12 SYMONDS ST - BUILDING INSPECTION 1
01
The Commonwealth of Massachusetts
Board of Building Regulations and Stand4editio
CITY
t OF SALEM
Massachusetts State Building Code 0 CMR, Revised Juntuury
Building Permit Application To Constru Rep ir Reno a /. -0
One-or Two-Fun ly D ngThis Section Fo°r itici 1 se n
Building Permit Number: /f�_,., � ate i
Signature: ""v'"" Vj
Building Commissioner/Inspector 6PRuildings Date
SECTION 1:SI E NFORMATION
1.1 Props Address: 1.2 Assessors Map At Parcel Numbers
� a �1/r+ o,,.a s Sz-
1.1 a Is this an accepted street?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Amu(sq 11) Frontage(tl)
1.5 Building Setbacks(it)
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: 1.9 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system O
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record
Zs et,-,t,
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin wner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S O �(`j`�� I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityrrown Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire S Total All Fees: S
Su ression
� Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
r -
w
SECTION 5: CONSTRUCTION SERVICES
5.11 Licensed Construction Supervisor(CSL) 9 L4, 6 3 5 ` )L-4_
1 —�)o V'®Sp a,i. License Number Expiration Date
Name of CSL-I folder
3 12 L0 w`C, S e��iQ t'�D� List C'SL'I'ype(sec below)
.odd` s T' Descri Lion
` ±r—G U Unrestricted(up to 35.000 Cu.Ft.
R Restricted 1&2 Family Dwellin
Si nature M Mason Onl
1 3 ��' > RC Residential Rooting Covering
Telephone S WI Residential Window and Siding
SF IResidential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Regbtered Hor�a Improvement CoJ�ractor(HIC) 7 D � g
L Registration Number
HIC Company Name or HIC Re utrant Name g
a 1�J -�.� S��na�oov �- �-
Add�+ ,
t Ja�!C1 - q-7 R (QDCL4 Expiration Dale
Signature Telephone 1
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(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 ..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , 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.
Signature of Owner Dale
1 SECTION 71b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, 024"t i- ,as Owner o Autho ized Agen ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. ( ��
Print Name (� _2,S_ l `
Signature of Owner or Atnhoriz gen Date C]
(Signed under the paii is and penalties of perjury)
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 fir(have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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
Type of cooling system Enclosed Open
). "Total Project Square Footage"maybe substituted for"Total 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 Leeibiv �t
Name (Business/Organization/Individual): ��yi CT
Address:Q -3 R UJ j j S -,-
City/State/Zip:ye A )o h a Y MA , Q 14 j,(3?hone #: 0, ri $ S 3 �8 a 3 t-1
Are you an employer?Check the appropriate box: Type of project(required):
I am a employer with I m 4. ❑ 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 me in any capacity, workers' comp. insurance.. 9. ElBuilding addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. [No workers' camp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
comp, insurance required.] 13.❑ Other .
•Rny 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 art doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site
information. 1
Insurance Company Name: A -r---1.. Nl� E'''n 1 tJ 1 ll A ref .vC dF�
Policy# or Self-ins. Lic. #: V W C G d 1 CS q '"I G'd I -a Q 1 i Expiration Date: nCqY 3— '�k o \Q_
Job Site Address: 1 -D, e-> tiL$ q= t- City/State/Zip: �o La z. X '119
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 cert(&under the pains and penalties ofperjury that the information provided above is true and correct.
SiEnature• N /\ \��/h Date:
Phone#: 9-7 3
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):
L Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
,
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VL/LY/LV44 I vHooUCFN 976.88 . "0 FAX 0 .967,2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
dwa rd F. Sennott insurance Agency, Inc, ONLY AND CONFERS NQ RIGHTS UPON THE CERTIFICATE
sib South Main Street HOLDER THISCERTIFICATiDO I NOT AMEND,EXTEND OR
P P. D. Box 457 AL THE QOVERAOE AFFORDED BY THE POLICIES BELOW.
Topsfield, MA ma3 INSURERS AFFORDINGCOVERAOE NAICO
" en e y ontrae ng ne. tin eat surance o
23R Hinter Street INSlNVA B, Trave Ors 19038 -j
Peabody, MA 01960 ,NE nA o
COVE RAGES NBURER G
THE POI RANCE LI81'ED BELOW PAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIM INDICATED.NOTW r7H67ANDINC
ANY REQUIREMENT.TaRM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR
LaY PERTAIN,THE INSVRANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS iUBdECTTOALL THE TERMS,BXCLVSIONS AND CONDiTI0N5 OF SUCH
POLICIES.A00RE0ATE L"T8 SHOWN MAY HAVE 86EM A9DUCED BY PAID CLMMB.
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CERTIFICATE HOLDER CAN ELLATION
aMOVLAANYOF THEAOMMCMW POLglu BE CANCELLED WORE TNF UPWAMh
. DAIe TIQICW,TNR IaiYILrO INWeaR WILL aNWALVOR Tp aNL';' 30 OAYB wRnTEN
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AIlTNDRQaq IiPeEiE1RAnK - '.
ACORD 25 1 zo09101) Robert Sennett . :
The ACORD name and 1090 are registered marh�2A ►tD CORPORATION. All fight* vBe ved.
CORD
i
RUG-01-2011 13:24 Sennott Insurance 97B 887 2404 P.01
r3 v .. . . .. . . . ...vv. .. .....d 1 . 07/28/2011
PR(�UCER 979.897.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
.1 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. Box 4S7
Topsfield, MA 01993 INSURERS AFFORDING COVERAGE NAIC #
INSURED Len GTbely Contracting Co Inc. INSURERA A.I.M.
23R Winter St. INSURER B'
Peabody, MA 01960 INSURERC:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWRHSTANOING
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.
LTSR DV TYPE OF INSURANCE POLICY NUMBER LJ T EFFE VE POLICY EXPIRATION LIMITS
GATE MMIODNYYY DATE MWDDIYYYY
GENERAL LIABAITY EACH OCCURRENCE S
{ft
COMMERCIALGENERPLLIABILITY _PREMISES E900 Fm')le $ _
CLAIM$MADE OCCUR NED EXP(Arty one"B ) 6
PERSONAL A ADV INJURY 3
GENERALAGGREGATE 6
GEN L AGGREGATE LIMIT APPLIES PER: PROOVCTS-COMP/OP A00 6
17 POUCY PRO LOC
JECT
AUTOMOBILE UABIUTY COMBINED SINOLE LIMIT
ANY AUTO (Ea&mmw t) S
ALL OWNED AUTOS BODILY INJURY 5
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY �^
NON-OWNED AUTOS (Pere $
ml0en0
PROPERTY DAMAGE 6
(Per eccidenq
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT A
ANY AUTO OTHER THAN EA ACC 6
AUTO ONLY: AGG S
_ EXCESS I UMBRELLA LIABILITY EACHOCCURRENCE $
OCCUR n CLAIMS MADE AGGREGATE $
9
DEDUCTIBLE 9
RETENTION S 6
WORKERS COMPENSATION VWC6010979012011 09/03/2011 09/03/2012 X I TORY LIMITS I ER
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR)PARTNERIFXECUTIVE� E.L.EACH ACCIDENT 6 S00,00
A OFFICERtWMBER EXCLUOM7
(Merreelary N NH) E.L DISEASE-EA EMPLOYEE A S00,00
a yas.deKHM Unaer
5VECIAL PROVISIONS below EL DISEASE-POUCY LIMIT 3 S00 DD
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/YEMCLE9I EXCLUSIONS ADDED BY EHDORBENIII SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIAATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OP ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
Evidence of Insurance AUTHORMED ACPACOCNTATIVE
Robert Sennott
ACORD 2S(2009101) ®1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
r Page No. _-k—of Pages
.EN GIBELY CONTRACTING CO., INC.23R Winter Street. 23311PROPOSAL � (
PEABODY, MASSACHUSETTS 01960 L
All home Improvement contractors and subcontractors -
(978)531.8234 Fax(978)531-9304 engaged In home Improvement contracting, unless o f
www.lengibelyCOntracting.COm specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered 7 p I
sed - with,the Commonwealth of Massachusetts. Inquiries m
h
J
To: /_____ ___— about registration and status should be made to the
.os_h_ _e.� m
lI 1 Director, Home Improvement Contract Registration, rr
One Ashburton Place, Room 1301, Boston, MA 02108
�-- (617) 727-8598. Owners who secure their own
/Y /7—7/`� construction related permits or deal with unregistered m
!J_._Q _I_-L..S.!----- contractors will be excluded from the Guaranty Fund r
/ Provision of MGL c.142A.
P,,,111.��ONE GATE REGISTRATION NO.
r'3 MA.REG. 300811
[B / CST o
JOb NAMENO / / LOCATION
. JOB
S iT Mti O
el)yyJbmil specifications and estimates for work to be performed and materials to be used:
4�_ 07
I�C �
_��g1�_���
�-ro
cL
Q
C
nncilo ref t d Its —rdG—
r.Ii�
CULE
II DI Oo� yR wmk or ortler IM1e meter als balers IM1a IM1 third tlay follow ng 1he -g g of tN3 Fg t speeffi d M1 1 vLto t b g e th k n or
�(((ffIII aaa\\\,,, (date).Barring delay caused by circumstances beyond Co 1 t co i m m o x win he Dialed by ate).TheOwner hereby
LIOC os nU u-g ae M1911ba acM1etlul'ng tletos are epproy mate antl that Su.h delays that e,e not.Jeb a by the contractor shall not be Considered a violations of this Agreement,
uAN rY rr
eamm wansess Ihat the work famished hereunder shall be free from defects In material and workmanship for a period of Nlw+ing Completion and mall comply with
_,nests of this Agreement.In the event any dell In workmanship or Materials,or his own b damage caused by the ns,forthwith yCre tractcomeclaue lace,one roGavaeplo be temedbd'a13 i.e.disc or Sred wllhln
Irminger coSuclh defeatnnassainlelslmlworkmanshi clean up.the
The foregoing
warl.rntieseall survive radical In Connection with the agreedwork. pa,mq or replaced,
ge or p. Connector
c r walla any p Pe gre pen
Propose hereby to furnish material and labor—/,e/pmplete in a9co/danch abov specifications,for the sum ot:
tlollars($ )
tent to be matle as follows:
upon signing Contract:
upon mpletion of
Nam.of cmmactonoesigrated Arelstrsm
(g ) co Saeei nddros>
($ )upon completion of Citylstae Pnonp
shall be made forewlth upon
- IS )completion of work on this contract. an. Feddrano No.
No agreement for home improvement contracting work shall require a down -
ant(advance deposit)of more than one-third of the total contract price or the _
mtounl of all deposits or payments which the contractor must make,In advance, au ,izeU we
for and/or otherwise obtain delivery of special order materials and equipment,
l ver amounts greater. ;Tn6 proposal may be vnN awn by us,"nm,ursptedwithin der>_
:eptance of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated.I understand
ryon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above.
I,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the
e of this transaction.Cancellation must be done in writing.
DO NOT SIGN THIS CONTRACT IFTHERE ARE ANY BLANK SPACES.
Date Z2 / sothre. Date
IMPORTANT INFORMATION ON BACK
........... .......
Department of public saret�
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 94763
Restricted to: 00
THOMAS R DOBBINS
19 CEDAR HILL DRIVE
DANVERS, MA 01923
Expiration: 5/1412012
Trv: 23757
Offia ul Consumer Affairs& Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration:4 100811 Ty pe: 10 Park Plaza-Suite 5170
Expiration: 6/23/2012 Supplement Card Boston, MA 02116
N GIBELY CONTRACTING COF, INC.
HONIAS DOBBINS
149 Main Street
Pe,00dy MA01960
Undersecretary Not valid withoutsignature