14 OAKLAND ST - BUILDING INSPECTION 6I D5 c�<_ k(z)q l
The Commonwealth of Massachusetts £ CITY OF
� Board of Building Regulations and Standards Q JkL&ICU
Alt Massachusetts State Building Code, 780 CMR 10`b N� ,/tevised,Wur2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
^ One-or Two-Family Dwelling
GThis Section Far Official Use Only
r Building Permit Number. Date A lied:
Building official(Print Name). Signature . . Date
l SECTION 1:SITE INFORNIATION'
1.1 Property Address: 1.2 Assessors blap&Parcel Numbers
I ii C-.-
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Coning District Proposed Use Lot Area(sq tt) Frontage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Requin:d 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? Municipal❑ On site disposal system ❑
Public[3 Private❑ Check if es❑
SECTION2. PROPERTY OWNERSHIP'
2.1 Owner'of Record: s n /"IJq O \ 9-7 L�:)
a �.ey.aA (7 a-r_e
t'4 (Print) city,state,zip
l t.4 e-) 4(z C is c,o S-1—
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction Cl Existing Buildin Owner-Occupied Repairs(:).zg4 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': L-t- iD v 1PD
a— R z- a. i o fir— (Qp er
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMcial Use Only
Item Labor and Materials
I. Building S oc9 1. Building Permit Fee:S Indicate now fee is determined:
❑Standard City/Tgwn Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x \
3.Plumbing S P Qther Fees: S
d.Mechanical (tIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
eo Check No. Check Amount; Cash Amount:
6. T 1utal Project Cust: S t 5,5 a ❑Paid in Full ❑Outstanding Balance Due:
,(� k 7-43 Jrl t/>
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) q�4" - 5
License Number Expiration Date
Name of CSL[folder
List CSL'fype(see below)
Li
No. and Street Type' - Description .
�Q A bOD\— ('_ A 6 / 9 6 B U Unrestricted 2 Family
Lip to Dwelling
cu. It.
R Restricted I&2 F:unil Dwellin
Cityfrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
9 S-3 ( S.D-352 _ 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/—.P✓ !e, b.vZYt�+o ti T HIC Registration Number Expiration Date
[IIC Cum ,my Name or HIC Regislmnl Name
-T—
N d Street i�fl1 b ( G6D Email address
_ —City/Town, State ZIP_ Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.4 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 Isivance of the building permit.
Signed Affidavit Attached? Yes .......... O No........... ❑
SECTION Tar OWNER AUTHORIZATION.TO BE.COMPLETED W HEN•
OWNER'S AGENT OR CONTRACTOR APPLIES:FOR BUILDING PERMIT'
1, 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:OWNEW 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 my knowledge and understanding.
40.--C 1 i-- I —
Print Owner's or Aut umze Agent umc(Electronic Signature) Date
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 nu have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program can be found at
w w.v.muss eov;'oca Information on the Construction Supervisor License can be found at www.mess.��ov�'dns .
2. When substantial work is planned,provide the information below:
'total floor 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
'rypeofcoolingsystem Enclosed Open
J. "Total Project Square Footage"may be substituted I'ur"total Project Cost"
1�1� The Commonwealth of Massachusetts
1, Department of Industrial Accidents
a , Office of Investigations
600 Washington Streel
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Len Gibely GOntractinq Co
.Address: 23 R Winter Street
City/State/Zip: Peabody, MA 01960 Phone#: 978-531 -8234
Are you an employer?Check the appropriate box:
�X I am a employer with 12 4. ❑ 1 am a general contractor and I Type Vct(required):
employees(full and/or part-time).• have hired the sub-contractors 6. ❑ nstruction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ eling
slap and have no employees These sub-contractors have g, ❑ tionworking for me in any capacity. employees and have workers'[No workers' comp. insurance comp. insurance.: 9• ❑ additionreq fired,] 5. ❑ We are a corporation end its 10.❑ al repairs or additions3.❑ I am a homeowner doing all work officers 1-ave exercised their 1 I.
❑ rg repairs or additionsmyselL [No workers' comp. right of exemption per MOL 12 ❑ airs
nsuan6e required]t c. 152, §1(4),and we have noemployees. [No workers' 13.❑
comp.insurance required]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy intormatioa t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such.
Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-coutractors have employees,they must provide their workers'comp,policy panther.
1 ant an employer that it providing workers compensation Insurance for my employees. Below Is the policy and job site
information.
Llsurarice Company Name: A. I .M. Mutual Insurance Co.
!'olicyiior Self-isu. Lic. ti: VWC-100-6010979-2015A Expiration Date: 8/3/16
Job Site Address: t LA 0 fl
n S-(`
Ctty/StatdZ ip;S
Z OAttach a copy of the workers'compensation atron policydeclaration 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 penaltiesda 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
In vestigations of the DIA for insurance coverage verification.
do hereby certify under the pains and penalder-ofperlury that the information provided above is true and correct
Signature- ��+-� Date 1 l /
Phone #: S 3
F
l use only. Do not write in dris area, to be completedby city or town oJJlelal
r Town: Permit/License#
g Authority(circle one):
rd of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
er
ct Person: Phone#:
ACOSkRE® CERTIFICATE OF LIABILITY INSURANCE OATE(MMDOYYYY)
1/18/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements).
PRODUCER cOm"ArrRobert Poulin _
Sennott Insurance Agency -"' _ PRION.Bo�ETB'. (978)887_4900 _ _ _�FAX mil.c978>897-2a0+
16 South Main Street L robertpoulin@s9ruLottinsurance.com _
P. O. Box 457 _ INSURE9j-A fgFFORDNIO COVERAGE __ _ "Co
TOpsfield NIA 01983 INSURERq Flrat Mercury InIce CompQ ny
nsuraLOOP_
INSURED INSURERB:S8£ety IndeIDnityIL 33618
Len Gibely Contracting Co. , Inc. 1NSURERC
23R Winter Street INSUNERD_, ___
INSURER E,: _ �
Peabody NA 01960 INSURER F:
COVERAGES CERTIFICATE NUMBER:CL1611860930 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN RE_QV.CED BY PAID CLAIMS.
INSRI _ ..___..___._._______.____._ ..�.�� ..__ �.___.— CY EPF POLICY EXPO
LTR TYPE OFIHSURANCE POLICY NUMBER UNITS
X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1$ 1,000,000
I AMA*a fo gCii�EO_..._..._ __ 100,000
,I CLMMSIAADE I-X OCCUR A ! ' G iSE$..tEa0aX1!RAwl . 'S
j imi-CGL-0000060987-01 1/29/2016 1/29/2017 5,000
—
_ PERSONAL B ADV INJURY S 1,000,000
C.dJ LAC REa -E LIMIT APPLIES PER. I I GENERAL AGGREGATE Is 2,000,000
C/ ' _I JECT FLOC H PRGOJCTS-COMPIOP AGG�S _ 2,000,000
OTHER:
'AUTOMOBILE LIABILITY Eaw I 1 MINED SINGLE OMIT S 1,000,000'
] _
B I ANY AUTO ,,. BODILY INJURY IPm Para ) S
ALL O'.N:ED ' SCHEDULED '
Ills, A'JTCS IX i AUTOS 1 6221693 d'1t1 03 f 1/29/2016 1/29/2017 tlOORY INJURY(Par eCCCIXII}�S
X_li mREDAUTOS i X_ AUTOS
WIEU ! I yOPERiBYI MAGE {{3 _, _
I PIP 'J$ 8,000
Px
UMBRELLA L AO 1
.._ OCCUR EACH OCCURRENCE :S
EXCESS UAB CL11M5-MAOE I AGGREGATE I
..--...PLOP_
DFD1 RETENTIONS i �S
WORKERS COMPENSATION PFR OTlI
AND EMPLOYERS'LIABILRY �$TAT_TEJ_. ER,__IL�_
ANf PROPRIErowPARINERIEXF.CUPVE MINI ' i E.L EACH ACCIDENT _ I$
GFICERN.EMUER EXCLUOE07 NIA
ry I , qr—
(ManCRoInNHI L C'}i I
E_ DISEASE-EA EMPLOYE S
PeSC 'PTION unJcr -
C_�SCF'PTIGN OF CPERaTiONS acww El DISEASE-POLICY LIMIT'E
i 1
� 1
! I 1
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,A 11N Ro HS SCMAWa,may W AMc IT SPaaa fa,e4Wn0)
CERTIFICATE HOLDER - CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
/ AUTHORIZED RE➢RESENTATNE
Robert Sennott/RP2 _
01988.2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
INS02512e1401)
A�� oRoe CERTIFICATE OF LIABILITY INSURANCE �o;ISAM0�I
� .
- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pol"Ies) must be endorsed. If SUBROGATION IS WANED,subject to
the terms and conditions Of the Policy,Certain Policies may requite an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endoreement(s).
PRODUCER 10007.001
Sa Inc dba S ennoh Insurance Agency WPC-T EL1A� KA8 87-4900 AIC
(978)887-2{0{
P O Box 467
Topsfield, MA 01093 AODnEN: _
NAIL A.—_
NwRewA A.I.M.MuWallnsuranceCompany 3375
RE
INbUD I
L,Dn Ginaly Contracting Company Inc INSURER a
I ----
INaURER C
23 winter Street Rear ! ----
Ycabotly, NA 01960-5941 ___
INSURER E
COVERAGES CERTIFICATE NUMBER: -REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN
Lµ. .. TYPE of Wsuat e 1 PoucYNUMI3ER LIMITS
•GENERAL LABILITY WHO S
COMMERCIAL GENERAL LIABILITY
. ...... I PREMNAES oowerwl 3 .
.._...GIN M6MADE OCCUR
I MED EXP tMry am paMml 3 ...
.. .__. I PERSONAL bADVINJVRY i __...._.._
IOENENN.AOOIIEOATE 3
mil+'. T6I:8L(v11E LIL4T APRlEB PER I 'i �I PRODUCTS•COMPIOPAGO 3
PRO.
, I
IF,mcoeffil
AUTOMOBILE LIABILITY
ANY AUTO BODILY INJURY(Pe WN )
.. -ALL ONHF� f—
AUTO, AUTOS SCHEDULED t BODILY INJURY(Pw a odors) 3
WINED ALAI US r _ µTO�.SNNED IWAId" 3
3
UMBRELLA LAB OCCUR EACH OCCURRENCE 3
.. ._EXCESS LAa CWMSAV" AGGREGATE {
DED I RETENTION 3 *---------� 3
— — -..
WpRR�q��QMpENaATq�, A07MD°E�M PLOp'IYERT'L IABILfr••' cunvE�x —_�_r! —__.-_-._-----'-_-'._.—_—�;.__��II---_—_----�t'—E L'—I---o_lT_II_S. !OR.
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U rv�� E 60 ,000.00. ...... L I I '
I DISEASE-POLICY LIMIT
I I
DEbclUP TxN1 OF OPERATM)M{I LOCATNIM6/VE/IICLEB(Aimee ACORD 101,AeelaonN Rewxrlm 6cMM,N,a mem xPAYm b m{NBeG)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE
THE 001111AT10N DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOR20DRErRESENTATIVE
0 1111MMI)ACM CORPORATION.All rights reserved.
ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD
• - � _�
LEN GIBELY CONTRACTING CO., INC. Page No. of Pages
PROPOSAL
� 23R Winter Street 27842 1
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
(978)531-8234 Fax(978)531-9304 engaged In home Improvement contracting, unless ..
www.longibelycontracting.com specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered
Submitted M with the Commonwealth of Massachusetts. Inquiries11,
TO:._�LQ.e y.G�—_L/-O_C about registration and status should be made to the
—LNik1a+ .�--k Director, Home Improvement Contract Registration,
One Ashburton Place, Room 1301, Boston, MA 02108
(617).727-8598. Owners who secure their own h
)C� /l construction related permits or deal with unregistered
contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
P ONE DATE REGISTRATION
N0./ a
�Co��) 3G—G7P,Y c^/�z MA.REG. 300811 .
JOB NAMEINO. JOB LOCATION
We hereby sub pecilications and estimates for work m be performed and release to be used: ..... .._
-Der
;pI_ of l t� -C-a ( , \ b� v Z-/lay s/.
_VerfYan L C�InQG.\ SLr c�o� 1� ctv 7 �J SO G r/a / PO/C re
ILc �s
`C , t ck r -�
-fee-
in, ssL
WORK aCH DU - "
Con,
9l g iM1 opror order ma meterleb before iM1e iM1ire day tollowing iM1e elgning ai iM1la Agreement unless apediled M1areln wtlll .,FP a will be the work on or
about W b).Bardnq delay carved by dreumatances beyond Conirectorb control,the work will be compleletl by (4a�S9r71ne Owner hereby
arknowle end green that the schetlulinp dales ere eppmxlmale and that such delays that era not evoltlable by Ua wnbedor shell not b Onsitlereas a A Iatlon his Agreement.
.._an rot eroaWidpns notseen et Ikrtedeadmele tier ere regWretlro Wrepaired In wdar to mnplete tlgs connect w111 be¢mplel0tl at$ per man hour(MAN HOUR).
WARRANTY n ('
The Conbactor warrants IM1aI the work IurnleM1etl hereunder shall ba tree Imm tlelecis In matedaf and workmanship for a pedod of.3 "�lollowing completion antl shall comply with
the requiremanm OI iM1le Agreement In iM1e event any defect in wprkmenahip Or materials,or damage ceusetl by iM1e ConlrectoA Ns subcdneetlOra,employees or agents,is discovered within
one year eXer wmpletlpn of any IoC,Including clean up,the Conlmder eheil,et Ms own expanse,brthwllh remedy,repelA 14rred replace,or cause to be ameded.repaired or replaced,
and 0:mage or such tlafed In materiels or workmanship.The lorepoing waneniiea snail survive anY Inspection pedprmed In connectlon wXM1 iM1e egreetl-upon work.
We Propose hereby to furnish material and labor—complete In accordance with above specifications, for the sum of:
. ..". dollars($ /S .<Cn,ah
Paymentt e'made as to ws: � Remove all lob trash.
All guarantees on all products from manufacturer.
%( �� upon signing COnlis Add permit cost if needed-we pull permit.
%( )upon completion of \ • I Notice: No agreement for home improvement contracting work shall require a
down payment(advance deposill of more than one-third of the total contract
%($ )upon completion a price or the total amount of all deposit.or payments which IM1a contractor must
make,in advance,to order and/or otherwise obtain deli ry of special order
sholl be mado tin upon materials and equipment,
Completiona A under this contract.
Note:Reis pmpa Imay be wMdrawn by us 6 not accepted within days. ^
A wrbee
Acceptance of Proposal I have read both sides of this document and accept the prices,specification 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 busing s day after the
date of this transaction.Cancellation must be done In writing.' =
DO NOT SIGN THIS CONTRACT IFTHER E ANY BLANK SPACE
S / /�J�y/ a 3d
gnatur wit -.4— 116 .""our .
// , IMPORTANT INFORMATIO BACK
�l Massachusetts Department of Publle3afety s
�TMl3 Boqid of 8411dinp Requlptfoapd:8tandards i
1
Lice(Ise
COnstruction.SuperVl80r.
^y,:: _' 1� I ♦ .l rd Fri .F v ' (.
K
THOMAS R DOBBINS x*"�-•`•*,�{'� � t41� ' ;� 1 A t� , r'.
1S CEOAR HILL DR
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DANVERS MA a1s23 ,. ?n r
x
' n
''Expiration: yyR
missi0ner 05/1412018
r
office of Consumer Affairs&Byelueu Resulagos
'License or roaisEratioa Yalid(or Isduel
— before the e: tiou date if touad re�ru to 4 S
v_ HOME IMP RQYEMENT CONTRACTOR (; ,p61ce of ull Affairs sad Busiaess;RoQgletiou s i x M .
Re0lstratlorU,� 00s11 •' :Typo:. .;IOP kPlazs Siiite3170 '� r
Explr(at�on�pI s rAPtNeteCOryOreUon Boo tOarMA03116,4
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LEN GIBELY CONTRAIF
INC. I a
Brian'Dobbins
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23 R WINTER'ST.
6: of valid.witbopt s store
PEABODY,MA 01080 Usdersecrebry
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