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7 SABLE RD WEST - BUILDING INSPECTION What is the current use of the Building? Material of Building? If dwelling, how many units? Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone ( ) Mechanic's Name 1. e t�a h L l( C mn,5.t Address and Phone—i t i Ittn Q r ;i fir'-4 h , 4 M A D t 7 6 Construction Supervisors License# Qct 1A`I C,-�, HIC Registration# I R j I Estimated Cost of Project$ 60 Permit Fee Calculation Permit Fee$ Estimated Cost X$71$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury X . Date N O Y Ir a � u o Y ,M � a a .� V o CITY-OF�2 LEn -- PUBLIC PROPERTY DEPARTMENT KIMBER EY DRISCOLL MAYOR 120 WASMNGTON b.MEEr•SALEK MASSACHMI'IS 01970 TEL,978-74S-959S 0 Rnx:97&740-9846 APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION, DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING i A SITE INFORMATION Location Name: ` � Building: Property Address: +-7 S 6 L.-e Rt> f .� Property is located in a:Conservation Area Y/N Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: Address: -7 Telephone: X , i4 �tJ O cZ b 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTiNc: BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: - - - - - - - --- --- Mail Permit to: b.av M The lCommanwealth of Massachusetts Department of Industrial Accidents Office of Investigations Ulf I 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information . : Please Print Leeibly Name B is( us ess/Organizatiott/Individual): Q 1_Y Ce! w SX— Address: I Ll R M A 1 7 !2M City/State/Zip:Pa 4 .bo Vt NA 6 i 9 Lt) Phone #: q 7 8 53 D3 LA Are you an employer?Check the appropriate box: Type of project(required): 1.KI am a employee with 1 44_ 4. ❑ I 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. t ?• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' cgmp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.El am a homeowner doing all work right of exemption per MGL I LM Plumbing repairs or additions myself. [No workers' comp. c. 152, §I(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box#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. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am at employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /� Insurance Company Name: A M v�' A .v c C O Policy#or Self-ins. Lic.#: &0 \ 3 CIr1 el O 1 a. O O rl Expiration Date: Q g" O 3 -O Job Site Address:-L S 6L. Rt, i. ] & S"t- City/State/Zip _in L_ zN N O 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 11,100,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ail 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 tinder the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: / n / -7 - D_ J Phone#: 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#: 11 MAP PRODUCER THIS CERTIFICATE IS ISSUED AS A NIATTER OF INFORMATION ONLY AND Ed%%ard F Sennott Insurance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE Acen;c In. DOES NOT.ANIEND.EXTEND OR ALTER THE COVERAGE AFFORDEDBY THE - POLICIES BELOW. 16 South Nlain Street Topsrield.NIA I)195: COMPANIES AFFORDING COVERAGE INSURED Len Gibelp ContrnctinIz Conlpanc bw COMPANY A A.I.M.Mutual Insurance Co LETTER THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO'`YHIC H THIS C ERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. ENCLCSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MA)'HAVE BEEN REDUCED BY PAID CLAIMS. (o lYl'E OI'INSLR:\NCE POLICY NUMBER POLICY'EI'FECTI\•L POLICY LCI•IRAIION LIMITS L1R DATEIMADDYYI DATE IMMIDD11Y1 GLNERYL LUBILH Y GENERAL AGGREGATE PkODI'CTS-COMP/OP AGO. I'J':' "JEP.:I a.L JEN EB{L LI}.BILITI ^ PERSONAL At ADV.INJURY J�'-L1l:`S`.L{DE L.R EACII'Y.CURRENC.E IIkE UAM{GE UnT'cnc lirtl ___ _ `IE0.ESPESSE IAn.ulr Pnvm \I.IORINILE LI\b Ll r\' n`.IBPEU.i I MIT -,IIIL1 ILL kl A AL -DILI I\II 91 I�0{l.{.:A UIWLITI 11Y.fC'ERT1'U{>I{OE 1A OFE SLI.\BILITI EACH OCCL RREVCE UMBRELLA FORM AGGREGATE OTIIER THAN UMBRELLA FORM {{'ORICERS COMPENSATION AND STATUTORY LIMITS THER ENIPLOY•ERS LIABILITY X A t-.I:•eo:v.IETo;: EL EACH ACCIDENT 500,000 L:i.fl 6010979012007 08/03/2007 08/03/2008 EL DISEASE--POLICY LIMIT 500,000 I\.\I` U EL DISEASE-EACH 500,000 EMPLO)CIE COMMENTS DESCRIPTION OF OPERATIONS OR LOCATIONS: HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE HEREOF.THE ISSUING COMPANY WILL ENDEAVORTO MAIL 11 WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION 'IR LIABILITY OF ANY KIND UPON THE CONIPANI'.ITS AGENTS OR REPRESENTATIVES. Evidence .of Insurance - AUTHORIZED REPRESENTATIVE __._... _r �...._.. .........�........................._..,......... ...... Board of Building Regulations and Standards - HOMEIMPROVEMENTCONTRACTOR - Registration:, 100811 Expiration; 6t23I2008 °Type;"Private Corporation LEN GIBELY CONTRACTING CO:, INC. Leonard Gibely 149 Main Street ,,,,` Peabody,MA 01960 Deputy Administrator O/ a �oa9rvrnorrec.ea/.0� o�./�asraci{uaell6 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Numbed,C,A\ 094763 Tr. no: 94763 THOMAS R DOB s 19 HILL D G DANVERNVERS, MA 01923 S ' commisa n to�er , k OL P ga No. Of Pages LENGIBELY CONTRACTING CO.,riN :©At8949 ROPOSAL 149 Main Street PEABODY, MASSACHUSETTS 01960 Ted me Improvement contractors and subcontractors . (978)531-8234 In home Improvement contracting, unless FAX(978) 531-9304 ically exempt from registration by Provisions of Submitted — er 142A of the general laws, must be registered 70: /C+. "1_—�! •v��pcS2 he Commonwealth of Meaeachuaetis. Inqulrles registration and status should be made to the r•7 ��/ e, pp � ��5. Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727-8598. Owners who secure their own ✓.J �C/a+, r`�✓� �/ /c7� construction related permits or deal with unregistered - contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. CPHONE MTE REGISTRATION NO. r f y y— i MA.REG. 100811 i JOB NTM6N0. r JOB LOCATION 978 '335- /�SSS Sa � As �S"� We hereby submit specifications andand eatimates for work to be performed and mmatleriels to be used _ ) y 12o0�% /c.c. /H CG/`rGhT — v7-✓J� All �OeI� U• -A .2— 3 T Ld c W 4°/z�`i �7,s�1/cr//- p v/c1 ✓ scL-.�/d.� A-..[- /q [/Oar n..+ t/o�� /4�tL� 0 /2 /�-'0I� /S/6 c/� c'v', _ nSL+!l c1l 4; c, T� RLI Lcry eS 1nr�-'°.G� ��/.�hd as—.vL ' �✓f�(/N�s7 -- 1,a�ll/ .L✓ts�i/ 3� �� C��f�f��t.�d A��. s11,� �ZS Lea �Ov�j nV/ho✓ �L�it�./,t� —a//itiyS cGIL/ng -YS bi �J'tSl^�!l L9�7 La` Wo✓IG, O _._-_- 3y00. -�c✓�,T. Construction relate perm -- WORKS OULE / Conbacbr II ap{ n y01[y rder the materials before the third day following the signing 0 this Agreement,unless specified herein wri n .fo cl Ile work on or about tle esrring delay caused by circumstances beyond Contractor's control,the work will be completed by a Owner hereby ckrwwlee00ppee and sprees Nel the xM1eduling dates are approklmete and Net such delays that are not avoidable by Ne contractor shell not be c tlaretl es v lgo e 1 Mrs. WPRRANIY The Contractor warrants Nat Me work tarnished hereunder sM1ell be tree tram doled In motenal and workmanship for a penned lowing c ply with the requirements of MIS Agreement In the Brent any defect In workmanship or materials,or damage caused by the Contreplo4 Ms a ontactora,employees o ants.Is e0 within one year after completion of any job,Ind ding clean up,the Contractor shell,at his own expense,forthwith remedy.mf correct, place,or cause W be re lad,repaired,or replaced, such damage or such defect In material or workmanship.The foregoing warranties shall survive any Inspection pedormetl In connection with the agreed on work. We Propose hereby to furnish and labor-complete in actor jth above specifications,for the sum of: -I Payment t0 be made as to A --I ') � ^ J dollars($ Name or comraamnomigneted Regale" Of Ernst Address upon completion of __ __ _____ _ CiNlState ._.-_____.. _ Phone .._ _.. _... shalt be made forewith upon completion of work under me contract. e IID Notice: No agreement for Dome Improvement contracting work shall require a down rvem payment(advance depoalU of more than one-third of the local contract Once or the total amount of all depoeae or p rymente.whlch the contractor must make,in advance, to order and/or otherwise obtain delivery.1 special order materials and equipment, Alen d S wnlcM1evar amount Is g(a N e:Tlap p a ey Ndrawn W us it not ac red wiMin days. , .r C Acceptance of Proposal I have read both sides of this document and ac apt the prices,specifications aA conditions stated.I understand that upon signing,this proposal becomes a binding contract. You are authorized t o the work as specified. Payintifit will be made as outlined above. You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Cancellation must be done in writing. l DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Bq r /1�// _, Date I S��siane ure Date IMPORTANT INFORMATION ON BACK 11�