10 ORD ST - BUILDING INSPECTION The Commonwealth of Massachusetts
^ I Board of Building Regulations and Standards Town of
Wilbraham
Massachusetts State Building Code, 780 CMR, 7'"edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One-or Taco-Family Dwelling Ext 118
/1 This Section For Official Use Only
Building Permit Num r: Date Applied: r
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
-Q O R D S`r-
I.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 R) Frontage(R)
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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
De p
Name(Print) Address for Service:
9--1
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Buildi Owner-Occupied epairs(&) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': _S'T Ri
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
O,m Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due:
i
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) O 9 V--�63 5_ -% t%``,J
V)a 1C,b t 2:.f License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
`(c 9 M.Qt O riT P.o d bpn V Type Description -
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
�1 Z U Residential Roofing Coverin
/ RC —�'
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) cQ \
IZ Cr'--y
HIC Company Name or HIC Regis rantName Registration Number
`ddres v - �.-78.5}i Expiration Date - -
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 Atlacr. c(!! 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
JJ SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
1 L-....r ,�/ C e-1 16 LY C,nv'C-- ,as Owner or uthonzed A en hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and -
behalf.
Print Name. - - ^� t .--t Q
%
Signature of Owner o uthonzed Aeen -:Date
(Signed under the l5ains and penalties of erju _
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 not 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 IO.R6 and 1 I O.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 Number of bedrooms
Number of bathrooms Number of halffbaths
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"
r .
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvesdgations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business organvation/Individual):
Address: / L4 C1 `/h ,g t S.
City/State/Zip:�P ra h. t tilil C i 9 6 O Phone.#: q ri
Are you an employer?Check the appropriate box:
general contractor and I a am I Type of project(required):
1.�'I am a employer with�_ 4. ❑ g
employees(full and/or part-time).• have hired the sub-contractors 6. ❑ New construction
2.❑ 1 am a sale proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub ccntactors have g• ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers'comp, insurance comp.insurance.t 9. ❑ Building addition
required-] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work 11. Plumbing repairs or additions
myself [No workers' comp. officers have exercised their ❑
right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152,§I(4),and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
•Any applicant that cheeks 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 must submit a new affidavit indicating such a
'Contra Ctors that check this box tram attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide then 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. nn
Insurance Company Name:_L 7 ! [ r S v s u A L
Policy#or Self-ins.Lic.#:_(j C 1 O Cl ') 9 0 a c'; O Expiration Date: C 9 -
Job Site Address: 1 O Q rzI City/State/Zip: SAIo sir M A
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 a 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties it.the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investilzations of the DIA for insurance coveraee verification
I do hereby certify under the pains and penalties ofperjury that the information provided above Is true and correct
Signature: Date :3 — 1-
Phone#:
QJf1cial use only. Do not write In MIs area, to be c_o_m_p_k_1ed_Fy_cWor town official
City or Town: PermittUcense#
Usuing Authority(circle one):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
0f / 2L)Ub 2 : U9 : 2u I M b935 U1 U2 / U2
011
a ISSi_C D:1[E 07/31/2008
QiMiii
—
RODUCER THIS CERTIFICATE IS ISSUED A.S A MAI TER OF INFORMATION ONLY AND
Edward?Sennot: CONFERS NO RIGHTS UPON ME CFPT1FICATF 1:0',DhR.THIS CERTIFICATE
DOES NOT AMEND,EXTEND OR ALTER?'HE COVERAGE AFFORDED BY THE
[Agency Inc 'POLICIES BELOW.
16 South Main Street
opsfield.MA 01983 — COMPANIES AFFORDING COVERAGE
INSURED —
Len Gibely Contracting Company Inc -
Jenness Street .CCMPAIY A Ai.M. Mutual Insurance Co
Beverly,MA 01915 LETTER -
THIS IS TO CERTIFY TH AT 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
TG AIFICH THIS CLRi IFICA:'E MAY BF I"SITFD OR MAY PFRT'AiN,THE INSURANCE AFFORDED BY'i AE POT H-1E s DESCRIBED HEREIN IS SUBJECT
�TO ALL TILE T3RMS,EXCLUSIONS AND CONDITIONS OF SL•.'H✓OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
( CO TIRE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
-- — LIMITS
Drµ DATE(MM/DDIYY) DATE(M MIDD/YY)
GENERAL LIABILITY GENERALAOGR.GATE
IFRODUCTS-COMP/OP AI
=COMME:iCIAL GENERALLIA811-1i P4BONA &ADV. YJURI
==CLAIMS MADE=OCCUR - r
_EACY.OCCURRENCE
=OWNER'S&CONTRACF03'S F HOT.
80.E DAMAGE(Anyw:tuel
I MEE EXPEN.^.E(Mpom_mcnj
AUTOMOBILE LIABILiT, i' .COMBINED FIN0.F
1LIMIT
_.—
AGTL
FALL O,VFFnhUTo> !DODILY IN'.IUft}
I SCHEDULLD A. (Pa penes— "
I
I�H B
RED AUTOS
NON OV.--DAUNS O;•ILY IN:`)El'
I GAI—Z:L\DILITY (Pn�lOtleN)
PROPERTY DAMAGE --_
EXCESS LIABILITI' E4Glry OCCURRENCE
_J
UMBRELLA FORM AGGREGATE
OTHER NUMBRELLA FORM v
WORKERS COIIIPENSATION AND STATUTORY LIM ITS OTHER
FA
L05'ERS LIABILITY X
Rop' TGSIEL EACH ACCIDENT 500,000
.41L,EXECIIrIVE 60109/9012008 08/03/2008 08/03/2009 EL DISEASE-POL!C Y LIMIT �00,000
L ESL:.
I ( L L E—kA^:.
EMPLOYELOYE E 500,000
00MMENTS DES�RIPT:UN')1+OPERATIONS OR LOCATIONS.
I
III
I
OULD M} OF THE ABOVE DPSCRI ED POLICIES BE CANCEI T M BEFORE THE EXPIRATION DATE
A N GE LA SI RO N I ERF.OP,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 WRITTEN NOTICE TO THE CERTIFICATE,
OLDER NAMED TO THE LEFT,BUT FAILURE TO MAD,SUCH NOTICE SHALL IMPOSE NO OBLIGATION
ICIO CIBELY RLLIBBITY OF ANY RIND UPON THE CO'.+@ANY,ITS AGENTS OR REPRESENTATIVES,
I I
49MAINST
EABODY, MA 01960 LITORLZED REPRESENTATIVE
1755
Page No
LEN GIBELY CONTRACTING CO.,INC. -rZO17O-,PROPIOSATL ."' i
- s '449 Main Street
Ile
PEABODY,MASSACHUSETTS 01960 "
All home Improvement conbactors Adi,.bconnact" B
(978)531-8234 engaged In home Improvement contreeting unleea
FA%(97W 531-9304 re
spaciflcaly,exempt from registration by_Provislone e1 u, -
Chapter 14M of Me general laws,must he glatered
Submi To 'with the Commonwealth o1 Massachusetts Inquiries
I /nn 111_LCL about registration and statue should be marts to the "" g
,, 1 f Director,Home Improvement Contract Registration, y
--/-Q-0-Ct1— I_ One Ashburton Place,Room lath,Boston,Ml,MIN k
/�
(617) 727.8598. Owners who see ure their own
. So ", IM1719 construction.related permits or deal with unreglstered
contractors will be exclutled from the Guaranty Fund
Provision of MGL c.142A.
/^-Bra P¢al4*WLIOX N6
G�aJ�74y_4y 7A �/��04 MA.REG.100811
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MMNAIOBIsI.Benlnp delay CauOeE Ly elrcume ¢eyOM LMV41010—.'NB wM1 as W eompl M By�l.TM Owner lyeebr
[Mrwad uq a,. wM]Wiry ddw wa eppvAvtoWNYauCll,alew NY OnMVMLdOw Na¢nYaCl>ae.�weY,a��l��bmnXG,a] Ilona e,.0 rwiwR
TN LUNealp wu,anO Nat Ne woM lumINM M,auMU Nell de leeelmm deleoa NmYpW wtl wwkmwMpbepwWd�YtI_xe-No a..WNXlmmdywlN
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war elureempaWnd eMkd aWualnp Wen WConeoclwdWlnMwm eNa:w.bNMN,enwW,rgtlC cnct wpleu,o,uuwmda,emedlad nw0ed.uregeoed,
euT demeGOp WCli denib w wa,kme,WIP TIe GNdnp wa„enlW du¢aurvM Ony klepx.Vdn WTrXr a au add MNWXywdu7Xwk.
YYB PfOP080 hereby to furnl - ecco ce with above specification, for the sum of. 1 atsnrtsnfhresr-'-Csmals<� _
112
dollero(a ).
Payrd tro be made aaro cos `c o/ IZW -) 1
x It alaNn,Careen;
baewe,p NdNw /
x(s{2�-1Ypar wmw.mrm Bnwl.dd.w � -�— 4 -- 7
x( Iwpr w.mpldo br
x( ldhdcemeoeaN upon
comp a um leash under Nb<dnlNd. ���lllliiii V TV1
NolaO: NOep00m0Molodo.lmp,owmenl wnVeNnp xwkebell rpYl,O,dawn
peymeN(edvvu deµel)01 mp0 ow aMNlrtl d Ne IONI onset prb w Ne / O
IOW emwX d all deposedr peymana xTM the dery r.make Nedve,rx. 1 -
W—1 drag.cherwde ablal .1.1 of.pact...meted.uq eaYlpinant. Bea
Acceptance of Proposal I hate read both sides of this document and accept the p 1`tq'q/L/8
Mal upon signing.this proposal becomes a binding contract. You are authorised to do No wort ,
You,the Buyer,may cancel this transaction at any time prior.to.mie
the date of this transaction:Cancellation must,be done In writing. Z.6r/7,,Z
T SIGN THIS CONTRACT IF THERE ARE 1
. +-2.5 L7
IMPORTANT INFORMATION ON BACK D� I
1'
p� CT 10 �
�\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
_ Registrar T:,100811
Expiration =r,(23/2010 Tr# 268971
r�t [Type Pnvate oration
LEN GIBELYCONTRACTING;CO:EINC.
Brian Dobbins
149 Main Street
Peabody, MA 01960 Administrator
( 130ARD OF BUILDING REGULATIONS `
License: CONSTRUCTION SUPERVISOR i Ir I NumbeC:,S,,$� 094763 �
r
B��teA.D511441943
'R�t €a 14Yfi01' r Tr.no: W63
19 CEDAR S, WA DRiiJ�°
DRNVENVERS, MR 01923
Commissioner i
i