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237 NORTH ST - BUILDING INSPECTION (5) 'RECEj The Commonwealth of biassachuse(�s' T�a ICE TY OF Board of Building Regulations and StandardsALEM M %V/ Massachusetts State Building Code, 780 d1a,H�A 2Ud,tfar 2011 Building Permit Application To Construct, Repair, Renovate Or Demol N One-or Two-Family Dwelling This Section For Oltkial Use Only ., I Building Permit Number: Date.Applie Building 011icial(Print Name). - Signature : .. Date f SECTION 1:SITE INFORMATION I— 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers S^t- I.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: IA Property Dimensions: "Coning District Proposed Use Lot Area(sq it) Frontage(It) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check If yesC31 SECTION 2: PROPERTY OWNERSHIP! 2.1 Owner'of Record: S��� �, 0-1 c"-� ale fz-e thme(Print) City,State,ZIP 7-3-7 NodVA 4ph!. Email Address o.and Street Telephone N SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Buildin wner-OccuI Repairs(s) Altemtion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposedr\V`o�rk-: 1 ell Z.O i✓T r. t n r.F7lN .c9r if, G /-�uk -r r.i�F 4 e 0- SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials) 1. Building S S Q©° 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard Citylfown Application Fee 2. Electrical S ❑Total Project Costs(item 6)x multiplier s 3.Plumbing S 23 Qlher Fees: 5 d.hfeclumical (CIVAC) S - List' 5. Mechanical (Fire S Total All Fees:S Su ressiun) Check No._Check Amount: Cash Amount: 6.Totai Project Cost: S r75 0 0�0- 0 Paid in Full 13 Outstanding Balance Due: t J'Y- l SECTION 5: CONSTRUCTION SERVICES 5.11 Construction Supervisor lr^Liccnse(CSL) l 6. SD wssS Y S','r License Number Expiration Dale- Name of CSL Mulder List CSL'fype(see below) d� DJ Q (J<-Vi t.on s T-- TYpe -- - . Description No.and Street - -' U Unrestricted(Buildings tip to 35,000 cu. 11. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masomy RC Rooting Covering WS Window andSidin �f SF Solid Fuel Burning Appliances T9 -5�4 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /0 0�1 ( —( Lle, Gr b.ol-� COS` HIC Registration Number Expiration Date f I IC Cuntp:m Name or HIC Registrant N:une 2`li g i.n./ tl�CtlJL CT N,, =w Street Email address AJ1S' _Ci Lfow State ZI-P. Tele home SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVITI(M.G.L:c.15L§ 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 Isivance of the building permit. Signed Affidavit Attached? Yes ........t� No........... O SECTION 7u.OWNER AUTHORIZATION,TO BE.COMPLETED WHEN' OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERb1IT I,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: OWNER'OR AUTHORIZED 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 any knowledge and understanding. Print Owner's o Authorized Agcnt Name(Electronic Signature) Dale NOTES: 1. 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 1I.G.L.c. I42A.Other important information on the HIC Program can be found at www mas,eov:'oca Information on the Construction Supervisor License can be found at www.nl� 2. When substantial work is planned,provide the information below: Total door area(sq. R.) N (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 'fypeof cooling system Enclosed Open 3. "Total Project Square Fooatge"may be substituted fur"'Tot:d Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AM 02111 www,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibis Name (Business/Organizadon/individual): Len Gibely C9Rtractirlg Ca Address: 23 R Winter Street City/State/Zip: Peabod , MA 01960 Phone#: 978-531 -8234 Are you an employer?Check the appropriate box: --, t.0 I am a employer with 12 4. ❑ 1 am a general contractor and I Type of project(required); employees(full and/or part-time).' have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity, employees and have workers' (No workers' comp, insurance comp,insu ance.t L13.E01 lding addition 3.❑ required.) 5. ❑ We are a corporation snd its ctrical repairs or additions I am a homeowner doing all work officers have exercised their myself.. mbing repairs or additions y (No workers comp, right of exemption per frepairs insurance required.)t c. 152, §1(4),and we have no employees. (No workers' r urance required) '�Yapplicant thatcbecks box MI must also fill out the section bolowshowing their worked'cmepensation . t Homeowners who submit this affidavit indicating they are doing all work and than him ouuideoontrsctors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contrsetors and state wbether or not those cooties have employeas. If the sub-coatraotors have ornployees,they must provide their workers'comp.policy pum4a. i am an employer that Is providing workers'compensation insurance for my employees. Below it the policy and Job site information. Izisurimce Company Name: A. I.M. Mutual Insurance Co. Policy 4 or Self-ins. Lis tl: VWC-1 00-601 0979-201 5A _ Expiration Date; 8/3/16 Job Site Address:7?, -1 /t!na� G z— City/State/Zip: Attach a co �,al,.,>< � 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 MOL 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 penaldes.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 DfA for insurance coverage verification. t do hereby cert(o under thepaGcs and penatles ofperlury that the lnformailon provided above Is true and correct Signature- A );�L ��� 1a 3 2 3 Date Phone H 4 '7 R Official use onty. Do not write in t/rir area, to be completed by city or town oJflelat City or Town: Permit/License N Issuing Authority (circle one): 1. Board of Health 2, Building Department 3.Cityfrown Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone N: � �_ LEN GIBELY CONTRACTING CO., INC. Page No. of PagesP RO POSA L " 23R Winter Street G 7 515 7.� PEABODY, MASSACHUSETTS 01960 All home improvement contractors and subcontractors (978)531-8234 Fax(978)531-9304 engaged in home improvement contracting, unless www.lengibelycontracting.com specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered Submitted ��C �`/ I 't J L with the Commonwealth of Massachusetts. Inquiries o J 7 I—'( _ about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727.8598. Owners who secure their own ' construction related permits or deal with unregistered —A Log vM/q contractors will be excluded from the Guaranty Fund Q ` Ei U Provision of MGL c.142A. PHONE OATG REGISTRATION No. (,j t -� .2 l [v I z- I.� MA.REG. 100811 JOB NAME/NO. A JOB LOCATION We hereby submit specifications and estimates for work to be performed and materials to be used: - RC, ST2,a A LL .. 1Ao ,A.,_ Rd ,'_Fs_ _ K � .hT_ R_aF—QAcic _a F Fko, -- 1 A,C�a F Now- FL_p�Q�t =,ao_-,CTA LC, 3 r—, 67 3_- LJ qT-o :� . iff-, Oii",, _S _FF/Tis t FY 1� V,< Lt_. —1 �wei 0qLLrFLArl-_r I .>s LiA, tT-e �.fLch E-OL_r � _.� . A LL_GpGiS r_A/,, c— S n P� L.A-� 3 Tra b L,nc lL 511, rice r_l coo- i -'7 .5O WORK SCHEDULE Contractor wAI not begin the work or order the materials before the third Eay following the signing of this Agreement,unless specified herein writing��Cgga�I���1ppr will begin the work an or about i[Sr(date).Barring delay caused by circumstances beyond Contractor's control,the work will be completed by—1_l.(G{T(date).The Owner hereby acknowle gr¢es I�FS511 the scheduling dates are approximate and that such delays that are not avoidable by the contractor shall ngl c pa�ililligi A vlorifirms of this Agreement. noden rot Orcoodiflan,notseen attimeof estimatethat are sequence,borepaired inordert0compoto Nismered,will da Wmplel6tl al$ per man hour(MAN HOUR). WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in material and workmanship for a period of following completion and shall comply with the requirements of this Agreement.In the event any defect in workmanship or materials,or damage caused by rho Contractor,his subcontractors,employees or agents,is discovered wine one year after completion of any job,including clean up,the Contractor shall at his own expense,forthwith remedg repair,correct,replace or Cause to be remarried repaired,ad r.placed. such damage Or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed upon work. We Propose hereby to furnish material and labor-complete in accordance with above specifications, for tthe sum of: Payment to be be made as follows: Remove all lob trash. All guarantees on all products from manufacturer. ($ )upon signing Contract: T 1 Add permit cost If needed-we pull permit. 95(3 upon completion of Notice: No agreement for home improvement contracting work shall require a _ -- down payment(advance deposit)of more than one-third of the total contract % n a 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 � ($ )shall be made forewith upon materials and equipment,whichever amount is eater completion of workaccepted under hn contract, rvote'.This proposal may be withdrawn by us if not accepted within days Authorized Signature f 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 d0 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 NO SIGN THIS CONNTRAA-CT IF THERE ARE ANY BLANK SPACES. " s,q'raara _ oea�J_�._V_-l\� Searches Bata IMPORTANT INFORMATION ON BACK Pew N !1 �'d 64'w .n hrl+gN?m 'uiK l ," a I:isn tr,y� a�,,frr•++x{a.9x yyny�,�y'G�t'+dSdC,>���n .w- ,y rN'i '- r .P,i,S"yl`r r%"' r . A.� n L -'h'' k � kY :a?'1.E �" , �ily.Y. p ,�' S=S?"�"$` f y.. •i r he yy�'4'y��h� t N:It ° a "Y.a11�!�. r 'fi�18'maF'}'JNpta to "A i AlrN i 4 I iH'I", Massacbuaattc Department Of P bllo'Satety 1 + m PX+ ° � ��"t 9 r nm�l Ia ITT// d Boar of Building Repulationa and Standd�r L `rye "o " ,i "fib, omra Yt n im it" , e p � t�l^plT+v ly'k,i" a x' ? '}fit 3 �,r!• 11,P+'�'x" x ;i Pr � License. C$-0YI;63 4 Yt..' �' ,Y � C 1 r it lyrt,ly bi t � :: r� '9u. w � � n y r�3y'k'� h• N' .4 ... 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