25 PROCTOR ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tito-Fa _ !ling
This S ton Fo fTici 1 Use Only
Building Permit Number' ate ppli ' /l
Signature: lz�'0 ?
Building Commissioner/I pector of uild Date
SECT TE INFORMATION
I!Propert Address: 1.2 Assessors Map& Parcel Numbers
i� �i7 o r`o a ST
Ma Number Parcel Number
1.I a Is this an accepted street'?yes_ no_ p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(fl)
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
-----------------
2.1 Owner'of RSLprd: h
a
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildings Owner-Occupied Repairs(s Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': 1, T R'b W V rt RG ler ^r% F -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x \
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List: �j rev
5. Mechanical (Fire S Total All Fees: S
Suppression)
eo Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S �� 0 ❑Paid in Full ❑ Outstanding Balance Due:
r
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) S I tO
r rj�h t N L. License Number E.xptrauon Date
N.4mc of CSL.Helder
L-(!3 Ij1'1A to Sr Paab fl�, List CSLType(seeW-ow)
A T Descri lion
U Unrestrictrd u to 35,000 Cu. FL)
R I Restricted 1&2 Family Dwelling
Si nature M klasonry Only
3 ( 3y RC Residential Roofing Covering
Telephone \VS Residential Window and Siding
S Residential Solid Fuel Burning ApplianceD Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) D D
1 ► C"' x THIC Company Name or HIC Registrant Name Registration Number
P ,q/^� p
O [..-� —1 p 5j( '��4 Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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
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
SECTION 7b: O/W+NER'OR AUTHORIZED AGENT DECLARATION
1, —o nJ CiFt .b.e L C n/�T ,as Owner o uthorized Age hereby declare
that the statements and information on the foregoing application are true and accurate, to t e est o my knowledge and
behalf.
T 1ell bc.r.r t
Print Name
Signature of Owner o Aulhonze Ag Date
(Signed under the pains an ena ties o r u
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 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 I IO.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 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'
l
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /^ Please Print Leeibly
Name (Business/Organization/Individual): L 2 ✓ lie . k> I_Y
Address: I Y Q M A t z 1! T
City/State/Zip:?� A 60 —,V., t 1A 6 11 i,h Phone #:_
Are you an employer? Check the appropriate box: Type of project(required):
1.Kl am a employer with��4 4. ElI am a general contractor and I 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' cgmp. insurance. 9, ❑ Building addition o
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.❑
'Any applicant the checks box#I must also fill out the section below showing their workers'compensation policy information.
'1lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit I n d I C a I i ng such.
�Comracwrs that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infonnanon.
t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: /A M M L2 A _6 .v S C O _
Policy # or Self-ins. Lic. #: 6O I O Ct 9 O 1 O D8 Expiration Date:
Job Site Address: S P2 oc--10P a ST' City/State/Zip: s A L, oivj M�
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 c. 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 in the torn of a STOP WORK ORDER and a line
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
Investigations of the DIA for insurance coverage verification.
do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct.
Signature + — Date — —2 ( ' C7
Prone#: R 3
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing.Authority (circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk. 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
i / L U U O L U Y L O YIVI O Y J O W U a / v im
o !
ISS1IC Ii,iTL 07/3112008
RODUCER TH1S CERTIFICA77i IS ISSUETI A.S A MAT I ER OF INFORMATION ONLY AND
�fidwa[d'?SennoC Inanl;we CONFERS NO RIGHTS UPON'17-IE CcRTIFICATE',:MDER.THIS CERTIFICATE
�AReacy Inc QQES NOT AMEND.EXTEND nR ALTER THE COVERAGE AFFORDED BY THE
'-POLICIES BELOW.
Ilo South Main Sheet �
ROpsfield,MA 01983 COMPANIES AFFORDING COVERAGE
SURED —.--
en Gibely Contracting Company Inc
Jenness Street - -�-COMPANY A Ai.M. Mutual Insurance Co
LETTER
overly,MA 01915
THIS IS TO CER,�Y TE 4T HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
I PER10D INDICATEG.NUTW:THSTANDINC ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OT.H?'RDOCUMENT WITH RESPECT
TG IA'HICH THIS CcRI ffltiA-..^E MAY BF ISSUED OR MAY PFRTA.IIJ.THE INSURANCE AFFORDED BY'C-IE.POIXIE,DESCRIBED HEREIN IS SUBJECT
TO ALL T}ti TSRMS,EXCLU510?:S AND CONDITIONS OF SLiH('OLICIL•S.LAtITS SFIOWN MAY IdP.'.'E➢EEN REDUCED BY PAID CLAIMS.
CO T\9E OFINIUFANCE POLICY NUTARER 90LICY E!'FECTIVE 90LICY E%PIRATION LIMITS
LIR DATE(M WDDIYYI DAIS(MMIDDIYYI
GErvERAL LIABIW TY —YGEN�MLwOG�:4ATE S
IFF_RODUI CIS-COMPICIPAU:;
�COM.IAERC.AL GENEH.1t!.IABILI'F5 P91(SONAL@ADV NJUR(
OOCLAIMS MADE=OCCUR I-CH OCCU40.ENCE
OWpSR'S,ECONTAALTO]'SIRCT.
f1RE DAMAGE(A�ry.n:tue I
HEL E%PEN..".E(Avyom pmrn)
ABTOMOEME I.D.BILITI 1' .CJMBINED'INOLF
LIMIT
I I L'
ANY AUTO ! (BODILY INJURY
ALL OWE,AUTOS I (Pn Vmon)
SCHEDULED A,
� W!HIREDAUTOS 90:'ILY N;`JF.Y
NOII O ::DAGTOS (9er z.omem`
OAId.vE:'\JI'-ITY
PR"PERTY UAMAI:C
EYCESS LIABILITY _� C9CH OCCVRREN/:C — —J
UMBFELLY FORM AG OREGA.
ti..: .... : yf^
__OTXERTHAN UMBRELLA FORM .w. E
__+
WORKERS COMPENSATIONAND TATLTI'ORYLIM117. THER
E➢n'LOITRS LIABILITY r:ELEACH
EPROPRIETOR( ACCIDENT 500,000
A AY.N✓.kSE%ECUTIVE
ICIERS ARE 6010979012008 08/03/2008 08/03/2009 ISEASE-POLICYL;Mrr S 500,000
'INCL
lL DISEASE-i AC:: 500,000
EMPLOYEE
COMMENTS!DESCRJPT:JN-)F OPERATIONS OR LOCATIONS.
I
HOULD M7 OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ECPIBATION DATE
4 NGF.LA SI R CI N I 1'HEREOF,THE ISSUING COMPANY WILL ILL ENDEAVOR TO MAD.(=WRITTEN NOTICE TO THE CERTHFICAT
OLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL P OSE NO OB W CATION
C/O GIB E LY R LIABILITY OF ANY KIND UPON THE COMPANY,JCS AGENTS OR REPRESENTATIVES.
I �
49 MAIN ST
I EABODY, NIA 01960 [UTHOKZED REPRESENrA'r1vE
1755
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.I.rnunB reMw
Pa9e No.
oELY CONTRACTING CO., INC. 20351 PROPOSAL
149 Main Street
,'BODY,MASSACHUSETTS 01960 All home Improvement goveractors ment and .Trsubcontractors
g tnise
engaged In home Imp Provisions of
specifically exempt from regallettlom try registered
(97a)531-8234 Chapter 142A of the general laws,
{ FAX(g78)531-9304 with the Commonwealth of Masseehusetts.Inquiries
a
,• about re fit
end status should be metle tot
/ 0,M E -1PAy ----------- Director, Home Improvement Contraaoealto^9Mtr02108
9 S
One Ashburton Piece, Room 130i,
(617) 727.8599. Ow nera who secure nrelleteretaio
p1 — eonelruetton relalatl permits or deal with unra9 Fund
Q ___--��' contractors will ba axcludatl from the GuarenH
- Provision of MGL c.142A.
sEais•an*ioN xo'pptE MA.REG.100611
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aebm Ne NIM aaY lollw'In01ry ID B 1 iry b OIB W Ue conVanar snail aml a° lollwl p Pbf rA cenll mmPb
J.fs_1t-l—faecal.eernnpeelesvdo-P�meu ens wiwcn pOlxv ul i c la alzcove,ae.
errdd 4�T�a�e�s Nal tie renWulrr, P e0,wmp4
r�s kmeranioer mAlenxs,or aem Da eee6ea e+'M1e Commcmr,ae sm><am,ano,e emPlwe
u.mr wananb Nei me vmrk to od'sd here=,r e:ee lme from a,nb own ecpa durcruw eb mw N�re�n�YINopaneno�en6nlenlonow�'nine yre�uWn wo k,a.capon
,ants W a')o PDraTnonL In tie av4nt erry 11olUG n xnr a
�nr cwndeum pI env l�e.I r.dean uv.me eommns�enen,a for the sum oi:
a+eorenmmemr'rel6 mworwnensm'.Tne roocarP welamlea seen cemwe em':nsl>a on
. I'rppOSB hereby to furnish material aallons
nd labor-complete in accordance with above specifl dollars($----�—
._.nt a be made as
Ne:mmwnn" mwroecrD^"°°nw . - --
'1JrJ. 1-)tip°"BIonIM Convacl:l
upon v,mpicten of svw Aoereea
- --Poore
.p
completion al Llryrsuk _
lsl open _
ip
f 6aell or,meae wrewiN aPoa vn
lx al� �wt
_°.cis /wmpleeon of wou�em ru wmren.
�r No epreemeni Mr M1cme lm"ovemem concrivig9'eor k 6nall reeulre a down�aDllrb �nbO
o agr ce dePosr of more Nan on""o1 me blel conlmd pries or the etuea sgwwre
oum of oil aePosla or DOYI^enb wllkM1 ale 6l order maloresa�renu Dmenl, ape wnl,amn.npueumlacelrao'^tmw
r oMlor a11161wbet OEt81n delery or sp%I Nqa:TNc pmpxalm v
i r4 rites,specifications end conditions stated.I undl
..:ceptanca of Proposal I have read both sides of finis tlocument and accept the p
n upon signing.this proposal becomes a binding contract. You are authorized to do the wide as specified. Payment will be made as outlined
i ...a,the Buyer,may cancel this transaction at any time prior to midnight of the third business day afire
f ...z date of this action.Ca -filiation IS CONTR be T F THERE Alone RE ANY BLANK SPACES. _
.1 apr'ewre
i u e IMPORTANT INFORMATION ON BACK
. y.
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
5a\
Registrat)Qr};:,100811 -
Expiration:-.6/23/2010 Tr# 268971
grype Private Corporation -
LEN GIBELY CONTRACTINGCO;)INC.
- ' Brian Dobbins
149 Main Street `
Peabody, MA 01960 Administrator
�. ✓die �Oo?xvnmu�eal!/a a�./�aaea��d�d �- .. .
BOARD OF BUILDING REGULATIONS h, .
License CONSTRUCTION SUPERVISOR. 4�
I Number. C$ti 094763
t _ B q date s0.5/14/4�43 s�
� 1t'` i .
Y �x 0rs�. 1a01(j Tr no: 94763
THOMAS R OOBBINS �: /.J f
19CEAARHIIL DRFYE� i.'
DANVERS,.
« :�I, Commissionerr.