13 RAVENNA AVE - BUILDING INSPECTION r
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APPLICATION FOR
PEPOW TO
LOCATION
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PERMT GRANTED
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INSPECTOO OF BUILDIN MI
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
IV www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business/Organization/Individual): L ✓ l r t i e Ly co .tee. _`;T
Address: / 't 9 M A 1,.J ST
City/State/Zip:'FP Q ho n� MA 0 t 9 b n Phone #: cl S 3 l 8.) 3 t1
Are you an employer? Check the appropriate box: Type of project(required):
I.X I am a employer with\c- 4. ❑ I am a general contractor and 1 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. I ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working cfor me in any capacity. workers' comp. insurance. w g. ❑ Building addition
[No workers' comp. insurance 5. ElWe 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 LE] 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.❑ Other
'.Any applicant that checks box H 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.
tComractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. (� M
Insurance Company Name: /R L
Policy# or Self-ins. Lic. #:(�O .0 O O ( a y O 6 Expiration Date: 9 - 3 . D 'I
Job Site Address: 1 3 A 11m �A✓A A V-e City/State/Zip: S A L,_, 14A 0 "l _) v
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepains and penalties ofperjury that the information provided above is true and correct.
^L Signature: p � L" Date: - i " —7—O Z
Phone#: —I g J 3 D—. '3 4�
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#: ���
PUIUG PROPERTY DEPARTMENT
120 VMSNINaTON STROM, UD FLOOR
r SALiM.NA 0/970
TILL. (979)745-SS95 EXr.380
FAX (Y7s) 740-98"
STANL[Y J. USOVNZ. JIL
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MC$,c 406 M I aclmowledSe that as a 000didon
of BmTdiag Pamit M .all debris res&Mg from the cX,nxMwbom wbvky
governed by this BuildinS Permit ahali be disposed of in a PmPerly liceoaed solid w,aate
&RXX al facility.as defned by MOL c W.SIJOA.
The debris wiD be disposed of at e o b
Location ofFaerlty
Sigoinue of Permit Applicant Dade
(PLEASE PRIM CLEARLY)
mSornanao.
C 6.oL' ObA. er,- - / -T-o 'Do bb (NS
Name ofPesmrt Apphcaot
L �..� G
Pam Name.if any
l Q 9 tLI,A
Address, City a State
The above statute mquirea that debris from the damolitia% renovation,rehab or other
aheradon of bmkIMS or ftwuae be disposed in a properly-licensed solid-waste disc oaw
Scility as defined by MGL clM S 130A, and the building Permits or iicemses we to
indicate the location of the hd*,
Page No. of Pages
y LEN GIBELY CONTRACTING CO., INC.
149 Main Street ,. f 33! PROPOSAL
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors P -
1-8234 engaged in home Improvement contracting, unless
(978) 53
FAX(978) 1-8234 specifically exempt from registration by Provisions of } 7
Chapter 142A of the general laws, must be registered i n
omitted with the Commonwealth of Massachusetts. Inquiries
To:_____Melia.-_Moran. ______._____.______ __. . about registration and status should be made to the j
Director, Home Improvement Contract Registration, i
_1-3_Ravenna_Avenue------------— One Ashburton Place, Room 1301, Boston, MA 02108 _
(617) 727-8598. Owners who secure their own C f'
construction related permits or deal with unregistered c
contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A t
PHONE CATE REGISTRATION NO.
97R-745-510R MA.REG. 100811
10-18-06-
- JOB NAM6N0. J09 LOCATION
Same RAMP
hereby submit specifications and estimates for work to be performed arM materials to be used
Remove__&_install.-.2_Harvey__sliml ine-windows-and-insulate--pockets-.--------
I
471-0-.00-i-permit____.._.-
___Repair_window__s i ll._that._is._rotted_by..._si sttr-ing--in-necv-wood---------.-.---- --
Replace right trim piece $ 85.00 -
41
Price to replace additional rot will be quoted at time fo service -
__ omove_7ob trash..____-_ __
A11 guarantees_on_ all__products_from._MF.G_.__-._.—_-__ .__-____.______--._______.--_
ustrucbon related permits: -
-tractor will not begin the work or order the materials before me third day following Vie signing ng of this Agreement unless specified herein writing.Contractor will begin Ne work on or
,al (detel.Baer ing delay caused by circumstances beyond Contractors control the work will be completed by 1eate).me Owner hereby
-howled s a do 295'Ihat the scheduling dates are approximate and that such delays that are not Portable by"contractor shall not be cdhas rer &,Id& ions of this Agreement. -
RRANTY
Contractor warants that the work furnished hereunder shall be free from defects In material and workmanship for a period of following completion and shall comply with
requirements of khre Agreement.In the avant any defect in workmanship or materials,or damage caused by 0e Contractor,his subeontectore,employees or agents,is discovered within
year after completion of any lob.Including clean up.the Contractor shall,at his own expense,fanhwith mmady,repair,correct,replace,or cause to be remedied,repaired,or replaced,
It damage or such defect In materials or workmanship,The loregoing warranties shall eurvve any mulectior performed in ronnedenwth the agreed-upon work. F _
C Prop Oise hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: -
��
/mart to be made as follows: dollars($ ).
ri 400 I upon signing ContmcC c k0 215 Vef� or - - - -e o1 C t torl0osi9nated ROBisimnt r
($ )upon Completion of ,_,.. .. ..
Error Address
(e )upon completion of
CiNr+tare Plead "
shall be made forewith upon qq ;.:
completion of work under the c'tl RZ, of Phone -a,n Feeml 10 No.
li.,f No agreement for home improvement contracting work shall require a down w$ im a O 1n5 .'-
ammnt(advance deposit)of more than one-third of the total contract price or Ua
it amount of all deposits or payments which the contractor must make,inadvence r— -
o nd odor am/or otherwise obtain delivery of special order materials end equipment,Illusion:amount amounfsgreater Note:This person may he withdrawn by us 1f rat accepted wiN'n days.
oce tance of Proposal I have read both sides of this document and accept the rites specifications and Conditions staled. I understand
P P p a p
' it upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above.
1u,the Buyer, may cancel this transaction at any time prior to midnight of the third business day after -
e date of this transaction.Cancellation must be done in writing.
/, /DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
,a ma �'16 L/ ( / � (.'%:%%s. Data "' • '4 sisaaw,a— Data .
' - IMPORTANT INFORMATION ON BACI(
FILE No.770 01/30 '06 09:46 ID:SENNOTTINSURHNCE FA;:1 978 887 2404 PAGE 1% 2
g Q CERTIFICATE OF LIABILITY INSURANCE f0113 /2006)
vRooucER Ol/30/2006
(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
P. O. Box 4S7 ALTER THE COVERAGE AFFORDED BY THE POLICI LOW.
Topsfield, MA 01993 - INSURERS AFFORDING COVERAGE
INsuREO en GT r. NAIC
y OntraCting CO. , Inc. WsuRER A. Penn ABY'rica Insurance Co.
NSURERS Safety Insurance any 394S4
INSURER C.
INSURER D'
INSURER E.
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTIN HSTANDIN
ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAV 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.
WSR TYPEOPWSURANCE POLICY a" POLICY EXPI
POLICY NUMBER /-� LIMITS
GBNERAIW=0TY PAC6543105 01/29/2006 01/29 2007 EACH OCCURRENCE E
X CONIMERCNAL GENERAL LIABILITY 1.000.0
RENTED E 5o 00
CLAIMS WOE �X OCCUR MED EXP(MyR.e pxYon) B
A 1 00
PERSONAL a ADV INJURY S 1.000,00
GENERAL AOpREWre E 2,000,0
GFNL AGGREGATE L WIT APPLIES PER'.
POLICY PRa PRODUCr9-C3WOPAGG 3 1 000
JECT LOC
AUTOMOBILE U,u, I - _
ANY AUTO
COMBINED SINGLE LIMIT
(EN eLAiWlul E
ALL OWNED AUTOS
8 SCHEOULEDAVTOS (BODILY NUVRY $
1
HIR[D AUTOS
NON-0WNED AUTOS BODILY INJURY S
(Pa aeciamU
PROPERTY DAMAGE E(Pe.Ae t)
GARAGE UABIUTY
Y AUTO
AUTO ONLY-EA ACCIDENT S
MI -
OTHERTIAN EAACC E
AUTO ONLY. AGG S
EXCESSNYBRELIA 114BILnY
EACH OCCURRENCE 3
OCCUR OCLAWS MADE AGGREGATE 3
DEDUCTIBLE S
RETENTION E
E
WORKERS COMI EN&1TION INC, W STATU- OM- E
EMPLOYERS'LUMNLITY
MY PROPRIETO"ARTNEWEXECUTIVE EL EACH ACCIDENT S
OFFICERAIEMSER EXCLUDED? .
If yet AeimSe,c,CA. E-L.DISEASE-EA EMPLOYE E
SPECIAL PAOVISIONS Nkw
OTTER E.L.DISEASE-POLICY LIMIT Is
DESCMPTION OF OPEIIATRIMS I LOCATIONS I VENICLES I EXCLUSIONS ADDED 87EN RRSBYfiNTISPECIAL PgpVISIONB
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION PATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MW4
`DAYS WRITTEN NONE TO THE CERTIFICATE HOLDER NAMED TO THE LEPT,
BUT FAILURE TO MAIL SUCH NOTICE SNA4 WPDBE NO OBLIGATION OR UAMWrY
OF ANY KIND UPON TIE INSURER,ITS AGENTS OR REPRESENTATNES.
Evidence of Insurance AUTHORIZED AEPRESENTAYIYE
ACORD 25(2001708) CACORO CORPORATION 1988
CERTIFICATE
OF INSURANCE
DAtY(,MMrDD1YY1
FRODvcrl C NO BJCHTS UPON iTR C6RT?SCATR L1) TTIIB A
Edward F Scnnott Insurance DO Aa2N0,YxrEtm OR�LTL>,TT¢CO cL A►PO D BY TRY
►oLl BELOW.
Agtnq Inc
16 Souch Main Street COMPANIES AFFORDING COVERAGE
Togsfield, MA 01983
Len Gibely Conuwiing Company Inc COMPANY A.I.M. Mutual Insurance Co
cETT[A A
COVIRAGES
THIS LS TO CTY.TtFY tE T TU POLICIILS by WSUR LMM HA N TO T RED NAMED A8 FOR TH POLICY llOD
INDICATED,NOTMTTNSTANDING ANY RE UrB"INT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOClluYNTW[T'H RESPECTTO WHICH TICS
CIRTTPICATE MAY RE ISSUED OR MAY PERTAIN.THE IN RANC!AFFORDED BY THE POT It"(094CEMO NEB.ErN IS SUBJECT TO ALL THY TERMS,
EXCLUSIONS AND CONDRTONS OP SUCH POLLCHIS. LTJSRS SHOYN MAY HAVE BYEN REDUCED BY PAID CLAW
CO TT7r 0r DDNRAW..S POLICY NIDEan PDLICY C➢PaC'TLVE souct'a>o•EaA LIMITS
L DATC(WUM /YYi DAIS(NJImD/TYI
Y_LaL t1A"arS DINERAL ADOSFGATa t
1 —�CnMMSICIAL Da)44L UNILIVV ' ro0➢WPn.rd+rogr.cL. I
'i . WMAOi�LLut tftSONaL tAOv.WUtr t
k OWN6.i<CON 1RAO'TOR'S fItO'I. I EACH ocEUtawcE I
r� Mi DAMAGC Ivry'nM&lfl I
` uSD.FSS)INfY wW ew pnMl S
.VTOW05U-E LIAZILITY COMPINID UNDLL I
n .Jnn UNIT
U 1,OWN ED.005 D00LY INJURY L
SCN A.ED.UTOL IMr pe..I
M I4F D A VTnt SOW LY I141WXY
WN{D AUTO$ In
LiMYj E
�k At ACaL aSM1'
P40TE91Y DAMAGE L
S)'CLES L.1At7LLtY fALN DCLU mcd I
uNCLl,A 7DRN ADDRIKAn i
7I1Ra Y11"VMDRLLLA FORM
OTn-
v OR�L➢'t CnMl'W1nT10N AND W
tM�mtaR'u.nurr
U010D7P01J000 UWJR000 06roS/0007 L
A rN1 oral tlFi nR1 X INCI. �a9AS I 0
Ir.RYNRRLEYfCUTIv➢ t 5XQW
nRIt7 RS A0.E O Dun Vi.
OTIILR
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IKSCR WwN nC OTL}.TTONK TfATKA CLAI RDIS
CERTMCATV HOLDYA CANCELLATION
SSSOULD ANY OF THE ABOVE DESCRIBED POLICJES RE CANCELLED aEFORE THE
E)MMATION DATE TRUSOP. THE 133U 40 COMPANY WILL E.vDEAVOR TO
AEArL LO DAYS WRrTMN NOTICE TO THE CERTff1CATE HOLD=NAMED TO TSB
Evidence Of Insurance LEFT,BUT PAJLURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LJABILLIY OF ANY KIND UPON THE COMPANY. TTS AGENTS OR
i RYPRYSENTATIVES.
AVTH00.riTD RBP0.YS[NTATIY'E
r
� ✓/ie ioanv�na�uoeall/ a�./v[aaurc/ur� .,'
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration_jp0811
ExPljajlGn_ 2,$/2008
1 - ��y� 9R'is Corporation
LEN GIBELY CONTRACTING�Of, INC.
Leonard Gibely
149 Main Street
Peabody,MA 01960 Deputy Administrator
� �'!e �ammmra+wieal0£ o�./�aoaaa�iiete!!a
s
BOARD OF BUILDIN¢..REgULATIONS
License. CN�STRUCTICN SUPERVISOR
Numb 094703:
a, 3
.j . 0 -: 0 Tr.no: 94763
R '
THOMAS R 008
19 CEDAR HILL DRI!(EG—
DANVERS, MA 01923 --�-'
Commissioner - /—
W