21 SUMMIT AVE - BUILDING INSPECTION � Z _ � Z�� � uC
The Commonwealth of Massachusetts
o Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
s
g umberJ Date Applied ` d ' + �Bw Buddin Permit Nldmg Off ctal`
, .' SECTION-1:LOCATION-(Mease indicate Block*and Lot#for locations for whic' treat address is-notavailable)`:• .
No.and Street City/Town Zip Code f r ' able)
,�'•x � SECTION'2rPROPOSEDWORK 1
w'
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Buildin RepaitW4Alteration ❑ Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: S T-'ff. r to !—rcFJ�l L p Q P;O rFr
elAe)
• 3�as t
SECTION 3:COMPLETE:THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION;,OR
CHANGE IN USE OR OCCUPANCY, .,,.,.,. "" `
Check - .. .. : ., ..,..
here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
s.SECTIONA:'BUILDI•i .: : ,, ., NG-HHIGHTANDAREA't'_
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check asapplicable) ' -
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
t SECTION`6:CONSTRUCTION TYPE(Check as apple@ble) "
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7i-SITE INFORMATION(refer to 780 CMR111.0 for details oweach item) "_ ,'• '"
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation P4A Historic Commission Review Prtxcess:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY "
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
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SECTION,9ePhbPERTY OWNER%AUTHOAIZATION'
Name and Address of Property Owner
S,w Etc-Ze �/
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: / /y���
/D_ /7/ 0
Title Telephone No.(business) Telephone No. (cell) e-mail address
-If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application: -
s z ,SECTION 10 CONSTRUCTION CONTROL(Please fill out Appendix 2) 4 -.,
' If builgitig is less it an35,006 cu.'ft.of enclosed s:ace and/ornot under Construction Control then.checkhere O`and skip Section 10.1 u
10i1Re' 'steedProfessionalRes oiisibleforConstructionControl. .-;",.„.., � ;;:, . .. x. ... _s' �, €.. _ : ', • �
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor s -z %% na`- ;. "i€ ., N '.
kQll
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
314C W,17fez Sf . /�>°/4hz�cLi�f q 0 l`/ D
Street Address City/Town State Zip
6' DAleeQ keen /ke1wml way , Ca.?7
Telephone No. business Telephone No. cell —e-mail address
SECTION-11':4VORKFPeS`.C(Jk1f'ENSATION INSURANCE AFFIDAVIT. M:G.L.c;152. =256 6 -
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the is ance of the building permit.
Is a signed Affidavit submitted with this application? Yes No ❑
SEG FION 12:tONSTRDETION COSTS AND PERMIT PEA
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ d 0� Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (I IAC) $ Note:Minimum fee=$ (contact m�unicipali Y)
5.Mechanical .the')$ --1 Enclose check payable to 7 (C l)
6.Total Cost $ of 8 O (contact municipality)and write check number here
s,
S ,
ECTIONI3:,SIGNATURE;OFBUILD„NGPERMIT,APPLICANT
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.
Toal ilnP66wv r V( 1-.o /o /8 /
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upcm application approval:; ,lO
Name ,.. r.° _Date :.
L
{. The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office oflnvestigations
600 Washington Street
Boston,MA 02111
�y fi
wnnv.massgov/ilia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciaus/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organiza[ioo/Individua!): L G c 6n i..Y Co 2Af77w A CO
Address: Q 3 ,R W t N tz .Sr
City/State/Zip: ' oPhone M 99 '6 S3 \ �3 3
Are you an employer?Check the appropriate box: Type of project(required):
1.91 am a employer with I a— 4. ❑ I am a general contractor and I
employees(full and/or pan-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-contractors have g. ❑Demolition
workingfor me in m capacity. employees and have workers'
Y aP tY.
'[No.workers'comp.insurance comp.insurance.t 9. ❑Building addition
required.] ._ 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised theta I I.❑.Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t C.152,§1(4),and we have no
.,.. employees.[No workers' 13.❑Outer
comp.insurance required]
Any applicant that checks box#1 most 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 most submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing We name of the submmmctars and stem whether or not those entities have
employees. If the sub-cmtmctors have employees,they most provide Weir workers'comp.policy number.
lam an employer that Is providing workers'compensation imuraacefor my employees. Below is the policy andjob site-
information.
Insurance Company Name: /A„�- �1 . N v-It/A L �,r.c Ca p _
Policy#or Self-ins.LLiic.#:_gib 0 ] O 9-7 a 0 1 3 Expiration Date:
-�8
Job Site Address:_sfr A SE,/.-N na n �, q L w-p City/State/Zip:�l
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjray that the information provided above is true and correct
Sipuature:. t C;� Date:
Official tar only. Do not write in this area,W be completed by ch.,or town o0zeid..
City or Town: - Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r
F
yFEB-04-2013 09:48 Sennott Insurance 978 887 2404 P.01
ROWCE 97$.887.4900 FAX 178.897.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ,
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
16 South Main Street ALTER THE COVERAGE AFFORDED GY THE POLICIES BELOW.
P. 0. Box 4S7
Topsfield, MA 01993 INSURERS AFFORDING COVERAGE NAICN .
+AuRED Len G e y Contract ng to., Inc. - INSURERA Catlin Specialty Insurance Co -+
23R Winter Street INSURERB! Safety Insurance eoyany 39454
Peabody, MA 01900 INSURERC:
INSURER O; .
INSURER E. .—...
:OVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 18 SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
7RNS T/PS OF INBYRAMCB OU POLCY NUMBER OA WMMI T6�IIM�IC T UMITr,
DEIIFJIAILuuaUTY 3700301537 01 29/2013 01/29/2014 EACH OCCURRENCE ♦ 1,ODD 00
X COrAMERCW GENERu LIABILm p ryaer✓roaM ♦ 10010
CLAIMS MADE u OCCUR MED EXP(My OM MM) a $
A PERSONAL A ADV INJURY ♦ AE
GENERALAGGRSOATE ♦
GEHL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO a
POLICY jR T LOC _ -
I
AUTOa10MLCUAMLm .. .
COMBINED SINGLE LIMB -
ANY AUTO (Ea sOCIANN) .
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Pe,Ix~1 3
B X HIRED AUTOS
6pw 80CILY )RY S
X NON-0WNEO AUTOS y,
PROPERTY DAMAGE S
(P:POeidOrA)
GARAGE LIABILITY AUTO ONLY-EAACCIDENT S
ANY AUTO OTHER THAN EA ACC
AUTO ONLY: AGO S
F3CESWUMORSUALIASIIJTV EACH OCCURRENCE a
OCCUR CLAIMS MADE - AGGREGATE ♦ -,_-
♦
OEDUCTEILE 6 _
RETENTION a a
ANDEMP6
ANp BYPLOIER6'WMIm LIMITS
ANY PROPRIEMPJPM FXE TNERICUTIVE Y�l E.L EACH ACCIDENT a
OFFICERMEMSER EXCLUOED7 LJ
aetwy In NH) E.L.DISFASE-EA EMPLOYEE I
�M �d des6�0e wow
JAL PROVISIONS Mw E L.DISEASE-POLICY LIMIT 6
OTHER
)EACRIFnOH OF OPERATIONS I LOCATIONS I VEHICLESI ELCLV=HS ADDED SY ENDORSEMENT)SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
BHOOLO ANY OF THE ABOVE DESCRIBED POMM 06 CANCELLED BEFORE THE EXPIRAYION
OATS THEREOF,THE SERENC.INSURER WILL ENDEAVORTO MAIL 10 DAYSWMTTEN
- Evidence-,of Insurance NOTICE TO THE CeRTWCATERMIER NAMED TO THE LEFT.BUT FNUVRETO 00 SOSHALL
IMPOSE NO OBUOATION OR WBa.RY OF ANY KIND UPON THE PMRBA ITS AGENTS OR .
.. ^• REPRESENTATIVES.
AUTNORDEO REPRESENTATNE 1`
Robert Sennott RIP
ACORO 2S(20119/01) 6 1968.2009 ACORD CORPORATION. AS rights reserved.
., The ACORO name end logo are registered marks of ACORD
Y^C 1
A4CC)P H CERTIFICATE OF LIABILITY INSURANCE ° OT26201°3
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), AUTHORED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. -
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. It 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 endorsement(s).
PRODUCER 01634-001 9299CT _
Edward F Sennott Insurance o.am, .110:
16 South Main Street
Topsfield,MA 01983
INSURER A. A.I.M.Mutual Insurance Company 33768
INSURED
Len Gibely Contracting Company Ina
23 Winter Street Rear -
Peabody,MA 01$60.6841
COVERAGES' CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES 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 SUCK POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE I POLICY NUMBERAm% LIMITS
GENERAL LIABILITY EACH OCCURRENCE f
{j
COMMERCIAL GENERAL LIABILITY A PREMISES(Ea owzuncm
CLAIMSMAOE OCCUR ' ✓ 4 '`.a' MFDEXP(Any.Pmeon) f
PERSCNALSADVINJURY f
GENEAL.AGGREGATE f
INLAGGREGATE LIMIT APPIJEB PER PRODUCTS-COMPIOP AGO f
CY C
AUTOMOBILE LIABILITYCOMBINED51 LIMIT
f
ANY AUTO BODLY INJURY(P.Pmmn) f
ALL OWNED SCHEDULED BODILY INJURY(P.v dmy f
AUTOS AUTOS
HIRED AUTOS NOWOMED P AMAG f
AUTOS
H - f
UMBRELLA UAB OOCUR EACH OCCURRENCE i
EXCMLIAB I CLMMSMADE AGGREGATE f
DED RETENTION II f
MURMI&M X MFMI lox
A A M ' NIA VWC•100-6010979-2013A 813/2013 91312014 E.L.EACH ACCIDENT f $00,000.00
'(Mmdarory In,NK))� E.LUSEASE-EAEMPLOYEE f $00,000.00
DE CRIPf OF OPERATONS bWvw E.L.DISEASE-POLICY UNIT f 500.000.00
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES JALmch ACORD 101,Additional Rmlerta 9chetlula,M mom aem:e M redubed)
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. -
AUTHORIZED REPRESENTATIVE
0 198 8-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
LEN GIBELY CONTRACTING CO., INC. Page No. of —Pages
—
23R Winter Street P
PEABODY, MASSACHUSETTS 01960 r 24868 'PROPOSAL
All home Improvement contractors and subcontractors
(978)531-8234 Fax(978)531-9304 engaged in home Improvement contracting, unless
Www.lengibelycontracting,com Specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered Submitted ` 7/' with the Commonwealth of Massachusetts. Inquiries
TO"�-"�- ��Q- -----.--_ about registration and status should be made to the
Director, Homa Improvement Contract Registration,
l One Ashburton Place, Room 1301, Boston, MA 02108
A - (617) 727-8598. Owners who secure their own
construction related permits or deal with unregistered
1-7 V contractors will be excluded from the Guaranty Fund
PHONE
Provision of MGL c.142A.
WTE REGISTRATION NO.
(I-7S 1-d7�S S�i��3 MA.REG. 100811
JOBCLLOOCATION I
We ha submit apeGllcallone en0 estimator for work Io be perbone antl materiels to be usatl: v M�
/-�--�6 t�1f1
moo., / -
/t
l4-- - --6Cta_ MQ/` `1171`� C li
,Od
Conlre o�i 1 ee a wolk or order pie melarlels belore Ina thir0 Eey Milowlnp the sipnlfip of tlllr Aarremant u`olers spedtiea herein wrgn�� wi-II pegln me work on or
about tEete).Barring delay ceueeE by circumetancas beyontl Contredore control,IIIa work will be com IeleE a jjr-J
acknowle gas n greet That me scgetlulinp Estee am epprwlmab antl Ihal such tlelaya mat are not avptleble W IM1e conlreclpr eM1all npl Oa mnsltleraE as vieleli I Neisogreemont hY
WARMN
The Conaedor w-rtanle met the worN IurnlshoE hereuntler shell be her Irom tlelece In matarl-I en0 workmensM1ip for a perlotl of tcllowin vnm lotion and shall com
Ne requtremenls of INa Agreement In Ina event any E61ed in woMmanMlp or m-racists,or Eemage caueeE by the C-nlmdor,his subconaeclprs,employees or-Bents,is tliacovered.tWith
hin
one yaer alter complallon M any l00.Inclutling teen up.the Conlraptor Shell,el his ow^expense,torNwiN came e p
such damage or apch Galati In mal9Eal9 pr workmenshl.TNa bra In warmnlles shall survive en Ins r peip gonad,re lace,or causeOto be mmetlieE,rapalm4 or replacoq
__ _ p � g _ Y pedlW peEprmeE in connection witM1 the ag bupon work.
We PIOpOSe hereby to furnish eteriel and lab r-coJplat(e11in accortlflnce with above specifications,for the sum of:
P y ant to be made as follo�owwssrvliv����J(�.1 �I /�CQ "" dollars
($ )uPo—n signing (red Cdn' ; \� �d f t/ M/
n,aolcanre con eslaoamegeei:vem
upon comPl rve
epon of - _
St 1AEE 1 -
%lS )upon cnmadefo t" -.
%($ - )shall be mace ior"iN upon ole/Slat Phoro
an
errnplegon of mo,andor lhle eentmeL 'pppq FeU Ile No
Notice: No agreement for home Improvement contracting work shall require a tlown d Selewren payment(advance career)of more ,an one-thirE of the total contract price or N
total amount of all deposits or payments wh eh the contractor must make,in advance,
W order and/or oNerwlse obtain delivery of special odor materiels and equipment, Bb^nure
whichever amount'=-gr t
No1e:Tpq Pmpoaal meY be E2wn lywll nole¢ePIBE wiNin tlaYs.
Acceptance Of Proposal. I have read tooth sides of this docyntent and accept the prices,specifications and conditions stated.I understand
that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified. Payment 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.
DO T SIGN THIS CON�JTT/IRACTT�IF THERE ARE ANY BLANK SPACES.
sianew, I w1a 3 sbnawre Dale
P Y/ IMPORTANT INFORMATION ON BACK P
a
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
License: CS-094763
THOMAS B. DA'BBINS +,
19 Cedar HBLDriva fil
5Danvers MA-01923
Expiration
Commissioner 05114/2014
011ice of Consumer Affairs& Business Regulation License or registration valid for iudividul use only
7.40ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
`—Registration: 10o811 Type: Office of Consumer Affairs and Business Regulation
.` :Expiration: 6/23/2014 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
LEN GIBELY CONTRACTING CO., INC.
Brian Dobbins _
23 R WINTER ST.
PEABODY, MA 01960 UnJers _ _ Z
Y Not valid w' ture
a