9 RAND RD - BUILDING INSPECTION CIEZ 6 (
t (A.- t
The Commonwealth of Massachusetts INSPECTIONAL SERIV!(CE�F
.� Board of Building Regulations and Standards SA{�LEhi
I Massachusetts State Building Code, 780 CMR, 101U NOV 13 i�ew It Ur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied:
D°g /
Building Official(Print Name). St Mature
SECTION L•SITE INFORMATION'
LI Pro erty Address: 1.2 Assessors biap& Parcel Numbers
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(it)
1.5 Building Setbacks(R)
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 Cl
Public❑ Private Cl Zone:
if yesCl
SECTION2: PROPERTY OWNERSHIP!
2.1 Ownert of Record: Q
f'\rvs nt4,� TCS J"J
Ntme(Print)
City,State,ZIP
L l �-V 0-) -75?.'J 4o
o.;md Street Telephone Email AddressN
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Number of Units_ Other Cl Specify:
Brief Des lion of roposed\VorV:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building S 0 o 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 $ 1�Qther Fees: .S ///� R
4. Mechanical (FIVAC) S List: //(� (a
5.Mechanical (Fire S Total All Fees: S
r's ression)
T Check No. Check Amount: Cash r\mount:
6. otal Project Cult S �7FOD� ❑Paid in Full ❑Outstanding Balance Due:
�s
nA CIVY C�0Pf1�rG� .
I
r
1 <<SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Ct CA Vl(,a, �C'_ � 4_ j L
n`
"'�--!,��� b�a-�✓S i . . License Number Expiration Dale
-
Name of CSL Holden List CSL Type(see below)
Type Description
No. and Street
U Unrestricted(Buildings tip to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.21 Registered Home Improvement Contractor(HIC) 10 y 8 t k
L—.D.CI 6�-t Ex.�LY HIC Registration Number •xprration Date
HIC Cump:my Nome or 111C e istmnt Nane
� � �
N treet 3? Email address
nA hn�1r 1LI /7 {� .t1�1
City/Town, State ZIP 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 IsAuance of the building permit.
Signed Affidavit Attached? Yes .......... O No...........❑
SECTION 7a:OWNER AUTHORIZATION:TO RE COMPLETED WHEN:'
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.
Print Owner's o \uthorized Agent 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 NLG.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. •av:'oca Information on the Construction Supervisor License can be found at vvww.nnass.e� _
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) .4 ,(including garage, finished basementlattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
fype of heating system Number of decks/porches
Type ofcoolingsystem Enclosed Open
1. Total Project Square Footage"may be substituted fur-rotal Project Cost"
The•Commot(wealth;ofMasspchusetts
Department oflndustrialAccidents
Office oflnvesdgattons
T Congress Street;Suite 100
Boston,MA 02114-2017
Workers'.Compensation Insurance AfCidavi udders/Contractors/Electricians/Plumbers
Applicant Information i Please Print Le ably
NaMe MusineSdOrganization/Individual):_t_: .Q.ti Cy, b.p i_V c., ~'i A-4 G"(ri,.,,,; ✓ Ct,
Address- ---S 2 LA-) � -e jr -
Ci /State/Zi - 6 oY A Q Va Phone M Of-)
Are you an employer?.Check the appropriate box.
1.®Tam it employer with 4. ❑ I am a,general cotttractor and I Type ofproject(required):
employees (full and/or part=time).! have hired the sub-contractors 6. .❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and'have'no employees These sub-comractor&have: g; Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. ins ra ce.$ 9. ❑ Building addition
required.] 5: We are a corporation and,its 100 Electrical repairs or additions
3.❑ I am a homeowner doing all work 01B." .l eve exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of`exemption per MGL
i 12.0 Roof repairs
insurance required.] t. a 152,§1(4) and we have no
employees. [No workers' " 13.❑ Other
comp.
"My applicant flier checks box#1-must also fill out the section below showing their workers'wmpensation policy infonnmion.
t Homeownps t 6 submit this affidavit indicating they we doing all work and then him outside contiaclo,s must"=nit a new affidavit indicating such.
:Contractors that check this box mast attached an additional sheet showing the name of the subcomiacto,,and state whether or not those entities have
employees. !f the sub-conbactors have em to ees,they must provide their workers'comps policy numtier.
lam an employer that Is providing workers'compensation Insurance for my employees.,Below Is the policy and Job site
informadom
Insurance Company Naine:� r /t jy �'J v `t V A
Policy#'or Self ins. Lic. #,- W C -[ G"J t? b D 1 n 'I'7 4- 14AExpur Lion Date — rj
Job Site Address 9c�—�p City/StatelZip
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 ofMGL c. 152 am lead to.thc 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 flay against the violator. Be'advised that a copy of this statement may be forwarded to the Office of
Investigations of the;DIA for irrsuranoe:coverage:verification.,:.
I do hereby certify
under the pauts,and penalties.ofper�ury that the mfrtrmadon provided above is true and correct
Phone#:
[[6.
fficial use only. Do not wrhe in this area,to be completed by city or town official.
y or Town: Permit/License #
uing AF
ity(circle one):
I.Boardalth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Otherntact Person: Phone#:
ACORQN CERTIFICATE OF LIABILITY INSURANCE DATE 02/ 6/2014 06/2014
'
-1QQW-ER 978.887.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
dward 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
'. 0. Box 457 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. -
i ups fi el d, MA 01983 INSURERS AFFORDING COVERAGE NAIC #
'J[[E0 Len Gibely Contracting Co. , In c. ___ INSURERA Catlin Specialty Insurance Co
23R Winter Street INSURERS: Safety Indemnity 33618
Peabody, MA 01960 [INSURER C:
INSURER D:
I
OVERAGES NSURER E:
I HE 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.
vi DD'
N NSR TYPE OF INSURANCE POLICY NUMBER DATE NWDOIYYYY DATE MMIDp/TWY UNITS
GENERAL una1LITY 370030214E 01/29/2014 01/29/2015 EACHOCCURRENCE $ 1'000,00
X COMMERCIAL GENERAL LIABILITY E
I_.. CLAIMS MADE OCCUR PREMISES Ea=urrerlce $ 100,00
MEO EXP(Any oiw pwwI) $ _ 5,000
--- --- PERSONAL B ADV INJURY $ 1,000,00
-- GENERAL AGGREGATE $ _20000 0O
�EN'L AGGREGATE LIMIT
MOIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000 000
POLICY JECT LOC
AUTOMOBILE LIABIUTY 6221693 CQM 01 01/29/2014 11/29/2015
COMBINED SINGLE LIMIT
ANY AUTO (Ea a Idenl) $
-� 11000,000
ALL OWNED AUTOS
BODILY INJURY $
IX SCHEDULED AUTOS (Par Nmw)
X 1 HIRED AUTOS
BODILY INJURY NON-OWNEDAUTOS (Per $
axtidenl)
f - — PROPERTY DAMAGE
(Par accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER AUTOO
EA ACC II
AUTO ONLY:
AGG S
j EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
I'NORKERS COMPENSATION _
AND EMPLOYERS'LIABILITY Y/NI T RY LIMIT ER
ANY PROPRIETOWPARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $
OFFICEWMEMBER EXCLUDED?
IMand.IWyin NN) E.L.DISEASE-EA EMPLOYEEI S
ll EdRO
IAL PRO Y WS VI PS
SPECSIOONS oebw E.L.DISEASE-POLICY LIMB $
T OTHER
SCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
oof of insurances.
ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL 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 I ABIUTY OF ANY KIND UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE �/ r�
Robert Sennott RP '4--° e
.CORD 25 (2009101) 01988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Ago o® CERTIFICATE OF LIABILITY INSURANCE DATE(MtND01YYYYl
oe1o11xou
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
BELOW.CERTIFTH THISATE DOES
CERTIFICATEFOF INSURANCER DO
ES CONSTTU�E AFCONTR ALTER THE COVERAGE AFFORDED BY THE POLICIES
RACT BETWEEN THE ISSUING NSVRER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the Pollcy(ies)must be endorsed. If 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 endorsement(s).
PRODUCER 01634-001 CT
Edward F Sermon Insurance t. - Ayd
16 South Main Street
Topsfield,MA 01883
INSUREDA.I.M.Mutual Insurance Company 26168
Len 0ibe ly Contracting Com Perry Ina INSURER B
23 Winter Street Rear -..-
Peabody,MA O1S60.6841
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 REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VWTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCHES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
INK
AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE POLX:Y NUMBER
LMITS
GENERAL LIABILITY —
EACH OCCURRENCE i
-Y-COMAERCLLL GENERAL UABIUTI' A�AL�YO-IYFI7YK/� S
7 CUIMSMADE 7OCCUR MUD EW+(MYOne Pa,30n) S
---{-- PERSONAL a ADV INJURY 3 -
_..J.__._.------ GENERAI.AOOREGATE S -_
.EN'L ACOREGATELIMT APPUESPER: PRODUCTS-COMP/OPAGG 3
_- CLICY F��L OC
AVTOMOBILE LIABILITY NEITSINOLE-DM S ---
ANY AUTO BOOILYWJURY(PeIPew) S
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Pei ecaoanV S
HIRED AUTOS NTNOSwNED _
f
S
UMBRELLA WB OCCUR EACH OCCURRENCE S
EXCesb LAS CLNMSMADE AGGREGATE S
CEO RETENTION 3 --
�'NrQY�y� L� tP ' j� X O
o�F1l+ pprygq pp�EXECUTIVE
A G' RMEMItA FUtCItlDED'I N NIA VWC-100-6010979.2014A 81312014 8/312016 E.L.EACH ACCIDENt $ 600:000.00
(MYneamry In NnH1MI EL.DISEASE•EA EMPLOYEE $ 500,000.00
�` kl Fo A EL.DISEASE.POLICY LIMB 3 600,000.00
DESCRIPTION Of OP'-rAYIONbl LOGATIONSf VeHICLEb'IAnacb AGOflD t01,Ae0iaonnl Remar4 SOMOYN,,ewore SPSp le nRuu00) -
CERTIFICATE HOLDER CANCELLATION li
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION GATE THEREOF, NOTICE WILL Be DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
1988.2010 ACORD CORPORATION.A rights reserved.
ACORD 25 (2010I05) The ACORD name and logo are registered marks of ACORD
LE ELY CONTRACTING CO., INC. Page No. �ot Pages
U4
` 23R Winter Street 26074 PROPOSAL
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
(978)531.8234 Fax(978)531-9304 engaged in home Improvement contracting, unless
www.lengibelycontracling.com specifically exempt from registration by Provisions of
,/I.-�// Chapter 142A of the general laws, must be registered
Submitted Tyr I" - with the Commonwealth of Massachusetts. Inquiries
To: -_ ,_!-- 0/_'__, U��`1_ about registration and status should be made to the
N� Director, Home Improvement Contract Registration,
One Ashburton Place, Room 1301, Boston, MA 02108
n'/ll 617 727-8698. Owners who secure their own -
0070 G v construction related permits or deal with unregistered
-J-- - - - L -- contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
PHONE G q / GATE �1 eEGISTflATION NO. ,
9�u - 39s� (9 �Sy l0 - oCl - �� MA. REG. 100811 /
JOB NAME/NO. JOa LOCATION
We hereby submit specifications and estimable for work to be performed and materials to be used: ICY
- ------- --- — — ----1— moor fLt'n 1,9/cc14lc/rT--
5�6 fir_— Ll 1 aAF5- -[stif� �tcQJ — 1�--/1 �SNN9C �1/n
vieeesslsvY--- 1�a hat �[n)sI)cc4/- l/
�F}iiv�Kd /A-CI--vg t r —_ ✓a v�S'/W7
/Lesfi off? /� aof o /!`16 —r</f- -�I _fie 1nes�dl c_7
�--o_ all__. led- es S/vs�.ey _S�a41vd,0 d 5--b%1--
- -- -/--s f r h s L i0us /9l/ C c2fi9 iiv fC� �- L eNcl v,Al
ifhes_ L�vsv�fr¢1�-
yo1. 0
WORH SC E E
unless pacified M1arei wribi C will begin the work on o
Contract o4bB thew rk o a nM1e terials before the third day following the signing of this Agreement,a ass spec a n g r
about g ey caused by circumstances beyond Contractor's control,the work will be comele d by dets).The Owner hereby
acknowled s and Be s that tlouscheduling dales are approximate and that Such delays that are not avoidable W the contramor mall n due rations at this Agreement.
Hltltl¢n rot r conditions nor seen at time of diameter Mel are secured to be repaired In order to complete Mir contract.will be complatrear$ per nM1ourfMAN HOUR).
WARRANTY
The Contacts'weureas that MB walk lumlahed hereunder shall be free From defects in materiel and workmanship for a period of Ilowing completion entl shall comply Wilh
the rpquiremams of MIs Agreement In the event any delecl in workmanship or materials,or damage caused by Me Contractor,his subcon tiers,employes or thi is discovered within
on.
year after completion of any fob,Including clean up,the Contractor shall,at his own expense,forthwith remedy,repair,correct,mplac or cause to be remedied,repaired.or replaced
such damage or such tlelect In material.or workmanship.The foregoing warranties shall survive any inspection performed In connection with the agreed-upon work.
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
dollars($ 00. Do
Payment to be made as follows: Remove all job trash.
/ All guarantees on all products From manufacturer..
—90( V )upon signing Contract. {A.- Add permit cost if needed-we pull permit. I
Is )upon completion of Notice: No agreement for home improve nt oifrecang work shall require a
down payme t(advance ban it)of r th oneihird of the total comradt
upon completion of pn or the tal amount of deed is r pay ants which the contractor must
me in a nee,to order held,oIn R obtain delivery of special order
Y ($ )shall be made forewltb open In
Is a equipment, —
completion of work under this contract.
Note'This proposel may be withdrawn by us it not accepted within days.
aruresoKsi], us.
Acceptance of Proposal I have read both sides of this document and acc pt t ricers, pecitications and onditions stated.I understand
that upon signing,this proposal becomes a binding contract.You are authorized to d the r as s Cified. Payment i11 be made as outlined above.
You,the Buyer,may cancel this transaction at anytime pri0 to nig t of the third usiness day after the
date of this transaction.Cancellation must be done in writin .
DO NOT SIGN THIS CONTRACT
IIffFTHERE R ANY BLANK SPACES.
sgnemm Fit ale
IMPORTANT INFORMATION ON BACK I► all
'
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor ;
License CS-094763
; i. rt
THOMAS R DOB IN '
19 Cedar Hill Drivle r
Danvers MA 019#3
,I,10' Expiration
Commissioner
0511412,016
die iParrunwceeoe�o�CJ�aoaac�urae6Gi
ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
4`-. N Office of Consumer Affairs and Business Regulation
Registratl n;_ 41- Type: 10 Park Plaza-Suite 5170
Expirapppri: .3-2(k'_�16"R Supplement Card Boston,MA 02116
'Ja4 .r'i J.,I1""
LEN GIBELY CONK INC.
THOMAS DOBBIN, _
23 R WINTER ST /
PEABODY, MA 01960 - Undersecretary Not valid without signature
t f