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 131
88
U 0Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) n 9 y �1 ( �
\ �B b Vl i License Number fspiratwn Dote
Name of C'3L-I ni lulilnerl r / I.ist CSL'Type(see below)
/'I .f Descritnion
�AJ ss U unrestricted(up to 35.000 Cu.Ft.
C L" R Restricted 1&2 Family Dwelling
Sig uture M Masonry Only
zj 7Z S 3 l 3�Y RC Residential Roaring Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance InstalEtion
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 9 g 1
I lIC C�puny N•ume orr[IIC'Registnmi N .� Registration Number '
u 4 t - _e 7 -Z3- J 0
A :n s- a-- ` -7 B S 3 $5 s�
Expiration Date
Signature c Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 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.
Signature of Owner Date
SECTION 7b:cO�WNEEW OR AUTHORIZED AGENT DECLARATION
6,LY as Owner or Authorize gent ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
`T'• �o bb tn:s
Print Name
Signature of Owner o uthorized Agent Date l l
(Signed under the ains an na ties of r'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 lei 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 I0.R6 and 110.115, 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 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"
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 LeEibly
1 COName (Business/Organization/Individual): L AP n/ Ct La L,Y t� i e A C�LSN C
Address: 14 9 N 81,.. SZ
City/State/Zip: Phone #: 9 9 5 3 k '8 3
Are you an employer?Check the appropriate box: Type of project(required):
4. ❑ I am a general contractor and I
1.� I am a employer with�_ 6. ❑New constmction
employees(full and/or part-time)." have hired the sub-contractors
listed on the attached sheet. 7. OR Remolition
deling
2.❑ I am a sole proprietor or partner- These sub-contractors have
ship and have no employees 8. ❑ Demo
employees and have workers'
working for me in any capacity. 9. ❑Building addition
o workers' con insurance comp. insurance.*
p• 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL c.
Roof repairs
insurance required.]t c. 152, and have no
employeees.es. [[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 arc doing all work and then him outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the time 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:A. M_t
Policy#or Self-ins.Lie.#: ( 9 9 D (� O t7 q Expiration Date: n/ (,�
Job Site Address:_ NcetiJ�et?6V S� City/State/Zip: � A Uo ni , / ' is O\=I
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 ofpeijury that the information provided above is true and correct.
Sltmature a a Date S-/" I y
Phone#
F
use only. Do not write in this area, to be completed by city or town official
Town: Permit/LicenseAuthority(circle one):
of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Person: Phone#:
I'
{ 4 : ISSUT DATE 07131P009
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
dwaid F Sennott In;utance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
ggency Inc DOES NOT AMEND.E\7END OR ALTER THE COVERAGE AFFORDED BY TIM
POLICIES BELOW.
16 South Main Street
npAfiel(L\'1.4 01933 COMPANIES AFFORDING COVERAGE
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=n QdLely Contracting_Company Inc
CoStPANYAAI.M. Mutual Insurance Co
THIS IS 70 CERTRY 7H.gT THE POWC�S OF WSURANCE LISTED BELOtV HAVE BEEN LSSUED TO THE MSURED NAMED ABOVE FOR THE POWCY
PERIOD AIDICATED.NOTWRHSTAWINC ANY REQl1IIll:T'IENT.TERM OR COWRION OF ANY CONITL4C7 OR OTHER DOCUMENT WITH RESPECT
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F.THE ISSUING COA@ANY tvRl ENDEAVOR TO FUR t0 WRITTEN NOTICE TO TU CEA rMCATE
OLDER NAUSED TO THE LEFT.BUT FAILURE TO ALUL R1CIt NOTICE SHALL p@OSE NO OBLIGATION
R L LABDITY OF.WI'MD D UPON THE CO\@ANY,ITS AGENTS OR P.FPRESENTAT:VES.
0 WHOM IT NIAY CONCERN
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LEN GIBELY CONTRACTING CO., INC. PROPOSAL
- 149 Main Street 18397
PEABODY, MASSACHUSETTS 01960
i. All home Improvement contractors and subcontractors
(978) 531-8234 engaged In home improvement contracting, unless
FAX(978) 5 1-9304 specifically exempt from registration.by Provisions of
Submitted Chapter 142A of the general laws, must be registered
To: /�.�,� G A10A) with:ihe Commonwealth of Massachusetts. Inquiries
-A- �-- _ --.- -----. - . . about registration and status should be made to the
y� ��// _ Director, Home Improvement Contract Registration,
/ --; /° ����y �� One Ashburton Place, Room 1301, Boston, MA 02108
(ons) 727 oars who secure their own
constructionn related permits or deal with unregistered
contractors will be excluded from the Guaranty Fund .
Provision of MGL c.142A.
PHONE DATE NEGISTRATION NO.
9 Aarg rays to J_ r7_/L MA.REG.100811
JOB Ni LO 7 JOB LOCATION
a SSLs`X SA�aM /r'7�
We hereby submit specifications and estimates for work to be performed and materials to be used:
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Construction re}l �ed permits:
(ava��feYS -- po �'ircAr `nor - ---
j1 w�a jra�d_ T� � n gDar vb _ NeGG1� f T
WORHS OULE /
— — �Qgac� PlosO,J CA(""i" �Q � 2
Co I I ill Lpt b IM1e�Q�)�tl��((th to als b M rh 1 tl tlay B Ih going of th's Agreement lesy� -a or the ork on or
obout 1Patol venI,g tlalpy ceuaetl by orc ata�"-s be, ofCo I turn so Ir1M1e wbrlg wp tetl by ( le a Owner hereby -
owle gas and steps hot the schedulingtlatas areepProxlmete t M1Cel ys en a fih4 Vlro er shall not be considereda Idid finis Agreemem.
WARRANTY (� �O
Tn¢Contractor warrants r.IM1.work furnish I M1ereuntler sM1all be 1 e Ir 1l,firr�pnE workmanship for a per,otl o/�nz /,{��t�(^Jo yy�'P�QfVlat. ash�all comply wiin
in.requirements of This Agreement.In the even)any tlelecl In wOIXmansBr or mat�lals,or damage caused by the Contractor,his oni96c IraclOrs,employ8§s or aged s,is Escoveretl within
n.year rifler complerion of any lob,including clean up,the Cars r shall,at his Own expense,forthwith remetly,repair correct,replace,or cause to be rerred.d,repaired,or replaced,
such damage or such perfect in materials or workmanship.The foregoing warranties shall survive any inspection performed In connection with the agreedupon work.
We Propose hereby to furnish material and labor-.complete in accordance with above specifications,for tlhe sum of:
dollars($
Payment to be made as follows: -
%is upon signing Contract;
'�1h—' Noma of Comranor/Desigr,etee Reglsvanl
%(s I )upon completion of �A suaen naerecs
%($ )used completion of -
clry/state Phone
($ )shall be made forewith upon
_yocompletion of work under this contract Phone he oral to No.
Notice: No agreement for home improvement contracting work shall require a down Na of san
Payment(advance deposit)of more than one-third Of the total contract price or the
dial amount of all deposits or payments which IM1e contractor must make.In advance, e s a
to order and/or otherwise obtain delivery of special order materials and equipment,
r.
Ii h 15greeter ota:o to p sal ybe wIlhdmwnbyusllnotaccepledwilhin days
Acceptance of Proposal I have read both is 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.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
(//,(��4 —� / Dare - 3'/0 signature oars
Signature � GLfLt/VJ�R'� � _
r
' 4
L.`- -- ri�e �oneiiaunuuinl!/r o�,ll'iiwsc�urae(ld
BOARD OF BUILDING REGULATIONS
s u License: CONSTRUCTION SUPERVISOR
j 4 Number. CS 094763
Birthdate: 0 5/1 411 9 4 3
f
i - Expires: 05/14/2010 Tr. no: 94763
Restricted: 00
THOMAS R DOBBINS
19 CEDAR HILL DRIVE
DANVERS, MA 01923 C
Commissioner
��te lJo�IV/Iepnu/grt�y. ty°✓l�m��.fwelre
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registratiort\ 100811
Expiration:-6l23/2010 Tr# 268971
;Type: -Private Corporation
;
LEN GIBELY CONTRACTING CO., INC.
Brian Dobbins
149 Main Street
Peabody,MA 01960 Administrator