Loading...
5 ROOSEVELT RD - BUILDING INSPECTION (003) 0 The Commonwealth of Massachusetts CITY OF WE` Board of Building Regulations and Standards ITYSAL OMassachusetts State Building Code, 780 CMR ReIVI riseJ:N<rr?0!/t Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dtvellh g [ This Section For Official Use Only Building Permit Number: Date Applied: building Official(Print Name). - Signature - - Date SEC I[ON [:SITE INFORNIATION` I.I Property Address: 1.2 Assessors Map&Parcel Numbers � * I • S R n �t;ve-A1-11 1.!a Is this an accepted street?yes_ no Map Number Parcel Number . rr. 1.3 Zoning Information: IA Property Dimensions: D . Zuning District Proposed Use Lot Area(sy It) Frontage(It) ++t 1.5 Building Setbacks(ft) 00 Front Yard Side Yams 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 es❑ p p y SECTION2: PROPERTY OWNERSHIP' 2.1 Owner '0"cco Sa��,t, mig N�me(Print) City,State,ZIP S �noagv�L� Rw �y1127`/1 o014 Nu.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Buildin Owner-Occupi epairs(s) j Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': �+ ¢ 1, w R a r SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Offleial Use Only Ito°1 (Labor and ibl:uerials) 00 i. Building S T. 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 1. Plumbing S P Other Fees: S 4.Slechanical (HVAC) S List: 5. \lechanical (Fire S rotal All Fees:S Suppression) 6b Check No._Check Amount: Cash Amount:_ 6. Total Project Cult S 7 j ❑Paid in Full ❑Outstanding Balance Due: Ml� lt �-o � c G .C . 1C)IZA SECTION 5: CONSTRUCTION SERVICES 5.1 CmtstructionSupervisurLicense(CSL) 1 5- 1Cy � g -T— jM bbt'� S _ LicenseNumber Expiration Date Name of CSL Holder List CSL"type(see below) 2.W I't.t e!n- S'� Type Description No. :mJ Street s U Unrestricted(Buildings tip to 35,000 cu. It.) e:i�O A bo o V A © � ct (e O R Restricted 1&2 Family Dwelling Cityffmvn,State,ZIP Ni Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances "' O `�( a•3 I Insulation Telephone Email'address D Demolition 5.2.Registered Home Improvement Contractor(HIC) 1_V Cnt-e,-r— - HIC Registration Number Expiration Dote HIC Company Name or HIC Registrant Name N Street Email address ��1 poP— MA /»a4&:Z City/Town, State ZIP fete hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.15L g 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 I,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:OWNERt ORAUTHORIZED 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. R l0 - ( -7- U Print Owner's o r uthix zc r gun one(Electronic Signature) Dale NOTES: I. An Owner who obtains a building permit to do his/her own work,or anowner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program),will nor have access to the arbitration program or Guaranty fund under 1MLG.L.c. I42A.Other important information on the HIC Program can be found at wwvv.rrtass.aov:!oca Information on the Construction Supervisor License can be found at www.nmss.^ov lddts . 2. When substantial work is planned,provide the information below: 'total floor area(sq. ft.) a .(including garage,finished basement/attics,decks or porch) Gross living area(sq. It.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths type of heating system Number of decks/porches 'rypeorcoolingsystem Enclosed_ Open i. "Total Project Syuurc FwGuge"may be substituted tar"rutal Project Cost" De I artment of ln(hustrial Accidents ' Qjjlce of lrrvestigations 600 Washington Street Boston, MA 02111 www;masstgov/din Workers' Compensation lusurance AI'liduvit: Builders/Contractors/Electricions/Plumbers Aol)licaut Iuformation Please Print Leetbly lame (Bus iness/OrganizatiorAndividual):_T t_6t,bet/ Conlra('kli /q _` 0 ;address '2 lc in �Pr- S� ry/State/Zi (7 /0/A l (20 Phone #: \rc You an employer? Check t e appropriate box: - r ! um a employer with 4° I am a general contractor and I Type of project (required), cmployees (full and/or part-time).• have hired the sub-contractors 6.. New construction I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g• Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp, insurunce.t 91 ❑ Building addition required.) 5.;!(] We are a corporation and its 10.❑ Electrical repairs.gr addition: I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL insurance required.] 1 9 c. 152, §1(4), and we have no 12.0 Roof repairs employees. (No workers' 110 Other coat . insurance required.) 4pp11Vant that chocks box MI must also till out the section below showing their workcn'compensation policy intormation. .mncuwncrn who submit this.aflidavit indicating they aro;,duing all work and then hiw outside contractors must submit a now affidavit indicating such. �uaoons that chock this box must attached an udditiorttd�shoct showing the name ol'Iho suit contrtwlor,and state whether or not those entities have •�:p:uYees, if sic sub•cootractors have employees,they must provide their workers'comp.policy number. mn an employer that is provlding workers'evmpensruiwt Insurance or�, f my employees, Below is the policy and Job site ;,unrurtiun• / Company Name: �• / • /t/.-I /�U1414 !/1suragee • 60 A ur Scif-ins. Lic. #: V WC - /00• GD/n'7 -79-20/0 4 Expiration Date: J- 3- / 3 Sac Address: �J 2 on s.�oC_t`" Al City/state/Zip: S 4 Ld M (t r A h j q—T 0 I loch u copy of.tbe workers' compensation puUcy decluratiuu page (showing the poUey uumber nud expiratiou du(c). i urc to secure coverage as required under Seofion 25A of MOI, c. 152 crux lead to the imposition of crirriinal penalties of a _p to 51,500.00 and/or ono-your impriswuript,us-well'as civil pcnalties`m the form of STOMORK.ORDER and a four up to $250.00 a day against the violator. Be 1¢vised that a copy of this statement may be forwarded to the Office of cstigations of the DIA for insurance coverage verification. !u itereby certify under �thee—pa4ins and penalUles ofperjury dart the lrt/brmadon pro vided above is true and correct. Date: #: 2 Official use only. Do not write in stets area, to be completed by city or town offielal Cit). ur'I'own; f Permit/License Issuing Authority (circle one): 1. Board of Health 2, Building Npartineal 3, CityiTown Clerk 4, Electrical Inspector 5, Plumbing Inspector 6. Other i Cuuiact Person: Phone#: I i I 1 AC�Zla CERTIFICATE OF LIABILITY INSURANCE DAre 18"1200 6 �--� 1nB/ ls 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(les)must be endorsed. If SUBROGATION IS WANED,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 CONTACT Robert Poulin NAME: Sennott Insurance Agency PHONE (g7g)887-4900 .PAX .UvC.N9..EATT___....___._..-_ .._...._...-. ._. ._........._I.lAAC,.N4):(979)997_2a0i 16 South Main Street E•MAL pooRESS:robertpoulin8aeottinsurance.com O. BOX 957 anIRSUR 9 AFFORDING COVERAGE NA1C0__.. ERl ._ .___ _._. ' ousfield MA 01983 wsuRERA First Mar Insurance Com an ._-_. ._...._. .__._..._.. ._-_._ _ .... �?FY ._ _.... P_Y...uNEu INsuREg e;Safety_ 133618 Len Gibely Contracting Co. , Inc' IndemnitYINSURERC: __ ._.._..._.._........._... .... __.. _ .____._._..__...... __... ___.__._.23R Winter Street WSURER D: NSURER E ...__...._' Peabody MIA 01960 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1611860930 REVISION NUMBER: I HIS IS TO CERTIFY THAT THE POLICIES OF INSU14ANCE LISTED BELOW HP.VE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD tN DICATF.D. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MUCH THIS CEH'IFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXC LUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rTR TYPE OF INSURANCE ' POLICY EFF POLICY EAP-r'- -- - I` 1 POLICY NUMBER LIMITS Y. CO'AUERCIAL GENERAL LIABILITY ' r ; EACe OCCURRENCE it 1,000,000 1F_OAO RENTED --- - —'— ?. .L" I>•a ([ I_x.;OCCUR �EkISES.IEaocqur9nnt xs 300,000 �.�,. RF .._ NJ-CCL-0000060987-01 i 1/29/2016 r 1/29/2017 MED EJ(P(Ar+LoeHP¢rson) IS 5,000 —.._ - -- - I PERSONAL IAOV INJURY 15 1,010,0011 E LIMIT_APPLIES PER !GENERAL AGGREGATE IS 2,000,000 . ._.I JrCi .I LOC : rPR 000TS COMPIOP AGG i S-- 2,000,000 AU IOMOBILE LIAWUTY I OYRIN' SW ELiMIT I _ _ S 117 000;000 AUTO { OOORr LYJURY IF Prram) 3 _T ..- - IL01`O.EU SCMF.DUlOD _ __ _.. ,xAUTOSNONO 6221653 CCM 03 iL/29/2016 1/29/2017 tlOUIIY INNRY(Per acc.Amlp i ' PROf ERIY 11AA1AGE. - -�--- - ..X.;.. F:REO AUTGS X AUOSWNEU I I1 FiP.6asm 1' 0,000 UMBRELLA LIAtl I OCCUR EACH OCCURRELCc S EXCESS UA9 . ... , CLAM 1Aa0E'r II �nGaREGATC _ I .__.._ . .._I (-- _._...I! WOPRIETOR/PAR7NER,fAF.CUi!VE S O RCTF litUNS I WORI(ERS COMPERSATION AND EMPLOYERS'LLAB UM MINI i I -._i,LANTE ).., ERn Ir)FF7CER,VEV.eEk EACCLUDED9 r^ NIA ! EL ACN ACCIDPIT S Illanoaory In NH) ---ir —. .__.. I_c... DISEASE-EA EMP CYEL.It JF.PT::pt Of;.PERAiiDNu Dcce -�—� — - --- E.L.DISEASE-POLICY LIMIT S r DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORO 101,Amt1onal Ramuk%SDMCWe,lnay M soocn a V mom space iS MgWM) I I I L 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. AUINORIZED REPRESENTATIVE i I iiobn:e SvanOCCJRE'Z _ ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD iNS025;_:IAcq Page No. of__�Pages LENGIBELYCONTRAStreet CO., INC. �8049 PR�POSAL ' 23R Winter Street PEABODY, MASSACHUSEUS O�960 7 All home Improvement contractors and subcontractors (978)531.8234 Fax(978)531.9304 engaged in home Improvement contracting, unless www.longibelycontracting.com specifically exempt from registration by Provisions of �- � Chapter 142A of the general laws, must be registered Submined /� }-��l,(� with the Commonwealth of Massachusetts.inquiries To:—/�/ Q�O about registration and status should be made to the 5 S�VT Director, Home Improvement Contract Registration, l One Ashburton Place, Room 1301, Boston, MA 02108/` (617) 727-8598. Owners who secure their own 2 b�a,1� ! 7, construction related permits or deal with unregistered / v ;Ol -r�- contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. PNONE DATE // REGISTRATION NO. �O/� I �' ��� MA.REG. 100811 JOB NAMEMO. JOB LOCATION 9r15 ' 9?9 ' 3a40 We M1ereby subnll spec. one and agnates br to be performed 9ntl�liate' be used: n �6�7 / ea l l( sous LT- /(6Y IC 111v w v if Re - �./ J- j t/�S�.tElr.�--�i� 6 ' o dc211, sol�r•f/sl o�/�aik ,JiOPr—_ � 0 sn G� r9lrtc� !}t��a„Q eau flog , o�yts,oys �esT �0112 D.emet' C'AFAN -b Th?"11 o=ar w,&Y Flyd�, b�Se hs/JL-�r/ c���.�w+f-r�—✓ e yetiT To p--ize, ---- WORK SC E � � contractor 1S0g1 w'.Tlkpr/J or eatlale Deloia ae IMrd day fallowlns the slBninB Iona Agreement unless specilied herein_riling Cr�a ill begin the work on or about ( a—at1�9rI slay caused by c...........beyond correcto..comrol,the work will be campleletl by ate).The Owner M1eroby acknowadg endagrs"""ae scheduling dea.are apprars"A'.And.het such delays lhalare nolavddeck by the cpmrador -g net a._nine red as lions of lM1la ABraemanl. Hidden rolwcaA when not_ena umnM a _Net-are_Ired a bancesired a order b_mplete are s_pre.wet as compared at$ per hour(MAN HOUR). WArm The Contractor wenena .'are wad Nrniehetl M1ereuntler shell be free from defect.In male....end workmanshi'A'. Im a perlotl of lowing completion and shall comply with the raquiremena of Nis Agreement.m me avant any defect In workmansM1lp m materials,or camas.caused ev the Oommem,hie erlen clam,emplpyees or.Bents,is discovered wBM1ln ne year otter completlan of any I. Indudn8 clean up.the Conire her shell,a his own erpen_,lorihwim remody, .a.V,_rrecl,repla or cause Ip be ram Wlec,repaired Or replaced, such demaBe or such def_Lir meatleW o.wse warp.The IsesgdnB waremi shell surviveany inspection pe.....dnn connection with are agreed-upon wad. We Propose hereby to furnish material end labor—complete in accordance with above specifications,for th sum of: dollars($ OD ) Payment to be made as follows: Remove all job trash. / Al.guarantees on all products from manufacturer. )upon signing Conaaq Add permit cost it needed-we pull permit %($ )upon complahon of Ueq ment h improvement contracting work shall require ven de osi of more than one-third of the total contract t upon completion of am al a its or payments which the contractor mus wants is to. i erwlse obtain delivery of Spec or shall be made forewith upon a 1, completion of work under this contract. o Note:This proposal may the windows by us It wit accepted wrens days. Acceptance of Proposal I have read both sides of this document and a e pric ,specifications and conditions stated.I understand that upon signing,this proposal becomes a bindin�contract.You are authorized to o t a pacified. Payment will be made as outlined above. You,the Buyer,may cancel this transaction at any time pri r t JrIdni ht of the third business day after the date of this transaction.Cancellation must be done in writ ng. . A con—r 4f`xITYIC Ivnurn wr �-rYv � �� ..,..... ......... 14R•1tb1'q*1-Yiul`2.+at{t�^t...,r-. tui4!%it!(feFBF°Ki¢?%fTl9lln.i4 dial IY�YNP�A-wuwr+edNt� nrw,....,..... . . .. . ,. ' .•.r ;:: :• Magsachusetta Departrnertt of Publla,Spfaty W " BAM of Building Requlatlon0 and Standards +,�t 8 tidy .r.•_. +. W i ,x_ : 4 rl« y.� ya�,h'.r S " e; Co4tr60on SuperV Bor 1 a.• y '� r ",y,;y t i�,' b �. 1: ,TNOMASR DOBBINS 10 CEDAR HILL DRY a i : DAWER6 MA O1B2] t fi ' r Expiration Cofnmissloner 06/14IZ016 < t: ` \ , j ........•. a r :..wg he�xK a , •."•••� �1B �GdJJJ9N09i[(MQ!(IL O�Ci'KQ�[ .»^••• .-- tl •• ��yA+J I �•2# k :, i ODice of consumer kABa1n&Butlneu ReOidaq�s .License or registrsdon valid for In4Iv dpl use oply ;,� ';,•.,;, , before the ez ir4on data f found return to "7 l HOME IMP ENT CONTRACTOR } P r da fd� Y zy. letrado v' w Office of l ousumer Affsin sad Business ltsguletios a m Reg > .00311 "� 7YPs , v + 10 Mirk Plaza Suite 5170 r I f 3 1, Prlvale Corpor8 On - ftosExptoa,MA 02116 .,m p r C � ax.'l�! �✓,. LEN GIBELY CO a ry M nf . 3 x� I ,, P' ♦ ^' �1`M am e ' 4 Brian Dobbina�"' 23R WINTER ST: v MAW. , .. _L._ = "yp t ✓ PEABODY,MA01960 "3',*:4 xudereeerets ` otvadd without sl ature e 3r ar �r w , 51 r x �}'�'^¢ �k[ 'u 4,.�' ,u4"". iM•.'k [? qe i}n x�,iByl"�,'S,` % �, kR{tyYra e e ♦ n iqx e .F F ?tip V l' 4 »' •�I b - \' � � 4 ".:�. �� d� rp. T . t • new y-' c } s yJa iv. �v t .vL y 'Ir �• ! t�1 x {.� �'r 'I M q !- ry ,a x'ra�t�r s�vrk' �• ti 'r , tF{ a t -�r iv ''&�, " 1 t�l4 � '�' . T %y "k /i`X• k ✓f 4 � :rk rkn x (ai.'... S< t:t \ r€Iffrj.✓• j •y `.. ( y' ♦ ' '&t " 1 any f i'.` )Y' )r�`§�. '3"4�M s1�( ( J 1 '? �lr� >, ,ty{waml"h"2 "' k w ` �^F' �ry � x, 'x '- " _ � k u�y• r 7:' C ?� r � ttll ' F 4�5.� �`'^� .ti is j�. "i i�d k ., 3�,n'g � 1 4 c �. �^r!`y� 'f,�£ 'k i �d+fiS ,t�F y�� S 4 •.F,I`�i'. eta ( r :I a-. •ti1ss.k 'Y"4 Yd rc °rl M: i":: 6?•�-. w tl a•.�,ld'x l ten- v s as r �'iI*s+' t � x x"�r •'.l.t..ES � 'r d>yN .M M.p l.Y 15 '� xr �'�`� r� `k*. �.,� .v4 p �Y'q�J q. 1 rc rrv;..tt1 •i f*jw� " f hi++k' e,t+,.�"�•ia' ' .5 3 r ��: eAj'`{i 1j9 1'1 « ' . WT �,+ 7 , rII S !r;kt� '.'S•+��h i >, }''' 4. ,�,ky r .� �� ,♦ L'. 1 t 1+ ��" 4 � � 4 ' '`ll'h1"�Sv,e W r1'�. .11 .,;a .iaa ki.•4lG'61� �3Aa7N;� 2s�i'Tm �