Loading...
24 ORD ST - BUILDING INSPECTION (2) 1 � � - �a�— ► y- ( 3S3 b3 G< z The Commonwealth of Massachusetts MEMO Board of Building Regulations and Standards IN SP EC T io NALCARVICES Massachusetts State Building Code, 780 CMR SALEM Reviser[M Z(1IJ LYL A U L Building Permit Application To Construct, Repair, Renovate Or Demllw iu 8 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Out plied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers L4 t)fL D S T 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 Lol Area(;q 14) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided L6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Lone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner]of Record: M� 'G R t ;-- Qf A.4o Name(Print) City,State,ZIP -vZ:?--1.1 430.? No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Build in Owner-Occupied epairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units tOther ❑ Specify: Brief Description of Proposed Work 2: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ Ct 3 �-'� 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ — Suppression) Total All Fees:$ ��� Check No. Check Amount: Cash Amount: G. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due: Mlk�tti� �'7- 1 SECTION 5: CONSTRUCTION SERVICES 5.1, Construction Supervisor License(CSL) ^ � 3 1'4— 1 (p twS License Number Expiration Date Name of CSLtklolder - U `;) I: - List CSL Type(see below) Z3 e LJ t onST No.and Street "M Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC pouring Covering WS Window and Siding t� SF Solid Fuel Burning Appliances 3 k 3A I Insulation Telephone Email address D Demolition 5.2II Registered Home Improvement Contractor(HIC) /D n &( I 1 —e, C, 6b L.Y Ccw-r HIC Registration Number xpiration Date HIC Company Name or HIC Registrant Name S r No.and Street Email address rthiiigsraffidavit � y,,,��- �'IR fl1aG�4 53)t?�3� /Town, State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) kers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide will result in the denial of the Issuance of the building permit. ed 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. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, t 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. . 8-/ �i --1 Print Owner's or Authorized Agent's Name(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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.ntass.eov/oca Information on the Construction Supervisor License can be found at www.mass.sov/dos 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 Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The'Commo `wealth.o M tL f ..assuchusetta: Department oflndustrialAccidents Oftice of Invesdgadons- I Congress'S&e4 Suite 100 Boston,MA 02I14-2017 wwrKmassgov/lia. Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(BusineWOManization/Individual): P.ti .�y. b. L�( v T n 4 c Tit u d+ Co Address: 2 LJ ,,'� -e Ci /State/Zi : t��., a Phone# °( 7 $ 3: ga .3 Are you an employer?Check the'appropriate box. 1.®,I am a employe:with 1 0'1, 4: ❑ I 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- fisted on the attached sheaf. 7. ❑Remodeling ship and have no employees These sub-contractors have.: 8; ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance. t 9. ❑Building addition required.) 5 ❑ We area corporation and its 10:❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers Have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. . right of exemption per MGL 12.[]Roof repairs insurance required.] t. - c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] -Arty applicant that checks box#1 must also fill It the section below showing thgir workers'compensation pohry information. t Homeowners who submit this ailidavrt rvdicafing they are doing all work and then hire outside contractors must submit a am affidavit indicating such. tCoatmetors tharcheck this box must attached an additional sheet showing the name of the subco�ractbta and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers comp policy numtier; I am an employer that is providing workers'compensation Insurance for my employees. Below is the po/Icy and Job site information. Insurance Company Name: •_ M t "i v T"tl A i, 1 a c r A,, Policy#or Self ins. tic. #:_ WC j b O 6 b ► Q ry a^ abt 4AExpitation Date: _ Job Site Address: V ©2 P S !- City/State/Zip• Sq Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as.requurd under Section 25A of IvfGL 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 t do hereby certify under the pansand penalges.ofperjury that the informadanprnvided above is true and correct. D to h ne S [[Official use only. Do not write in this area,to be completedby city or town ojficial.y or Town: Permitlldcense#ing Authority(circle one): oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspectorthertact Person: Phone#: 4. acoRo® CERTIFICATE OF LIABILITY INSURANCE °"08101/2014Y°' lei oarov2ola 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. It SUBROGATION IS WAIVED,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 endorsemenl(s). PRODUCER 01634-001 CRRIILACT Edward F Sennolt Insurance16 South EAf1p�L,P.Et11 An1C.NP.: Topsfield Main 01983t ADDHESB: Na Iecwret AFFORDING COVEOAGE INSURER A. A.I.M.Mutual Insurance Company 26158 INSURED Len Gibely Contracting Company Inc EfiElYRER 13, — — 23 Winter Street Rear `-- Peabody,MA 01$60.5341 —_ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED WAMED 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, MR AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.y ILTR TYPE°FINSURANCE I Sli VND POLICY NUMBER MMIDDIY M�YY _ LIMITS GENERAL LIABILITY - EACH OCCURRENCE S COMMERCIAL GENERAL UABILRY A�MAGETORFM. . S S CLAIMS MADE OCCUR MEDEXP(Anymmpmson) $ PERSONAL S ADV INJURY $ GENERAL AGGREGATE f EN'L AGGREGATE L;ANY IMRIT APPLIES PER: PROOUC;7 COMROP AGO E I)SCE _ OC IABILITY 1 t MIT $ BODILY INJURY(Per mrwn) S D SCHEDULED AUTOS BODILY INJURY(Per acadenq S TOS NON-OWNED O DAMAG S A LIAR OCCUREACH OCCURRENCE S IA6 CLAIMSMADE AGGREGATEfr Cp' RRETTpENTIONNSLAST V. THOO�Y�RP5q LWgBI�QTRY��� CV-I-tyX TORY IJIAITS °EREMPF l&EJ%WRECNT"EI N N/A VWC-100-6010979.2014A er3reoia 8lsl2ou EL EACH ACCIDENT f 600,000.00 l�n NnHtl) .- EL DI SEASE-EA EMPLOYEE S 500,000.00 ON OF�PERATIONS 1*1 w E.L.DISEASE-POLICY LIMIT S 50D,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remu s Schedule,a more space Is meulmd) 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 REPRESENTATIVE ©1988=2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD ACORN, CERTIFICATE OF LIABILITY INSURANCE DATE(MWIxVYYYY) 02/06/2014 PRODUCER 978.887.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 16 South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 457 Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC# INSURED Len Gibely Contracting Co., Inc. INSURER A: Catlin Specialty Insurance Co 23R Winter Street INSURERB: Safety Indemnity 33618 Peabody, MA 01960 NSURER C: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICY N LTR , SRZ TYPE OF INSURANCE POLICY NUMBER DATE MMIDO DATE MWDDIYYYY LOUTS GENERALIJABILITY 3700302145 01/29/2014 01/29/2015 EACH OCCURRENCE a 1,000,00 X COMMERCIAL GENERAL LU181LffY DAMAGE IORENIED PREMISES Ea oaurrM>ce $ 100,000 CLAIMS MADE T OCCUR MED EXP(Any one pereon) $ 5,Q0( A PERSONAL SADVINJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S 2,000,000 PRO- LOC POLICY JECT AUTOMOBILE LIABILITY 6221693 COM 01 01/29/2014 81/29/2015 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per Person) $ B X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Par accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EAACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE 5 $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER IJ ANY PROPRIETOR/EXCLUDED? E.L.EACH ACCIDENT $ (MandatorOFFICERIy in NH) EXCLUOED9 u It es,dto7 in NH) E.L.DISEASE-EA EMPLOYE $ R yes,AL PRO under SPECIAL PROVISIONS bebW E.L.DISEASE-POLICY LIMB E OTHER DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS Proof of insurances. I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Robert Sennott RP ACORD 25(2009/01) 01988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD e II ' LEN GIBELY CONTRACTING CO., INC. 9 23R Winter Street 26061 PROPOSAL P BAE ODY, MASSACHUSETTS 01960 All home Improvement contractors and subcontractors r (978)531-8234 Fax(978)531-9304 engaged In home Improvement contracting, unless www.lenglbelycontr�ing.com specifically exempt from registration by Provisions of t . Chapter 142A of the general laws,must be registered Submitted .--, with the Commonwealth of Massachusetts.Inquiries To: -. �. �. - -- --- -bout registration and status should be made to the n Director, Home Improvement Contract Registration, One Ashburton Place,Room 1301,Boston,MA 02108 ---- ((( (617) 727.8598. Owners who secure their own n Q construction related permits or deal with unregistered _)r'�_9C—!..-. contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. pg og— wTr/:) 1180elPAnoNNo. 1, yyi— 7 MA.REG.100811 JOB NgMF/NO. ( JOB LOCPTION WaM1 ebysubmllspecillcatipns entl sgmates for work lob performed and m 1 JYe Is to be used 6 /10gm� �n`ree„�n�^T,___=�!^�.r3/� /}ouSlS b .S•kf�0 -_ 0,(y ex%STilas La it,IiN3 T/t /G-L Joent �/ 1141 .6'-iel .6ro -uQ r—" e/ PILO E✓ StV 1 S' lit S% C ell Iea6 /�l� _�cf� r+ �2 C/tnu it -2�.or�Leh.q �iUs — !j t• -bs/ It'ni rl .0 3 69 e&',a TV Lv l.So eir nn !l // nn � t pWAJ urrL ,9°r �'B�_c'�.�p �of _ .-�rN/sfolt �•es'G. Sh _.�NS� p- -- i bill - -- - -- ---- ---- �b Cliff 3 8 6 oo woRx sc o 0 rouri. Conlmcto a orN ar oNer 1M1e mdoe atalRls bolero Ne birtl tley I011owinS the si0^ing of this lrgreemonl,unless sDecilletl M1ereln wmm 5yWa p/ pnlselgln rAho o abom�alel.Baubg tleley causes by circumstances Ueyontl ConVacbrs control,the work will be completetl byn— IE 1 eby HWan rq rban nd lsoeon alWredestinare llwlaBe ryWratlbCenrepale�sinca'�r�0 ar^h Pbb Wsantr t,lwil�mmplebtl etShall .r man M1louonIrMNNO�RIa nl. WARRPNTY The contractor warrants that the work Welco a hereunder shall be free Imm dead-in malarial entl workmanship for a pa.M of ollowinq completion a^a shall comply wiln ro the mpulremanls of Nls PpraamenL In Ne.rent any Uefwtln workmansaip or materials,or tlomeBe muin.setl by the Gonlre<bG his subcon brs,employea...... or agents,is recovered within such damageor Such e armed detect In meterllolslor up ain the Contractor In The foregoing warrantorrshop survhre a,spection performed in oonnaMml with In. ,.ad a an to upon. ,d rapalreq m mplacatl, We Propose hereby to furnish material and lacy—complete in accordance with above specificatic ns,for e�sjum of: y �l dollars($ J .�O Payment to be made es fold tom\ Rem a ell job Inch. [�/y� � All Suammoua on all ptWw0.a he I.manulecturer. (S.y I upon eigninB coneiph�, /ems add permit cost 11 headed we pull permit. —%(S )upon completion of — NotiOe: No^greema or home' provemant contracting work shall require do pay I(edv c depo f more than do third of the lo�raid- -%(S—)upon completion of Ori orth totals ounl al all Iep its or payments wM1Iranor must me n vent to or er a to othemis e1Nery o eclat order shell be made lodeve,upon mat Is cold pment aLISM9-IBL %lf l completion of work under Nis contract. here 111,prcpoul may as willl W uail^m..,led witin Gaye. as ACCep}aGCe D} Proposal I have read both sides of this tlocument and cc t is s,specifications and conditions stated, understand that upon signing,this proposal becomes a binding contract.You are authorizetl do h ork specified, Payment will be made as outlined above. You,the Buyer,may cancel this transaction at any time p for o idnight of the third business day after the date of this transaction.Cancellation must be done in wr in . DO NOT SIGN THIS CONTRACT IFTHE ARE ANY BLANK SPACES. J. FJS"n9" FI slv^awre Dore IMPORTANT INFORMATION ON BACK 1 ...................:ac.._.__:......... >.:_.a... Massachusetts -Department of Public Safety Board of Building Regulations and Standards C,mtructiun Supers ism License: CS-094763 r r„ THOMAS R DOBBIN �•r' - 19 Cedar Hill Drive t3 Danvers MA 01923 - , Expiration Commissioner 05/14/2016 Office of Consumer Affairs& Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: 100611 TYPO Office of Consumer Affairs and Business Regulation -_ ��yy ' xpiration: 6/23/2016 Private Corporation IO Park Plaza-Suite 5170 Jr�3. Boston,MA 02116 LEN GISELY CONTRACTING CO., INC. Brian Dobbins 23 R WINTER ST. __ PEABODY, MA 01960 Undersecretary Not valid wit ut signature r