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10 VINNIN ST - BUILDING INSPECTION (2) r o �� L v► uN K)os TherCommonwealth of Massachusetts tr Department of Public Safety Massachusetts Slate Building Code(730 CMR) ' n Building Permit Application for any Building other than a One-or Two-Family Dwelling U I (This Section For Official Use Only)- - - ( ^ Building Permit Number: Date Applied: Building Official: J J SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not availttle) =/> .9 v , g r, S r� .�Ts Kr Fu�vRrt/4l K/n ( O w ST S ALo� cm-o No.and Street City/Town Zip Code Name of Building(if applicabl% of n l 1 SECTION 2:PROPOSED WORK. Edition of NIA State Code used If New Construction check here❑or check all that apply in the two rows below r—_,a O Existing Building., -- Repairer- Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 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 ®L- n Is an Independent Structural Engineering Peer Review required? r� Yes ❑ No� Brief Description of Proposed Work:- q T Q IV!PG2.ov� F6 e r-ti� KOf� ' l )-ALYG16A-Ay d- ipz� -42 Cz-D f 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 CNIR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(hiclude basement levels)&Area Per Floor(sq. ft.) Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2❑ I-3❑ I-f ElNI: Mercantile ElR: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage Sl ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: PP Y' A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal required❑or trench or specify- Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: i\lip t ni_l:;nnnn enn_�agj� t r,_ces: 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: Dues the built ing can twin an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner ThaenAs A,,,&.IhulL 10 V (A-AlI -S ,oia,. 0 14i^ Name(Print) No,and Street City/Town Zip Property Owner Contact Information: -7 9L g)- 23n�� _- - 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. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix.2) If building is less than 35,000 cu.R.of enclosed space and l or not under Construction Control then check here❑and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - - - L.e,g CI e �t_rrcoti-t Company Name '-MM r eb,-,e9 C Name of Person Responsible for Construction License No. and Type if Applicable ' 23 2 60 tA.; vt�S �p.a banV ^'A G Iq G Street Address City/Town State Zip 9'785�- A 2 3 �t �o�3-�Y ti-1 334 Telephone No. business Telephone No. cell e-mail address SECTION 11:lV0RKEI6'C0N1l1F.NSA I'ION INSURANO:Ab FIUAVI f M.G.L.c.152.§25C 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 issuance of the building permit. Is a signed Affidavit submitted with this application? Y No ❑ SECTION 12:CONSTRUCTION.COSTS AND PERMIT FEE: - Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal.factor)=$ 3. Plumbing $ d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) $. Mechanical Other $ Enclose check payable to 6.Total Cost $ z(o Z'7.5 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT 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 yunderstanding. C 7 Please print and sign name Title Telephone No. Date 7D,3 r2 U.' 4014 to ( ni Lin 11 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date The'Common wealth,of Massachusetts Department oflndusiriaiAccidents Office oflnvestigadons I Congress Street; Suite 100 Boston,MA 02I14-2017 www..mass.goy/dia., Workers'Compensation Insurance Affidavit: Builders[Contractors/ElectriciansLPlumbers APMicant Information Please Print Le ibly Name (Business/Organization/Individual): L e.ti C c Address:— LJ t ., e. rc. City/State/Zip: F42.A q n Phone Are you an employer?.Cheek the appropriate box. 1.® I am a employer with 0'1_ 4. 0 I am a general contractor and I Type of 1.project(required): employees (full and/or part-time).• have hired the sub-contractors 6. New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 9. [] Remodeling ship and have no employees These sib-contractors have: 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.; 9. ❑ Building addition required.] 5. �,We are a eolporation 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. [No wQtkers' comp. right of'exempGon per MGL insurance required.] t.. a 152,'§1(4),and we have no 12.0 Roof repairs employees. (No workers' 13.0 Other comp. insurance required.]' 'Any applicant that checks box#1 must also fill out the section below showing Uvir workers'compep satin a policy information. t Homeowners who submit this afndavn indicating they are doing all work and then hire outside contractor;must submit a new affidavit indicating such. 'Contractors that check o this box must Attached additional sheet showinng the name of the subeontractoisnd state whether or not those entities have eruployees. U the sub-contractors have employees,they must.provide their workers'comp,-policy number. I am an employer that Is providing workers'compensation Insurance for my employees. Below Is the polky and Job site information. - Insurance Company Name: Policy#or Self-ins. Lic. #: Y/�(/C - i t5 O �j O 1 C y ry 4 DOItioExpiration Date: Job Site Address:-] Q V C I city/State/Zip:. 2.A Lv n-. M A Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required undar.Section 25A ofMGI,c. 152 can leacj to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as.civil pensltiesin W,e 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 covcng;q;verificatimL,:. a I do hereby eerdfy under Me pa and penaWes_ofperjury that the Information provided above Is true and correeL Signature- �� ��,o^ Dat Phone#: OVIcial use only. Do not write in this area,ea be completed by city or town officAd. L6. y or Town: Permit/License# ing Authority (circle one): oard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ther tact Person: Phone#: .a a® CERTIFICATE OF LIABILITY INSURANCE B;D�Ix" o„ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE°HOLDER:4THIS 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(Sh AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:It the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If 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 Edward F Sennolt Insurance M. ; 16 South Main Street. Topsfield,MA 01983 ass: INSURERM AFFORDING COVERAGE NAG a . A.I.M.Mutual Insurance Company 26168 INSURED INSURER B, Len Gibely Contracting Company Inc 23 Winter Street Rear Peabody,MA 01960.6941 - COVERAGES CERTIFICATE NUMBER: - REVISION NUMBER: THIS IS TO CERTIFY THAT 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 TD V*aCH 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I TYPE OF INSURANCEWWIPOLRYNUMeETe LMRS 0 GENERAL UAMU" - EACH OCCURRENCE s COMMFRCIALGENERAL UABIMy ' ., RE S[!1P CLAIMSMADE OCCUR Z " 3'. MEDFXP(Anyane Pelson) s yv� t s PERSONAL a ADV INJURY f _ GENERAL AGGREGATE f ENL AGGREGATE LIMIT APPUES PER - PRODUCTS-COMR'OPAGG f CY ODOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY MURY IN,Pe,wn) f ALL OWNED SCHEDULED AUTOS AUTOS BODILY NJURY(Poreocemp f HIRED AUTOS AUTOSVAVNED s t UMBRELLAUAa OCCUR EACH OCCURRENCE IF EACESS LIAR CLAIMS MADE AGGREGATE s �yppIDED RRNE1IEhffgIOIN S S{q{U. s AND EMPLOYERS LIABILRY X Yl1MTS O \. A a� I���L �� ECUnv NN NIA VWC400.6010979-2014A 81312014 $1312016 EL EACH ACCIDENT f 600,000.00 I(I'M�.a�nC�etory In NNHiiel ELDISEASE-EAEAPLOYEE It500.000.00 DESCRIPTION OF OPERATIONSWe EL.DISEASE-POLICY UMR f 500,000.00 DESCRIPTIGN OF OPERATN)N61 LOCATION81 VEHICLES(AnacA ACORD 101.A44Monal Rema,ks SCBseYle,a npn apacels,aeulae) 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. AUMORIZED REPRESENTATIVE (D1988-2010 ACORD CORPORATIO .All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of.ACORD ACORQ 01/3 CERTIFICATE OF LIABILITY INSURANCE 0/2015MIUDIY5 l/3 !PRODUCER 978,897.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION I Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 16 South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 457 -- Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC9 iNsuaeD Len GT e y Contracting Co. , Inc. wSuaeaA: First Mercury Insurance -0 23R Winter Street INSURERS: Safety Indemnity 33618 Peabody, MA 01960 INSURER c: INSURER O: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREU NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT WI IHS TANU I NG 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. NSR 7' ILTR NSR TYPE OF INSURANCE POLICY NUMBER DATE DATE JMWODfYMI LIMITS GENERALLLUNUTY MA-CCL-0000OS1263-61 01/29/201S 01/29/2016 EAcHoccuRRENCE s 1,000,00 x COMMERCIAL GENERAL LIABILITY PREMISES Ea eccurronce E 100,000 CLAIMS MADE O OCCUR MED EXP(Any ane pm ) $ 51000 A PERSONAL a ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,0061 GEN'L AGGREGATE Lim r APPLIES PER: PRODUCTS-COMWOP AGG $ 2,000,00 POLICY PE0 LOC AUTOMOBILE LABILITY 6221693 COM 02 01/29/2015 01/29/2016 COMUWED SINGLE LIMIT ANY AUTO (Ee eccitlem) E 1,000,0_0 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per r ) E Pnwn X HIREDAUTOS BODILY INJURY JIII I I x NON-OWNED AUTOS (Pe'.WdenQ $ - --I PROPERTY DAMAGE (III {PM ecuannl) E GARAGE LIABILITY AUTO ONLY-FA ACCIDENT $ ANY AUTO EA ACC E j OTHER THAN _ AUTO ONLY: AGO $ 1- I IIrE--EXXCCCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ (OCCUR ❑ CLAIMS MADE AGGREGATE $ I— $ DEDUCTIw E $ RETENTION $ $ WORKERS COMPENSATION - AND EMPLOYERS'LABILTY YIN TORY LIMITS PER AIrY PROPR,ETOWPARTNEWEXFCUTIVE[:D E.L.EACH ACCIDENT $ OFFICER,MEMBER EXCLUDED? -- IMe.d.toryInNH) - E.L.DISEASE-EAEMPLOYEE $ SPECIAL PROVISIONS b Qw E.L.DISEASE-POLICY LIMIT' $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS i'roof of insurances. I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIDED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUINO INSURER WILL ENDEAVOR TO"L 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT fA1LURE TO 00$0 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR HEPRESENTATIVES. AUTHORIZED REPRESENTATIVE Robert Sennott RP ACORD 25 (2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD J Page No. of Pages LEN GIBELY CONTRACTING CO., INC. PROPOSAL 23R Winter Street 25534 e - PEABODY, MASSACHUSETTS 01960 All home Improvement contractors and subcontractors (978)531-8234 Fax(978)531-9304 ,,II 11 engaged in home Improvement contracting, unless www.lengibelycontracting.com TtioAq,NCdkT qo specifically exempt from registration by Provisions of Chapter 142A o1 the general laws,must be registered Submitted / \` with the Commonwealth of Massachusetts. Inquiries To: _J. p_�}�k I-(1n Yq —i'}O/�-LA_-- about registration and status should be made to the Director, Home Improvement Contract Registration, 'U I/ •�r_n\S - — One Ashburton Place, Room 1301.Boston, MA 02108 V (617) 727-8598. Owners who secure their own construction related permits or deal with unregistered __—Sa�y,yt_I•to _��.�{ Cj_ - contractors will be excluded from the Guaranty Fund r Provision of MGL c.142A. 1 P O EGlaIgITON NO. - MA.REG. 100811 JOB NnM O. f— JOB LOCATION ti Ra C We hereby sub II speciflcat era a estimates f r work to be performed and materials to be used; a—/Le—Ja r �('j�-aud ------ ---+�ri uM base&—0 �c-a4-pe t Ls r n CrPaj-P� R—utt Quin)' � - v C Construction related permits: 3 _vn- -Ud--e-- �ss 1;P14 r s ad Cranf r _ G n" WORKSCHED LE Co d II ,in the work or.,do,the meterlals before the third Ley mnovi ng the s gnTg of fh s Ag L. mass p 'I tl herel to, Jv'Il beg thew k on or eboJrt} J�a�Nate).Barnng delay caused by circumstances beyentl Contractors control, he work will be completed by Were).The Owner hereby eckli6 via ease agrC aes mat the echetluhall came are approximate and that such decays that are not avoidable by the contractor shall o be consldom asra Ttions of Nis Agreement. WARRANTY The Contractor warrants that the work fumishetl hereunder shall be free tram debda in metellal and wplkmanshlD far a period of following es or ag.no.a end shall comply with the requirements of this AWeamont.in the event any defect in workmanship or materials,or immege caused by Na Contractor,his su noedors.employees or agents,Is discovered Comm,with ne year abler mmplegon of any IOC.including clean up.the Contractor shall,at his own asperse,forthwith remedy,repair,correct replace,or disuse to be remedied,repaired,or replaced such damage or such defect in materials or workmanship.The toragang warranties shall survive any Inspection perlormetl In connection With the agreed-upon work. We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: D 9 v o Ai i-T 1-r r L ' do 1 m(s n'7� ). Payment to be made as follows: 7 S-� l P Q 1 �/e.♦'-'-{'p y ui . I ns}A - /p 1 i �}7 Uy'-s 3�� �— a"XuSo, s N tv e t S u��ac esN.; PfdB 410,31X7.o o f�✓ C factfmAAndglqua0O firse_C_hcr--iIwv f� %($ 1 upon signing Contract; --�--- _ %is tJ��ks��11` )upon W J '"" street Morena— -- ----- upon completion of` ciyistete —__ —Poona ,6($ 1 )shall be matle for _ upon ---- — \T completion of work under this common. Phone Notice: No agreement for home improvement contracting work shall require e d No amamay payment(advance diapason)of more than one-third of me total contract price or e fatal amount of all deposits or payments which the contractor must make,In adverted, rimm to order and/or otherwise obtain delivery of special order metadals and equipment, whichever am is greater. ".m ThisloWsslmaybewi dawn by u9 it not aw.aptBd within days. Acceptance of Proposal I have read both sides of this document 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 NO�THIS CONTRACT IFTHERE ARE ANY BLANK SPACES. f �m \\� sienmare Dote W 1 aghamre Dun IMPORTANT INFORMATION ON BACK I ..„oe.w•n.,w.«,.....ha+r:e+.wintx,w,:.aw.rw�..:'I` .. ,w+=-a.., __ NO- .a...av .-:. (� Massachusetts .Department of Public Safety `. Board of Building Regulations and Standards Cun#truedun Supun'Isor License: 0S-0i �e3.., i Expiration. Commissioner 04/142014 is f cs7��rwnarru+arr�d�w� I Mee of Consumer Affair#&Butloew Regulation License or rQistratloa valid tor Indlvidut use only OME IMPROV NT CONTRACTOR beforo.tho expirstioa date. If(Quid-return to: Regiotra0 . . Office of Coneptaer Affair end Busiaoa Regulation 4 Typo:' 10 Park Plaza-$uite 5l Expir Supplement Card So;ton,MA 0:116 LEN GIBELY CO ,INC. � : y a THOMAS DOBBIN ' 23 R WINTER ST PEABODY. MA 01960 Voderseeretery Not valid wiEhout dt;natar i t t