81 PROCTOR ST - BUILDING INSPECTION (2) V
The Commonwcalth of Massachusctis
Board i Bud Town of
Building Regulations and Standards
o � Massachusetts
State Budding Code, 780 MR, T"edition Budding Dept
Building Permit Application To Construct, Rep or, R ovate Or Demolish a glkUM�
One-or Tu o-Fumrh Otirlling
This Section For Official Use dol
BwWing Perrnh Number Date Applied: I
Signature:
Building Commissioned Inspector of Buildings Dste
SECTION I:SITE INF'ORMAVO
1.1 Pro'peVy Address: [ 1.2 Assess gn ap Parcel Numbers
1.Is 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 n) Frontage(n)
1.5 Building Setbacks(R)
_ Front Yard Side Ymds Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.SSa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system,O
Check if vesCI
SECTION 2: PROPERTY OWNERSHIP'
2.1 Oweer'sof Rec�osrd: 1 t
f t [ .nrt1.n 4 t Y \ FfZO c V9
Name IPrint) Address for Service:
J1i o A a4 7t eck
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Buildin Owner-Occupied Repairs(s) D Alteration(s) O 1 Addition O
Demolition O Accessory Bldg.O 1 Number of Units_ I Other O Specify:
--
Brief riptioon of Proposed Work': :;Y rz . 12 /Ir7 A r 1 4p L, s inn Fa ml
a �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Omclal Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S ❑Total Project Cost'(Item 6)to multiplier
) Plumbing S 2. Other Fees: S ���
a_Mechanical (HVAC) S List:
s Nechantcal (fire S Total All Fees: S
Suppression)
Check No. _Check Amount: Cash Amount:_
A Total Protect Cost: S O�o� 13 Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
u er%isor CSL
5.1 Licensed Construction S p (CSL) 0 q-��-� _ ( L1 . l0
" O 6 Lip Lwcnw.NumOar ENPIranon Date
Nypt Yl'CSL Helder 1
Y y 9/s lA r v fir' �a 4 6 aF� Lt,i CSL type(><v below)ry
AdJr T Description
U Unrestricted Jup to)),000 Cu. Fl.
a " R Restricted 1&2 Family Dwelling
Si mre M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidi
SF I Residential Solid Fuel Elurninit Appliance Installation
D I Residential Demolition
S.]`rp-egistered Home Improvemeot .Contractor(HIC)
Cit D D � t
HIC Com in Name w H C Rep�u�tCName Registration Number
1-F1 A r-v C ?-�1'nq
C- 3
spintion Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.# ISC(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..........O No...........0
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 matter
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, L G-z b.o Lr Cr-, -= ,as Owner ci Authorized Agent ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
��nb 6,ui
Print Name 3 y ,OI
Signature of Owner ut oriz Agen Date O
Si tied under the airs ins aperjury)
NOTES:
l. 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 W 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 110 R6 and 110,RJ, respectively.
2. When substantial work is planned,provide the information below:
Total Goon area(Sq. Ft.) (including garage. finished basementiattics.decks or po«h)
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
Tspeof cooling system Enclosed Open
1 "Total Project Square Footage'may he +utismwed for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
u,p www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information f t �+ Please Print Le¢ibly
Name(Business/Organizatiowlndividual): Lei D o L. l r� L A P I nz6 �
Address: I L( 9 At,t� ST
City/State/Zip: q Phone#: 9 119 5 3 l 8 a 3
Are you an employer?Check the appropriate boa: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hued the sub contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner- These sub-contractors have g, ❑Demolition
ship and have no employees employees and have workers'
working for me in any capacity. 9. ❑Building addition
workers' coin insurance comp•insurance.=
[No P� 5. ❑ We are a corporation and its ME] pairs or additions
required.]
3.❑ 1 am a homeowner doing all work officers have exercised their pairs or additions
myself. [No workers' comp. right of exemption per MGL insurance required.]t c. 152, §1(4),and we have no
employees. [No workers'
Other—
comp. insurance required.]
*My applicant that checks box#I 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the subcontractors have employees,they must provide their 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. ,,//��
Insurance Company Name:—A M A� ,e S C n
Policy#or Self-ins.Lic.#: (D—q Expiration Date: M I D
Job'Site Address:
\ City/State/Zip:,2A Le"t" ,i 1 0 70
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$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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature' Date s 8 `
Phone#: C ? S -1 8
Official use only. Do not write in this area, to be completed by city or town oJrciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Phone#:
Contact Person:
ti
ISSIZDATE 07/3L?009
ROD ICER
'dward F Sennott Insurance TIM CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
Al Inc DOES NOT AMEM).E\?END OR ALTER THE COVERAGE AFFORDED BY THE
to South Main Street POLICIES BELOW.
upsficlLL\I.4 019S3 COMPANIES AFFORDING COVERAGE
NSUHEU — --
en Gibely Contracting Company Inc
cobbANY A A I.M. Munial Insurance Co
u :.
: _ .:sApA..
THIS IS TO INDICATED.
THAT THE POLICES A I'1 RELi QU CE LISTED BELOW HAVE BE-ISSUED 70 THE INSURID NA ABOVE FOR THE POLICY
PERIOD BJDICATID,NOTWITHSTANDBVG ANY REQU1REb1ENT.TERM OR CONDITION OF ANY CUNT ACT OR OTHER DOCUMENT WITH RESPECT
TO WHICH THIS CERTIFICATE MAY BE ISSUED OR NUI PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN b SUBJECT
TO ALL THE TERMS,EXCLUSIONS CONDITIONS OF SUCH POLICIES.LUIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO ME or 1.4rVRABR POLKT tMCTIL'e POLICB'ELTH ICp LIA p041LY NUMa[P CAn IMMI o.An RAWDM{n UMI[I
GENERAL LUBILI{Y cm EFu.co[[cnn
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EFLOV COCOMPENSATIONA.ND V
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G\pLOITJ[SLWILII'1' ATLgtITS STATE OTHER., ARu[rACaEVTt°[ ELEACRACCEDEVT 900,000
!InC14 AY.[
501097901'_009 06/03i2009 08l03/3010 ELDLSEASEPOLICI'LHII 1 500,000
DLS EL EASE'EACH
EAOILOIEE 50D,000
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HOUEDAN'VOFTIE.iaONEDESCRIBEDPOLCESBECANCEI BEFORETBEWMATIONDATE
F.THE Erx`NO CORIPANI'ILIlL ENDEAVOR TO LIAL 10 IwRrrTEN NOTICE TO TIE CERTEFICATE
OLDER NAMED TO THE LEFT,BUT FAILURE TO ILVL SUCH H0nCE sHALL DD'OSE NO OBUOATION
R L1A86JTY OF.WI'31ND LrEON TIE COAIpANY,RS AOENTS OR p.FPRESD TAnM
0 WHOM IT MAY CONCERN _
llrBOR17.ED REPRESE.I TAME
6169
r 1 ✓ �( Page No -4-01 Pages
pR0'POS�AL
�N GIBELY CONTRACTING CO I C. � `�• �,I,L�
PEABODY,MASSACHUSETTS 01960 S„ ' p8 home ImproyemenLeontreytore aria sabeonlractors
"- w e'` engageQ In home Improvement contraml4ll� unless
(978)531-8234 epeglQgelry exempt from�rgglatretlon by-Provisions or
FAX(978)531-9304.y -3 -4. 6 CheDtar�142A:ot the�9enerol'laws;.moat Da re9lateretl
COR MAn)L. with,the l:pmmonwealth ot'Meeeechucena.Inqulrlee
6ubmnNtl I ' i � ����,/_-_M_-_______-- ¢bout reglsirellon and¢torus should-be made to the
one Ash
Ilea ma Improvement Contract Reglsir02108
85go owners who secure their own
(677) 727
\— rmlts or deal with unregistered
M construction relelad'pe
Ct_f=� contractors wlli.tie excluded from the Guaranty fund
Sv -1 D Provision of MGL c 142A -
oATe ,. seelsnanlm MA.REG-100811t
JOB LOCAMN
Joe N.MO. - S
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CC ((�� L ��t• -�A cf� �r7 A�T—--A
permits:
--------- ��,-, sop �125_-�Lr..9-t�—_-_--------------
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Gonsiructioh ralal0tl permits: �p 1/ ' ?47kp/.y_j�P_,p__�----
LWIn the wmk on
w
WOPH eCHEOIItf plkn,pN pinpd Nl Apree en4ul apetllled hNNn wtl ate) The OwAer hallW
G nlre III 1 NBwM Ne N alar'el Let N NNtl% Naxnpacta ehxl rot Oe conYEe10E rkla0meal Nla Ap�eemanl
h ul�—lEll.e 19tl 1%c tlW ImeM llletwctl b1tl lhale,elM eMtleE19W rk III Ee PleleOW
cknmvletl9 U09rBIla N6lN echeE ll etl tea are WpMJmY. �: �Va�MI M9 canPletlon eM shell or to0rces.
�ypeMNTY � qa CGnVeCla,hlA UcaAp yqe, mpbYeaOar epBnb lnaSCWereEw'NM
TAO Gonlnclor werlanls xlet the woA NmishBtl henunEe11ep11��ha�aor mealOMe,oMrcEemeG ce°DPW a rplaca,mCeuse to be ramg9eQ repelleE or regaceE.
Ne requl,amema of txk A9rwment.In Ne eAn19%Cebc hw,bMwM reNeQV.reDlvr,angst
neyeel abet WmPle0M a1'enY K'blcluEiy d9M UD.NB COMmcla�epell al Ma awn a4e ° MtNetll cpn ecilanwlNNe e9reebupoa'waA.
such Uama9 aeePh tlelecl In materiel orwrkll;neMO The Mrepdn9'.wrleAe 61uY eurvNB a%Mspenle � r (�����
We PfOpOSB'hereby to furnish meterie�aritl labor compl�t�hi'acc�dr�deny,�'w ih above s�citl dollars('or$`-"tl' ' 'f�w) '
Payment tq be matla es follows � •
�r m0
If) 9 i 9ConlracG acamnvrotlorMama nepls°°m - - --
" Cv IoL - -- -
)aPon pleb°n of samAhe
Clryls t p
�) cMp laat lmona doef war k under this rao ell°"°'
cehbam.
Notk ant letivenca tlepasiebot more Nan oneNlNrol{Me totekmnVecapriw or Ilse Nama cl seksman � (��
I 1 dal amount of ell tleposlle or Doyments which Ne mntreMr moat make.In etivence, xM°tlzatl epnawre cars.
to omer entllor pNem'ise obtain tlellvery of¢pastel ortler matehels enE equlpmen6 NMe.Tnb arepce°'^°Ih°'"sMh1BWOP''ue 11 n°I°cceplea.nml°
vl I. r
Acceptance of Proposal I have read both sides of this document and edcepi)he popes,specifications and conditions s ated.I uad nderstand
;You�the Buye�smay cancel lhisltransactloo at any time prlor.tp midnightpof the third businessedaylove.
after,
the date of this transaction.Caneelletion must be done In wilting. „ ,. `.
Ti DO-NOT SIGN THIS NTRAC7IF THERE ARE ANY BLANK SPACES.
.q om•
.0 same.-.
spemo IMPORTANT INFORMATION ON BACKy
ION ON BACK jillm-
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• ✓�fC lJ0/IL//f4/b[V!(ll�� O�'��.Ul1CILfldP.lr
Ih
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number. CS 094763
Birthdate: 05/14/1943
- Expires: 06/14/2010 Tr.no: 94763
Restricted: 00
THOMAS R DOBBINS
19 CEDAR HILL DRIVE
DANVERS, MA 01923
Commissioner
rpm �iEe �io�r�iute¢�� o�./�aaaac�tirfe(A
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Repistra(Iggy, 100811
Explietlon:. 6123/2010 Tr# 268971
,Type: Private Corporation
LEN GIBELY CONTRACTING-CO.,'INC.
Brian Dobbins
149 Main Street
Peabody, MA 01960 - �--
Administrator