4 SURREY RD - BUILDING INSPECTION 1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
dy�b Massachusetts State Building Code, 780 CMR Sr\LEM
Renised,tlnr?011
4,d
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Ttvo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Sign u: Date.
SECTION 1:SITE INFO MATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1..1 SV22.sy go
1.1a Is this an accepted street'?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Tuning District Proposed Use Lot Area(sq 11) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ¢finer'of Record: M
1!r�r o.c A-1 cst2lir-s .� A i v roi IYq
Name(Print) City,State,ZIP
LA 181 qs 78 `3d
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building wner-Occupied epairs(s)CR, Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work'-: -erT e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S '3 O 8 0 "t L Building Permit Fee:$ Indicate how fee is determined:
Electrical $ ❑Standard City,I own Application Fee
2. ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ /�
4. Mechanical (FIVAC) S List:
5. ,Mechanical (Fire $
Su ression) Total All Fees:$
p Check No._Check Amount: Cash Amount:
6. Total Project Cost: S 3 t o 8 ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
bc�, w 6 S- �, to
Liccnse Number Expiration Date
Name of C'Sl. I-(older
List CSL I'%pe(sec below)
i
No.anJ Street ,�A� "" Type Description
r/ y v' ^ (D I IT 6� U Unrestricted(Buildings u w 35,0(l0 Co. It.)
l aO.4 �-O A V , I/"/ R Restricted 1&2 FamilyDo eu
Cltyllown,Siatc,ZIP M Mason
ry RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Apti4
I Insulation
'rcie hone Email address D Demolition
5.2RegisteredHomeImprovementContractor(HIC) � D0gl)r IfIC Registration Number
I11C'Company,Name or HIC Registrant N�{me
Street /; 1:3 Email address
Ci /Town, State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
kthis
kers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
affidavit will result in the denial of the Issuance of the building permit.
ed It
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
to 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:OWNER( OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 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./ 9 —
f' .-t�
Print Owner's o Authorized Agen Name(Ilectronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
oca Information on the Construction Supervisor License can be found at tewtv.m:�ss.¢n—,dvs
2. When substantial work is planned,provide the information below:
Total Boor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
"rypeof cooling system Enclosed
3. "Total Project Square Footage"may be substituted for"rota) Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leotbly
1\T3Irie (Business/Organization/Individual): .1� T t �j y \/ C A."�T�.d G—r
Address: R (A 7 ( MJ -L
City/State/Zip:ye A )n r, 0 Cl t Ckk a'hone k 0 '1 $ S k 3�
Are,you an employer?Check the appropriate box:
Type of project(required):
I am a employer with I 7Z _ A. ❑ I am a general contractor and I
employees (full and/or part-time)." have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for mein any capacity. workers' comp, insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.[1 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL - 11.❑ 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.] 3.❑ Other
"Any applicant that checks box N 1 must also fill out the section below showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that check this box must anached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information
I am air employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. t � /s Insurance Company Name: 1-1 /S'� ► 1 U 1 V A Z C . rZ A
Policy n or Self-ins. Lic. N: t/ J ( 1 (] Q 2 q�� I -a r, 1 1 Expiration Date: M 3
Job Site Address: LA Sz, rLeL_V V f;_,� City/State/Zip: (_,Pr" ®)c-n
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 andpenalties of perjury that the information provided above istrrue and correct
Sienarure: DaterM
Phone #: C1 ri Rrj 3 R —,;k- `3te
Official use only. Do not write in this area, to be completed by city or town officiaC
City or Town: Permit/License Y
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone k:
tennett Insurance ' -
YRODUCER 976. 8 �fi900 •` .i E"�.; 978 88? 2A04 P.
Edward Fs Sennott Insurance FAX 976,S$7.2�04 i I � I ..�i.�..
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORAIATIOH
16 South Main Street Agency,
Inc' ONLY AND CONFERS NORIOHTS�IPONTIIECERTIFICMA NOIAER.TICS VERTIiICATTIF pOEs MOT AMENO,EXTEND OR
P 0• BoATE
x 457 ALTER THE COVERAGE AFFORDED BY,THE POLICIES BELOW.
TOpafield, MA 01983 #', , II
"IIUN4U INSURER AFFORDING COVERAGE a
QM e y ontroct no ME, NAIo a
239 Minter Street . ININI A:` t in ec a tv mca..nceeZo
Peabody, MA 01960 INBUw III-Trave- e- ---rsL�` --.4_ 19038 {
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COVERAGES INSUPFR G'+ 3
THE POLICIES OF INSURANCE LISTED BELOW hAVE SEEN 188UED TO ~
ANY REOUIRBMENT,TERM OR CONINTION OP ANY COW THE INSUAPO NAMED ABOVE FOR THE POLICY PER100 WDICATED.NO7wRn67ANpNc,
µAY PERTAIN,THE INSURANCE AFFORDED BY THE RAOT OR O7PIBR DOCUWENT WITH RESPECT TO WHICH TNIB CERTI
POLICIES.AOOHEgA7E LieTB OR
BROWN Y POLICIES OESCRAMOIII RHEREIN IS SVSJECY TO RICATE MAY BE ISSVED TA
Tril Me1BU MA HAVE BEEN REDUCED BY PAID CLAIMS• _ THE TERMS,®(ELUSIONS ANO CONOITION90F SUCH
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e V].dence Of Insurance NOTICE TOMCiNTPKATe NDIclR K"I TO nX WPT,WT FAILURE TO D
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AcoRU 25(2009ro1) Robert Sennott
The ACORD name and logo an re0lelervd rnarli9 W CORO RD CORPORATION, -}AII IIght*L D$orvod
Edward F. Sennott.Insurance ONLY ANDCONFER$13$UC .A$AM VVI v~
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07/28/2011 „
v NDoucEq 9]8.887.4900 , FAX 978', BT.1404 TH18 CERTIFICATE 18198UE0 8 A MATTEER OF, INFORMATION
a Agency, Inc, R,ONTHECERTIFICATE
16 South Main Street HOLDENITHIS-CERTIFICATE DOWNOT•AMOND,`EXTENOOR
P. 0, Box 457 ALTERTHEICOVERA EAFFORCEDEIYTHEPOLICIES'BELOW.
To sfield, MA 01983 1.
Len GT e y ontract n Co Inc, INSURM AFFORDING COVERAGE+¢ NAIC N
uIsuRED g IN$VNER A,' A.I .____ ......
23N Winter St. • "`.
Peabody, MA 01960 IN6uR8Ra.
INSURER c:
INBVRER 0:
ANY REQUIREMENT, E KM OR CONORION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT OTO WHICH ITMIS CBRTDIFNKAT D, OE RHU I`A I<„
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES OESCRIBED HEREIN IS$V94E0T TO ALL THE TERMS,EXCLUBICN$AND CONDITIONS OF St'Cn
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Pages
Page No._—of N
Ic
LEN GIBELY CONTRACTING23146 PROPOSALk CO., INC. n
Ig
23R Winter Street 4 ''c
PEABODY,MASSACHUSETTS 01960 All home improvement contractors entl acting, unless
engaged In home Improvement Contractin8,unless'. a
(978)531.0234 Fax(978)531-9304 specifically exempt from regisiratlomust be registered
Chapter 142A or the general laws,
wWw.lengibelytOntractio9•cOm i with the Commonwealth of Measachuseha.In4uirlea by
/.�0D�Si _`--___._ about registration end statue shoultl ba me is a the
Submitted - ----,_ - Diractoq Home Improvement Contract RegfinsArep270B a
o
To: / - - One Ashburton Place,Room 1301,Boston,
y' (617) 727-6598. OWermlta oh deal with it n
Q y�.r�/� -- q �1� construction related pif
/ ^� 6 / / ._ contractors will be exclutled from the Guaranty Fund
I-_—— Provision of MGL e.142A.
g'C"Mu ".No. D
acre MA:REG.300811 >
pgaNe S r/y� 9°%'� !! - L 3 -Al ,,f y 0✓f1 # (
ros rocnTloN _•��� '�s
dormed aM rnelenal%W be Ueed: !� Ze 0/
We M1emoy sObmll apecil1ce40M eM 6eYmal Ill
l w0,k 1 be pe ----- 7/
Cell-
l„l slur sli,Eld r9_ro�,c� / h;r �7v`r
try
_ 8Ar
IL
gj ILO
-BLS
— ---- ------ — ter
—_--- d -
Consvucdonrel�lgju—v'
. .- IN P9 ,N 'lI0 cI plM1l tlbY l L
U p n realty a
Tn O
WOaN aL DUtE a Isbl IM1 In Ad YI IIh YgdL gt Bl c 101 In 1 n Ih 'd tl Im '
Oon A'daml
eenlmct OF' Int/wdY 4 p delay 0 by I c ntl Y Inal I Wltl de oYN I Im
hoot ✓Kl�alleell+i^ w na Ili6 III g PI I 1 0 do II Fe wtnin
vcknox egos end vg,ees lnal Ne ecM1eduln0tl le aDD Oa k ^%hIDM p pd_1
wAFnANTy IIIa Lonl,ecla,n � g�aUelem^dod. apal,eaan Ferreira.
Tno berries.,warenla IM16 .11 In 1 Ne wotk to w were
ne,eunae,anall 061,Ba I,MI at ills n mat a 1 podPa en a ssymall^w'llh IM1e agreB0uP0n wptk.
M1 L11.1m shell,alnbawn.m nse,IonnwiN mrig ,opal,.wnecL raD
me neutral o1D oils an any Db.indudin9^clean up.�le xn kmanship o,mvlo,ials,^,tlam ge roused
one year a or wm p for the suOm o�f.�
such damage or soon aplm is mmp,'mloo,�a�wnansnlp:Tne roragoing wono^ueampleteVin accordance with ails ecifications, 0
We Propose hereby to furnish material and It -comp duffers($
j Payment to be in its as lollb s
I1 ,an al Cle' ( er—a, wmcw/oosgre os geyn -
10 ) pD epletion of s,om•wmu
Pnrm
1 u compl¢lion of Ciryle,ala 4' •^
—%Ism-1 soon - Fe , DNa.
atoll de made lol¢wiN upon pry e
--%(5— )completion of work unroof this contract.
Na ma _
I" Nollw: No aOreement for eome'impmvemenl wnvadi"work shell Contrast
advance, m e ^ e,
payment(otivence deposit)of mate Than one.lhiid DI the tole)rd ems price of lee it not amplobwilM1n
I Iolal amount of all deposits or payments wnich lee al order mala and
equipment N^w hl al nay ne,ses n M
), ID prtlor andror olhern'1%e obtain tleliverY DI special ntr of materials and ,
¢e e!
l Acceptance of Proposal I have read both sides of this document an ccept the prices,specifications and conditions slated.) e dSUM
may cancel this transaction at any time prior to midnight of the third business day after tl
{ that upon signing,This proposal becomes a ead bg conlracL You are authorized to do the work as specified. Payment will be Made as outline SUM
You,the Buyer, y
ellation must be done in writ `ACK
�
"k- DO NOT IGN THIS CONTRACT IF THERE
RE ANY BLANK SPACES.
date of this transaction.Canc .
oaa
F W/ o�. '•� 6 // sm^owe IMPORTANT INFORMATION ON
f
4 61pnv m
1 ,
.. ,
+- M Isachusetts Dcp a tmcnt ul Public'Safct� r
Board of Building Regulations and SI Ind trdx s
Construction SUF,r.isor uCenSe
License: CS 94763
Restricted to: 00 '
THOMAS R DOBBINS jl}
19 CEDAR HILL DRIVEi
DANVERS. MA 01923
Expiration: 5/14/2012
( nuuuianioncr Tro: 23757
✓�e [JOvvnNviet(�(L[{/L u�✓!'GUWUC'/lu0v�l0 . ,o
, t
- um.e ut Consumer Affairs& Business Itegulatiuu License or registration vulid for individul use only _
"�'•::';"'HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
/ Office of Consumer Affairs and Business Regulation
Registration:.:100811 Type: 10 Park Plaza-'Suite 5170 -
Expiration:, q/23/2012 Supplement Card Boston,MA 02116
..Et.GIBELY CONTRACTING CO,;INC.
-iOMAS DOBBINS -
':9 Main Street - 4��.6---�6»B�_ "'[,` •_
eabody, MA 01960 Undersecretary `-y--`Not vta'lid without signature
J