13 SUMMIT ST - BUILDING INSPECTION u
The Communwealth of Massachusetts
L13uild
tCl TY OFBoard of Buildm Regulations and Sim lords SALEivIMassachusetts State Building Code, 7S0 CMR Revised Mar 2011g Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family fhvelling
[his Sacfioa For-OfFicial Useber: DSte .14.
int Name) $tgnature .' D
SECTION 1:SITE INFORMATION'
LI Property Address: 1,2 Assessors Map& Parcel Numbers
_a Qirnm, e-T— S—r—
l.la Is this an accepted street?yes_ nu Nfap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.01 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesE3
SECTIONZ:, PROP.ERTB'OW(qERSHIPL
2.1 rt of Record:
U _ 'n v K — A
Name(Print) City,State, P
1 S[I M fi LEI Fi—r �q� C)95a
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK°'(check all that apply)
New Construction ❑ Existing Buildin wner•Occupie epairs( lteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work":
SECTION4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item OfBelal Use Only,.,
Labor and bfatcrials
I. Building Q I..Building Permit Fee:3` ' Indicate how fee is determined:
�. f:(cctrictl S ❑Standard.CityfCuwn-Application Fee.
❑'rotai.ProjectCost(Item.6)xmultiplier x
3. Plumbing S 2• Other Fees:'S
1. Mechanical (liv.\C) S List:
i. Mechanical (Fire -
5n� tresimt) _ 1,0111 All Fees:.S_
Cluck No. Check Amount: Cash Amount:__
rlI'ntul Project I'n5C S` p I,.
,ud in Full Cl Outstaudim, Il;tl:mce I?ua: ---. -- -
t
r
sEc,rION 5: CONS'l-RUCTION SERVICES
5.1 Construction Supervisor License(CSL) —
\ ;��� A F C License Number Expiration Date
Name of CSL 11older List CSL'Type(see below)
CT M,,Zluau
Description
No. and Street
tricted Buildin s u lu 3i,000 cat. R.
cted ISr2 Pounil Dwellin
City/'ruwn,State, ZIP r
Cuvwnnduel Burning Appliances
S3tion
I'ela hone Email address U I Demolition
5.2 Registered Home Improvement Contractor(FIIC) e7),R I
L zJ.fl L H C Registration Number Expiration Date
I IIC Company Nane or Fl1C Registrantame
7 Z � tit .o =
No =d Street ,y �� / CJ-5(��� Email address
ci /Town,gnie,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 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
Fonmy
bject property,hereby authorize
in all matters relative to work authorized by this building permit applicationElectronic 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 or i�adt tcd Agant'3 N,Illle(Goctronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do hisiher own work,or:m owner who hires an unregistered contractor
(not rcuistered in the Home Improvement Contractor(HIC) Program),will net have access to the arbitration
program or guaranty bind under M.O.L. c. I d2A. Other important information on the FIIC Program can be found at
www mrtss.euv%uca Information on the Construction Supervisor Liccnse can be found at ttww.naas .!n,�Lt•
2. When substantial work is planned,provide the information below:
Turd floor area(sq. lt.) —(including garage, tinished basementlattics,decks or porch)
Gros; living area(sq. R.) .__ Flabitablo room count _
Nnud+er of tireplaccs_ --_------ Number of bedrooms --_.---_--------
Nunther of batten„tttts __ __ __ Number of halbbaths _ _ _ _ _
P%lw of heating iyiwin
t-- L +Ld I'nq.�a �yacir� I'�n�t.l�e• in.ty he still;tinarrd ti'r 1'.'t.tl 1'111jed Co,(" - - -
The Cotnntonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 lVashington Street
Boston, MA 02111
www.ntass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (BusinessiOrganiz tionnndikidual): Len Gibely Contracting Company
Address:
23R Winter Street
I
City/State/Zip:
Peabody, MA 01960 Phone.#: 978 531 -8234
At you an employer? Check the appropriate box: Type of project(required):
1.® I am a employer with 12 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2. rtner- listed on the attached sheet.. 7. ❑ Remodeling
[] I am a sole proprietor or pa
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.=
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself tNo workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
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 anew affidavit indicating such.
CConnactors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
lam an employer tliat.is providiitg workers'compensation insurance for my eoployees. Belo iv is the policy and job site
information.
A. I .M. Mutual Insurance Company
Insurance Company Name: p y _
Policy#or Self-ins. Lic. #: 6010979012012 Expiration Date: 08/03/2013�n
Job Site Address: �Su tti.� . y City/State/Zip: Cl��rye ,/ 1,4
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature i —�� ® /2� Date / 4 v�o l 3 _
z�
Phone#:
Official use only. Do not write lit this area, to be completed by city or town official.
City or Town: PermitlLicense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
_LFh! GIBELY CONTRACTING CO., INC. - Page No —/_at Pay"
23R Winter Street
PEABODY, MASSACHUSETTS 01960 25289 PROPOSAL
All home improvement contractors and subcontractors
(978)531-8234 Fax(978)531-9304 engaged in home Improvement contracting, unless www.lengibelycontracting.com specifically exempt from registration tr Provisions of
Sub lilte0 {� �` Chapter 142A of the general laws,must be registered
To: ( ri'9N� L /-Ie il✓L,, with the Commonwealth of Massachusetts Inquiries
X about registration and status should be made to the
Director, Home Improvement Contract Registration,
t S C One Ashburton Place, Room 1301,Boston,MA 02108
(617) 727-8598. Owners who secure their own
S'°/C y /)Jh. / �d construction related permits or deal with unregistered
contractors will be concluded from the Guaranty Fund
mroae Provision of MGL c.142A.
_ 5-VL 25 once necrsrnnnorveo.
/ 7 S _/y- MA.REG. 100811
0
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graop-upon work.
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of /
Paynrem to oe matle se 1.1l vS _ (( _ dollars l$ ,SP_f
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1 spurt si9nrnJ Conpnry` �
is l upon aomplelmn of G Nanmar t,onlwnorrbezq,a:rraunomalrau,
steel.area.,
IS__I upon carnplerion of
f5 xnpu be mode oral upon aM/slvre
It 1 conrpiulian to work under lM1is conrear, ena ,roan
noun_ No a9memom ter nomeD nnrovemem oorrlmctlog work moll coup a down Name ev N _ ��—
I.,o nl(pavane.a ...in ru ro Inan o e-NiN OI Ills to
contract price
tic or lna L Io1;,1 amuuut ul all deposits Or pdymenls rMicn tto he contactor mug make,in ativance,
erder:rrld/or otherwise obtell delivery of special drdel materials and equarnerl, Auluei 'ipr
whlely sLoncmL1_5_9rea12t.
1 Nm he r throw,to,us rl nal ueceaad ts,
Acceptance Of Proposal I have read both side.of this document and acres h that upon signing.This proposa understan
l becomes a binding contract.You are authorized I de ih workr sespeofielfications and d. Payment w Ilobel matle as outoaled. ned above.You,the Buyer,may cancel this transaction at any time prio t midnight of the third business day after the
date of this transaction.Cancellation must be done in writing.
DO NOT SIGN T IS CONTRACT IFTHERE ARE ANY BLANK SPACES.
n:r1a
IMPORTANT INFORMATION ON BACK Mill
iue UU.L GY 1V : 1V : 7J 4U14 SLEW: ruu1."l,A1 %Sl;I. "liu; rV/o0j1VjLrftgrd 1 OI 1
CERTIFICATE OF LIABILITY INSURANCE "TF'0124/2012
THIS CERTIFIGTE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOWER. THIS CERTIFICATE
DOES NOT AFFIRNATIVELY OR NEGATIVELY AIIaPID, === OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIPICATE OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING MSURER(S)I AUTHORISED AEPRESENTATIVL OR PRODUCER, AND THE
CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an ADDITIONAL MSV=, the policy(ies) must be endorsed. I£ SUBROGATION IS WAIVED, sub]ect
to the terms and cenditiena c£ the policy, certain policies may zequise an endorsement. A statement on this caztiFioake does not
confer rights to the oertlflcate holder In lieu of ouch endorsecont(s).
R°DUCG coff
Edward F Sennott Insurance "[!"
exoua v[.x
Agency Inc 1"-IP:Lx LKI. Arc. Nat,
16 South Main Street
pRaoum
Topsfield, MA 01983- LUST°XRR LOS.
axeau0t+1 APPCAD[Rc cwLGvi �a
A.I.M. Mutual Insurance Co 33758
Len Gibely Contracting Company Inc R
23 Winter Street Rear ,Ns11aA D:
Peabody, MA 01960-5941 IesOm.D:
aemua s:
[XLVPPA F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 1S TO CERTIFY THAT THE POLICIES OF INSUANSCE 1ISTED BELOW HAVE 0X N ISSUED TO THE INSURED NARCD ABOVE FOR I= POLICY PERIOD INDICATED.
NOFHITHSTN[DINC ANY REQUIR[p@n, TTAN OR CONDITION OF ANY CONTRACT OR OTHER DOCIBffiAF WITH RESPECT TO MACH THIS ®LTIFICATE MAY BB ISSOEO OR HAY
PERTAIN, THE INSURANCE AFI'ORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERNS, EXCLUSIONS AHD CONDITIONS OF SUCH POLICIES. L101I'PS SHOWN
HAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY EYP —.CY EXP
= TYPE OF INSURANCE POLICY NUMBER OeAnnm, Aw/ , LIPHT3
GENERAL LIABILITY aAI.°CcV.. '[
❑":'IM[MCI^�43h�.. � =L[n' DAlRDe TO P[NILO $
❑o,: ,. ,.,. `o,X .R eRG,pae,...e�.aael
MOLD eiv IAnv o,u pec.onl 6
opapiDXV L�,I.JO0.Y ,
wxvluL XUw.[w°e 6
[
AUTOMOBILE LIABILITY Wle1xG eieG.i L[wi $
/wY un: lea xel0ent)
` BOPILY INJURY (psi peifop) $
�•_�JnT.LJ M.:V:1 _
.:1 T.fX:.fl AI!,Y.: a0D[LT INJURY IPQ.epi0entl 1
�Y[PLU M:JB �pe��X 1
�l'N-'F'x[J IY+Uv 1
�:MURM':.. ':.Al � ra'.,F:R BXG OCCVRRLNCL I
11:"", ::r.. E] •:V3.YX:y,[L RGDRSOATL f
�4[O;1IlL[ 1
❑I:tl'ILLf I'Jn $ 1
WORKERS CONNINSATION ® b
AND EMPLOYEES LIABILITY
1:1E iF,^F'R:]h'N?AAI:lEIEi [.L. ucx Aian[91
$ boo,coo
A CIGCUTIVD OPr IC3TI AR3 _
❑ inc' ® oral 6010 97 9012 012 a.L. vveAee -voLlm LDIIT s 500,000
08/03/2012 08/03/2013
L.
1.eNPLmv f 500,000
CERTIFICATE HOLDER CANCELLATION
1
Evidence Of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
PDIPIMTION DATE THEREOF, NOTICE HILL BE DELIVEPRD IN ACCORDANCE WITH TIME
POLICY PROVISIONS.
FEB-04-2013 09:48 Sennott Insurance 978 887 2404 P.01
RODucrA 979.887.4900 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
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
16 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. 0, Bon 457
Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC9
42UPAO Len GT e y 4f6kracting CO. , Inc. INSURER A. Catlin Specialty Insurance Co
23R Winter Street INSURERS Safety Insurance Company 39454
Peabody, MA 01960 INSURER C:
INSURER 0:
NSURER E.
:OVERAGES
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 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.
TR Ng TYPE OF INSURANCE POLICY NUMBER DATE MB DATE "oolYrON LIMITS
OENERAL LIABILITY 3700301537 01/29/2013 01/29/2014 EACH OCCURRENCE s 1,000 DD
X CONMAERCIAIGENERALUFBIUTY PREMISE tGlee4vnLme- _i 100.0
CLAIMS MADE u OCCUR MEO EXP(Arty am ae m) S 5.000
A PERSONAL SADV INNRY i V 1 DOD 00
OENERALAGGREGATE s 2,000,00
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO i 2,000.00
POLICY .'PELT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea aWd W)
ALL OWNED AUTOS BODILY INJURY i
_X SCHEDULED AUTOS (Per person)
B X HIRED AUTOS BODILY INJURY
Ivey aaaNe.n) i
X NON-OWNED AUTOS .�..
PROPERTYDAMAGE S
IPer eacidFm)
i
GARAGE LUIBIUTY AUTO ONLY-EII ACCIDENT B
ANY AUTO OTHER THAN EA ACC s
AUTO ONLY: AGG i
ET(Cfi991 UMBRELLA LIABIIJTY BACK OCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE
DEDUCTIBLE .� B _....
RETENTION i i
WORKERS COMPENSATION I TORYLIMITS I R
AND EMPLOTERS'UABILRY --'"-"
ANY PROPRIETOWPARTNERIEXECUTNEn E,L EACH ACCIDENT i
OINaICERIMMINE) EXCLUDEOT L.�
NE EL.bISEASE-EA EMPLOYEE i
yy des beuAder
SPECAL PROVISIONS ball. EL.DISEASE-POLICY LIMIT 1 B
OTHER
,ESCRIPRON OF OPERATIONS I LOCATIONS I VEHICLES I OICLIBBIONS ADDED BY ENDORSEMENT)SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIN BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL 10 DAYS MIBITTEN
Evidence of Insurance NOTICE TO THE CERTIRCATE"OLDER NAMED TO THE LEFT,BUT FAILURE TO 0060 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY IRND UPON ME NSURFA,ITS AGENTS OR
RPPAESENTATNES.
AUTHOAG.ED REPREBENTATNE
Robert Sennott RP
ACORD 23I2009101) 01986-2009 ACORD CORPORATION. All Tights reserved.
The ACORO name and loge are registered marks of ACORD
l
tit Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
11m.uu:ugt Sup.ni. i "
License: CS-094763
I Is
THOMAS B. 003BINS rr
19 Cedar HiR:Drive �g
Danvers MA-01923 , g
y
r
t+V Expiration
Commissioner 05/14/2014
.� Olt-ice at Consumer Mrairs& Business Regulation License or registration valid for individul use onI}'
Yj0ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
" t7R,egistration: 100811 Type: Office of Consumer Affairs and Business Regulation
Expiration: 6/23/2014 Private Corporative, 10 Park Plaza-Suite 5170
Boston,MA 02116
LEN GIBELY CONTRACTING CO., INC.
Brian Dobbins
23 R WINTER ST. �' . s
PEABODY, MA 01960 -_----- -- ----- -
Undersecretary Nut valid w' ut t�ture
If