237 NORTH ST - BUILDING INSPECTION (3) t
L
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
/ Cvl Massachusetts State Building Code, 780 C'MR, Vh edition OF SALEM
I Revised Jwaarury
Building Permit Application To Construct, Repair, Renovate Or Demolish a i. '008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I Date Applied:
Signature:
Building Commissioner/Instor of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: III Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner;of Record:
I p i_ G Z�-7
Name(Print) Address for Service:
9-) g -7 S-( s 9 13 S
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildi Owner-Occupied epairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units I Other ❑ Specify:
Brief DescriptionofProposseedWork: L..p F'T <' a n NI_QtAa G-T Mv1I- --a_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) $ List: r
5. Mechanical (Fire S
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: I S a O� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) D — ( L .
DO b b L ---c License Number Fapimtion Date
Name of CSL-147 - List CSL Type(see below)
1 t1 °j M �p�
i) e Description
AdJres � U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signal re*�7 M Mason Onl
RC Residential Roofing Covering
ielcphone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Reg tered Home IryQrovemeot Contr or(HIC) I Q U �$ 1
..,.,� r 7 6.,0 l 8-lJT'
HIC Company Name or 111C Registmnl Nam Registration Number
� � GYM 4w 4 - -2 (� a
AddrCs`s f�
C-j' 'j �S'3l �''� Fspimtion Dale
Signature 'telephone -
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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i , 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:OWNEW OR AUTHORIZED AGENT DECLARATION
C 1, L o L Qi Y ICFL-f -r-- ,as Owner or Authorized Agent 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 r-; — 3- f
L
Signature of Owner or tit orize Agen Date
(Signed under the sins tin ena ties o 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 Volhave 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 110.116 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"
/ JL
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
u,p www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elecctrici Print Leetbly
A licant Information Please
L r LK Cr, i A :Lti! �n
Name(Business/Organizatiotinndividual): Q r✓ t b o
Address: I Lk `)i "t � S<n
City/State/Zip: Phone #: C1 9 $ 5 3 l $ a 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 11 6 New construction
employees(full and/or part-time).' have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.0 1 am a sole proprietor or partner- These sub-contractors have g. 0 Demolition
ship and have no employees employees and have workers'
working for me in any capacity. 9. ❑ Building addition
t
comp. insurance.
[ Iu workers' comp. insurance 10.0 Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself: [No workers' comp. right of exemption per MGL 12.0 Roof repairs
c. 152, §1(4),and we have no
insurance required.]t employees. [No workers' 13.0 Other
comp. insurance required.]
-Any applicant that checks box R 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 must submit a new affidavit indicating such.
tConnactors that check this box must attached an additional sheet showing the name of the sb-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide then workers'seta policynumber.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. U��A� 0,S C —
Insurance Company Name: /�_ p �
Policy#or Self-ins.Lic.#: 4, t_ `7 10 a / Expiration Date: ( d
Job Site Address: -7 Arlo A�� �"; City/State/Zip: -S AL.c
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirationdate). --
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 ofperjury that the information provided above is true and correct.
Slenature Date- — Z" t 0
aa
Phone#: -!
Official use only. Do not write in this area to be completed by city or[awn ojftciaL
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" ISSLM DATE 07/3]PO09
RODUCER ` .
THIS CERTIFICATE IS ISSUED AS A NUTTER OF INFORMATION ONLY ANU
Edward F Sennotl lniwance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE
1, DOES NOT AME?U.EXTEND OR c ALTER THE COV Been Inc E E7L4GE 0
-
AFF RDID BY THE
POLICIES OLICIES BELOW.
16 South Main Street
Dp,Ciekl M.A 01983 COMPAI�S AFFORDING COVERAGE
NsuRED — --
En Gibely Contracting Company Inc
CoMPANYAALM. Mutual Insurance Co
THIS IS TO CERTffI'THAT THE POUCB:S OF INSURANCE LISTED HELOtV HAVE BEEN ISSUED TO THE RJSURFD NAMED ABOVE FOR THE POLICY
PER10D BJDICATED.NOTxTTHSTAPIDING AHY REQUTAE\'(ENT,TERM OR CONDITION OF ANY CON1A4C7 OR OTHER DOCUMENT WITH RESPECT
TO\\'F{ICH THIS CERTff1CATE MAY BE ISSIJID OR\L41'PERTAPI.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBIECT
TO ALL T1Q TEAN15,EXCLUSION5.4ND CONDIT10N5 OF SI1CH➢OUCQS. LUIITS SHOtVN MAY IL46'E BEEN REDUCED BY PAID CLAIMS.
CO T\9[Of LY[URANR IbLICI'NVFIH[R IOUCY'[TPTCTn'[ POLICY EF11PAilOF
Llx t`ATC IkILDDITYT D.aR IHHIpMTYI Ltxll❑
O[A[RAL LIABILIFY GEII[F.LL wOUe EO.+TL
PP.OVVLZY WYM1PF AGO
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lYOR1SR5 COMPENSATION AND .ATLLFf TS STATE THER +
ll LOlTJCS M LITV LG •
u[Peoem[Tea —�
I � a[u[F_ac¢OvnvL EL EACH A[CIDE VT $O(I,(IO1/ I '
!IHCICYS N:L �;
II KL Ly ca 601097901'_0t19 OS/O.ii10U9 OSiO3ROlCl EL OWEASE POLICY LIMIT 500,000
EL DOEA5r_EACH EAVLOYEE 500,000
i
I I
i HOULD ANY OF iiTE.a80VE DESCRIDEO POLICTES BE CANCELLED BEFORE THE EY➢@ATSON DATE
F.THE tSSt@[G COMPANY WILL ENDEAVOR TO FEAR 10 MrrEN NOTICE TO THE CEA i:ATE
OLDER NuM0 TO THE LEFT,BUT FAILURE TO FLUL SUCH NOTICE SHALL BIPOSE NO OBLIGATION
R LLABaJTY OF ANV K iD Iry ON THE CO\PAM',RS AGENTS OR RUPESENTArras.
NCO 1VHOA9 IT MAY CONCERN �_�yD
CX- Cam'
tirmoRIZED REPRESENTATIVE
6169
Page No. ___�,_pl Pages
PROPOSAL
�. LEN GIBELY CONTRACTING CO., INC.
l» 1 149 Main Street 2�7 J 2
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
engaged in home Improvement contracting, unless
(978) 531-8234 specifically exempt from registration by Provisions of
their
FAX(978) 531-9304 Chapter 142A of the general laws, must be registered
T� with the Commonwealth of Massachusetts. Inciulries
TO: ,G.i-- Rg V-`-' �-�-'a-M-h— about registration and status should be made to the !
J Director, Home Improvement Contract R'UDAegistration,
One Ashburton Place, Room 1301, Boston, MA 02108 4E{pt
M own
construction related permits or deal with unregistered
contractors will be excluded from the Guaranty Fund
- ---- O f7 Provision of MGL c.142A.
PHONE (( // (� p GATE REGISTRATION NO. MAR.EG�I00811
—Q7 /p l� -1 9 Rs I• JOa LOCATION /'f
JO NAMENO. /�. ^ \J
We hereby submit specilicalions and esamatea Airw-orrk ttoo`bre pedom al and mateen
nels be d
1
.L
P-�w
( 'TTJ__�+-5pvGT�cJq ���4Sht <C
io.11
-(Re—i;-1� •` "gym-._�S�,rv_GG i di fIODo�
Construction related permits:
- rXL
WORK SCHEDULE e nl s pe mTetl h el 'd g. on t will beg the work an pr
Convect r Wit not beg N k o orderthematerials before In.N d tl y lotto g IM1e s 9 Ing f Ih A9 ,The Owner hereby
a ont p�H[ le) Burning delay d by circumstances beyond Contractor's t pl Iha wo x III c mpl t b Otvie
acknowlaogas—a a9raes '"'e schetlul ng tlates are aDPrazlmale end That su h tl lays that era oI W dabl by th contract.,shall not be sl,fere0 acom4on enrl shall comply with
WARRANT
The Contractor warrants that the work furnished hearmiddr shall be tree 1rPDor metecls In melenal antl workmanship ca a ict., 0l awl g
the requirements of Nis Agreement In the event any treacl e,wekmaasM materials,or damage causetl re Ninvilth nse tody repair,co his au replace,
or cause
to bee pr agents,Is reed or a vwlh n
one
hyear afterorsudl detect in materials or wo clean up.the Contractor rkmanship.The foregomgswarmarea shell suhall,at his own rvive ve any l inspection performed in conduction witme agreatlupon wo remedied,reported or replaced
Suc
We Propose hereby to furnish.material and labor-complete in accordance with above specifications,for the sum of
tlollars
Payment to be made as follows: Y
- !(s I upon signing contract: vameofcormiwer/Oeaig„aletl Registrenl
q is 21.12— ,pod completion of ��� sveeiAmress 1
,(g )uPon completiono Clryletate-- - - Pilo
($ a matl a on Phone - - F.......No
.
completed rk under this contract.
Notice: No agreement for home improvement contracting work shall require a down Name of salesman
payment(advance deposit)of more than one-third of the total contract price anhydride
me Auialard r sq"aw®
totalamount of all de posits or payments which theaonrder most Make ieuipmet,
to order and/or othetwise obtain delivery of special Omer materiels end equipment, Nee.ThispmPosed mayawHal.lyusn nolacrreplatlwlNi" bays.
Whtc
galv
ons
Aacceptance of Propposal I have
mes a ebboth sided f this
are ur authorized to do he worEnt and accept the krlas specified,specifications
will be I made tassoutlined above•
P signing, binding
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 N T SI N THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
k—% kc Dora
Dale b"z
signowm p a IMPORTANT INFORMATION ON BACK
I - vv nv r uwn r rue A.vrr l nwr,.r rr i nCHC AM:ANY Id LANK SPACES,
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 094763
.�„ Birthdate: 05/14/1943
Expires: 0 511 4/2 0 1 0 Tr. no: 94763
Restricted: 00
THOMAS R DOBBINS
19 CEDAR HILL DRIVE G—
DANVERS, MA 01923
Commissioner
7k �oor,r�seonrre¢ o�,/ �uee!!e
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
ReglstratignV% 100811
Expiration;,;&23/2010 Tr# 268971
,Type: Private Corporation
LEN GIB ELY CONTRACTING CO.",;INC.
Brian Dobbins
149 Main Street
Peabody, MA 01960
Adminis
trator