40 WALTER ST - BUILDING INSPECTION �\ The Commonwealth of Massachusetts
Board of Building Regulations and Standards Cl'CY OF
A LEi%Nv[
Massachusetts State Building Code, 730 CNIR SX/ar
LReviseed Mar 201 l
\�1 Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dsvelling
'[his SzctionForOf6cial UsiQnl
Building Permit Number:.'. D'te A h di.
Building Official(PrintNa. );.; - �: Stgnatu _ - Date -
SECTION I:SITE INFORMATION
L! Property Address: 1.2 Assessors hlap&Parcel Numbers
L is Is this an accepted street?yes_ no Map Number Parcel Number
F
Zoning Information: 1.4 Property Dimensions:
g 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.O.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 yesO
SECTIONz:; PROPERTII'OWNERSHD'�
2.1 Ownert of Record: D Q-7!7
Name(Print) — City,State,ZIP
H 0 (,vAL`r-.-a. 5-,-- IU7-737 Z71 `t
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW'6heck all that apply)
New Construction ❑ Existing Build' Owner•Occupie epairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ClAccessory Bldg. ❑ Number of Units_ Other ❑ Specify: .
Brief Description of Proposed Work : f/P Ps /Y2t.1 r r� t�F4 2IA T zrs a
GCca
SECTION 4: ESTENLATED CONSTRUCTION COSTS:.
Estimated Costs:
Item Official Use Only
Labor and Nfaterials
I. Building ; 1. Building Permit Fee.S' Indicateh'ow fee is determined:
❑
2. Electrical 5 Standard.dtyf' ownrApplication Fee.
`
q'CotalPiojectCost .(Itemb)xmultiplier x
J. Plumbing S 2. Other F es: $
I. ,Mechanical (fiV:\C) S List: __< ^L
i. \lachanical (Fire 3
I
Sn� ires;ion) _ btal:111 Fees:.S
'hack No. _Check Amount: Cash Autonnt_—
n fatal Project Cost: S g 3 f ❑ Paid in Pull 0 Outstanding lialnnce Uua: __-- -- -
,
src•rtoN 5. c• .o:VsrlwcrlONSERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL I!older below
List CSL Type(see )
j Q_ *.-,k' '-V Type Description
No. and Street -
,�]� U Unrestricted DuilJin s u to 13,000 cu. R.
R Restricted ISc?Fnmil Dwtllin
City/Town, State, ZIP bl \lasonr
RC Rootin Cuverin
WS Window and 5idin
SF Solid Fucl rlurning Appliances
Insulation
lilt hone Email address D, I Demolition
5.2 Registered Home Improvement Contractor(11IC) 1 D 0 $ 11 a3 qf
¢w b r+ Zv! er-7 e o i FIIC Registration Number Expiration Date
I IIC Company Name ur FIIC Registrant Name
d Str et 7�53i�3� Email address
tea, � f�rQ
City/Town,State 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
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 7h: OWNER' 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 applications is true and accurate to the best of my knowledge and understanding.
t'rint Owner's o , uthurized:\;tn _�yV,unt(Gectrunie Signature) D,ut
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Honte Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty find under M.O.L. c. 142A. Other important information on the HIC Program can be found at
www m;tss.�ov%oca Information on the Construction Supervisor License can be found at ww•w.na, rls),adlri
2. When substantial work is planned,provide the information below:
Total floor area(iq. 11.) _(including garage, finished basement/attics,decks or porch)
(iros; living area(sq. It.) -- Ilabittble room count
Numberoftirrphlccs_.---_----- Number ofbcdruoms .--- -----_---_---_--_--
Number ofbathroum.i Numberoflialubaths —
I Cpe of Iwming iyit ill --__—_- Nnllll)er af,leck 'IIUrChc.i
I}ptolco.,ling ;yucm F:nclo;cd Open
..I"„tdl I'nq:rt i,pi.n.a w.ry he sub;titnrtl t;,r"•f„r.11 I'MiCLI C0:1 '
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
U1V 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
H'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibly
Name (t3usinessiorganiutior✓Individual): Len Gibely Contracting Company
Address: 23R Winter Street
City/State/Zip:
Peabody, MA 01960 Phone #: 978 531 -8234
Are you an employer? Check the appropriate box: T
Type of project(required): �
1.0 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.[_] 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
working for me in any capacity. employees and have workers'
(No workers' comp. insurance comp. insurance.t 9. ❑ Building addition
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 1 LEI Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.[] Roof repairs
insurance required.] t c. 152, §I(4),and we have no i 13.❑ Other employees. [No workers' __.__.._.
comp. insurance required.]
'Any applicant that checks box#t 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 anew affidavit indicating such.
iContractors 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A. I.M. Mutual Insurance Company
Policy#or Self-ins. Lic. #: 60109 79012 012 Expiration Date: 08/03/2013
Job Site Address: y D 4J R i—-C-- ,r_ Sa� City/State/Zip: S A(.. /-s, 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 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.
1 do hereby certify under^t—h�e pains and penalties ofperjuty that the information provide//d above is true and correct.
Signature: `p —7 c-L e Date b t
phone #:
Official use only. Do not write it: this area, to be completed by city or town official
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#:
w
FEB-04-2013 09:48 Sennott Insurance 978 887 2404 P.01
4141 ER 978.887.4900 FAX 918.337.2404 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. Box 457
Topsfield, MA 01993 INSURERS AFFORDING COVERAGE - NAIC0
4suRsD Len GT e y Contracting CO. , Inc. INSURERA. Catlin Specialty Insurance Co
23R Winter Street INSURERBe Safety Insurance Coepany 39454
Peabody, MA 01960 INSURE
"M3URER 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 tNooj
TYPE OF INSURANCE POLICY NUMBER OATS MMI DATE Mw�INRAYYW UNITS
OBNERALLMOUTY 3700301537 01/29/2013 01/29/2014 EACH OCCURRENCE 3 1,000 00
DAMAGE O'KER10—
X CONMIERCIALGENERALLMBILITY PREMISES Eietuerenea_ a 1DD.D
CLAIMS MADE uOCCUR MEDUP(AAyQMWW) f 5,
000
A PERSONAL A ADV INJURY S IJ 000 00
GENERAL AGGREGATE A 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO 3 2 000.00
POLICY jEA LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ee avJdenn
.. ALL OWNED AUTOS BODILY INJURY S
X SCHEDULED AUTOS IPal perean)
B X HIRED AUTOS BODILY INJURY
(Pe,90al"nt) 3
X NON4WNEO AUTOS
PROPERTY DAMAGE 3
' IPw eaudeNJ
ICARAMLIABILI Y AUTO ONLY-EAACCIDENT a
ANY AUTO OTHER THAN EA ADC a
AUTO ONLY: AGG 3
EXCESS/YMBNELLALIABRITY EACH OCCURRENCE S -
OCCUR CLAIMS MADE - AGGREGATE
a _
DEDUCTIBLE a .....
RETENTION B a
yYONRERa COMPENSATION TORYLIMITS ER
AND EMPLOYERS'LIABILITY YIN - —�-�
ANY PROPRIETONPARYNER ERECUTIVEn E.L.EACH ACCIDENT s
OMFFICEE�EMMNIIE EXCLUDEDI LJ
NNE.L.bISEA3E-EA EMPLOYEE 3
yyvs dem Mundel EL.DISEASE-POLICY LIMIT a
SPE41IAL PROVISIONS below
OTHER
MCRIFTION OF OPERATIONS I L OCATNINS l VEHICLES I EAOLVSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESOMI II POLICIES BE CANCELLED BEFORE ME ERFIRAYION
DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL 10 DAYS WRITTEN
Evidence of Insurance NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,out FAILURE TO DO So SMALL
IMPOBE NO OBLIOATION OR LIABILITY OF ANY RAND UPON ME INSURER,ITS AOENTS OR
REPRESENTATNEA
AYTMORlrEO NPAEBENTATNE
Robert Sennott RP �J"
ACORO 2E 12009101) 01990.2009 ACORD CORPORATION. All rlghia reserved.
The ACORD name and logo are registered marks of ACORD
r uA. cus a-a aVaV ..R.J aVic riVNi. r:vu1d11/RViJtll{. 1V. S'7 /O:JOIDJI,rIrlt�f9 1 OL 1
CERTIFICATE OF LIABILITY INSURANCE °"T°''T"''T°'12
onzaizuiz
THIS CERTIFICATE IS ISSUED AS A NITPICK OF IRFORHRTIOR ONLY AND COREERS NO RIGHTS UPON THE CERTIFICATE HOWER. THIS CERTIFICATE
DOES NOT AFFIRNATMLY OR NEGATIVELY ANEIID, === OR ALTER THE COUERACEE APPORIND BY THE POLICIES BELOW. THIS CSATIFICATE OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSVIRO INSVRSR(S), AUTHORIEED REPRESENTATIVE OR PRODUCER, AND TEE
CERTIFICATE HOLDER.
IMFORTAXT: If the certificate holder Sa an ADDITIONAL INSURED, the policy(Les) nuat be e"oreed. If SUBROGATION IS WAIVED, aubject
to the terms cad conditions Of the policy, certain policies may squire Be andocvment. A skateaaeat on this certificate does not
confer rights to tM cerLiflaate holdez in lieu of ouch enaoceementla).
F0.0DUCBR CDY}xCe
Edward F Sennott Insurance Blui`
xDM vwx
Agency Inc (A/C. a `""'
16 South Main Street
x..IONEL
Topsfield, MA 01983- caarolsR mx.
I.RNSOM ..I.cwawca c x
Len Gibely Contracting Company Inc - ..a: A.I.M. Mutual Insurance Co 33758 -
23 Winter Street Rear
Peabody, MA 01960-5941 ,aiDUR D:
'ixLVafa L:
IXEYNBP 1':
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CEKr= THAT THE POLICIES OF INSUF NCE LISTED BELOW HAVE RISEN ISSUED TO THE INSIPID NANED ABOVE FOR I= POLICY PERIOD INDICATED,
NOTVITHSTANOING ANY REDUIRO@1T, TpW OR CONDITION OF ANY CONTRACT OR OTHER DOCOIm.T WITH RESPECT TO WHICH THIS ®ITIBICATE MAY BE ISSUED OR NAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERNS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. L.UTS SHOWN
NAY HAVE BEEN REDUCED BY PAID CLABfS.
POLICY NoNNER POLICY EFF POLICY EXP LpITS
TYPE OF INSU CB Data/wrc Ju/mrl
GENERAL LIABILITY BACK OCCVPIWW '1
❑v":IM[NCi^:.4:A3i.^.L LI'.B=L[TI pAEa4L'10 Rf MLD
LID: In. NAIL EIINi.El
.m PRpla[alex.eea,ifu,ml N
NLD aYv IA,ry en"psaenl f
❑ aLRVOxAL f ADV 3eJWT S
fi NJ". a'dP C:i!I1 1.11r^APPI.Ri M: DaxaRa4 yMapfT6 {
❑1'T�LCY El:.V4'l:l•❑wA
AVTOMBILE LUIBILITY ..INS.aiNGLB UNIT {
❑let AL i. lea.Luaencl
Al'.VS a00141 INJURY (P..'—.) S
.:1 T.IX'-.!l a:'V:L a00I LT INJV\Ylpe f¢lYentl S
�:1I PLD Tl:i9 PRQ .N Dntl f
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Cp)pJ:L AGQWATB W,Ly S
F1C[U:,INLI f
❑I:E'I1:l.i l'il. S 6
WORKERS CONVERSATION ® +wm _
AND ENPLOYLES LIABILITY _
ox-
ME iF.C4`R:Ii^W'?AAl:igi5i 0.4. YAGx AGrla[ai 6 500,000
A C\BCI:TIVB OBCIR.S au
❑ i n.:' ® ex.^,1 6010979012012 a.4. Dnaaaf -.M.C,Llxn a 500,000
OB/03/2012 08/03/2013
\.L. DivYwzY - Lw erelareL 9 500,000
CERTIFICATE HOLDER CANCELLATION
1
Evidence Of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH TILE
POLICY PROVISIONS.
:,+XOnum wnnvcmvva ,
Page No. of� Pages
1 LEN GIBELY CONTRACTING CO., INC.23R winter street 1. 25358 PROPOSAL
• PEABODY;MASSACHUSETTS 01960 All home Improvement contractors and subcontractors
(978)53"234 Fax(978)531-9304 - engaged In home Improvement contracting,unleas
wwg jen lbelycontraclln corm specifically exempt from registration by Provisions of
9 9 Chapter,142A o1 the genoreldewe,must.be.registered
Submitted K,��/&n L?�j��c with the Commonwealth of,Massachusetts.Inquiries
To: / about registration and statue should be made to the -
Director.Home Improvement Contract Registration,
VO LA)[lk—✓ ST One Ashburton Place,Room 1301 Boatdn;MA 02108
(617).727-8598..Owners who secure-thefr.own
q construction misted permits or deal with ure n8fatered
/MA �// 7� contractors will be excluded from the Guaranty on
j�yr/g,.�[il•tNOy�Q =4!/. Gen>=ni'i'^.gjP1 Provalonol MGL c.t42A .., ..
" E MA.REG 100811
73/- l7/� �f°
.KIB LOGTKIN
We Mreby submit apedfloadom tartab
end e6ameln brwon Mba paMnned e,d metabe Met
d ice
z N- y9✓•s - .BBB 28 4/ -X
1��,.r/wry rGert�s l-y .1�.hSpr c�' ✓scale T1i ew �,., ^n �Zcr� s,�
yr Lo i-� y of S�irzf/iin , Ovov 03R L/F ldovle[ be
6 of 'Ice /4 LV404a-
•j�y ElC� OVBy .�rol F�fLJ .� A/0•+� A✓m, L-v Its /4 h-e
,q evw2 � Vol o� /S0, o " t
w�g c✓
' , /, f.sS�i�»�• 1,ls�d// c4° �-•P ed� � a.// edd�cS
n /!/ ce"4 L e ti'Q .» wit ✓� �. '�fi.;, ldt Ln /s/!
Co6V lid j/chf /^fey. /)n'bF. ��80 oo yes
n, I - Pezn;t
eyes
CV✓b! . yvtevn .—
WOgK a TILE �Na meb,kR bokre Me NIN tley idbMrq IM agNnp k Nle Rpreemonl,unle9e apx]IIW b r In wrr an w m
eboolrrinp Oeley ceuea0 by clrcumalermea oeycntl CommctoM1 conV01,Na woM will Ue complele0 by �1 IDe ner Kenby
echncwlMpeceM Oerwa Nat Me9Metlullne Eelea ere cpproxlrrele vd Nele,Kb tlalMMat e,e not evdUcde by Ne conVecbrMdl rat boccneMetN ee`lolellmaoll /greemenl.
typgggryry Idloxln Y IY EellaA mmPN wYln
Tne�u Vempr wenvito Nei Ne work NmkneE MY UMer eMll Ee tree I�ortl�wU In malarial eM wtxkmc,Mlp br a peMO W Iv�aa^oraW o ate"Ia Naw.arotl wlNln
IMr Vemenu of Nle Na,wmariLNMa ennl en tlelM In nerFmenaM bMb,or 6nlneBe ceuseb WMeCmhuton.litse clo�'emro be ramNle],repelreE,or replew0,
ne Yoar eM1er wmplellon M eM Ire•MCIUNry cben vp,Ills Conlmcror Pall,el Ma own e✓pMu,brMMN ren,etly,reW r,wrtecl,rep
auto mmsae«auto ales N metedeN mwwwn.,anN.me Impolnp wanenlda enec earvlw am lnalacldn performed 1p mnnemlm win me acceo-,acn work.
We Propose hereby to furnish material and labor-complete In accordance with above specifications,for the sum aja6ove
dollars($
Payment to ba made ae follows: -
_x(s S00 I
uwnejaNw rant/ rwm.✓conu.nmo:uwwq.Nalrem --__
_%MIA—)ooM eonordirn of
_x(E -1 upon wnnplebon of
eher be made bmAM.,on to No. --
—%11 I oo nPle,on alwa*under Mie mNacl. `
Notice: No egraemem for home tmprwemem cuneecwg work shell rewire a do+o
peYmem u,,,o ice depoelo of more Nan one-und of the total oontreci price or Me
total amount of out depoWta or Payments whdh Me wnrdoor moat make,M advance, a nw
b order erdlor oNerwlas obtain delNery of special order nationals and asePment, dwe
n la emmer u:m car tl ewrypawnpwn m,apoopwd wu,ln
Acceptance of Proposal I have read both sides of this document a d acce t the prices,specifications and conditions stated.I underact,a
that upon signing,this proposal becomes a binding contract.You are authorize to do a work as specified. Payment will be made as outlined above.
You,the Buyer,may cancel this transaction at any time pr to midnight of the third business day,after the
date of this transaction:Cancellation must be done In writing. `
� 77,130 NOT SIGNTHIS CONTRACT IFTHERE ARE ANY BLANK SPACES:
77{/ odm, �w S�.�S syrawa no.
IMPORTANT INFORMATION ON BACK llll�
�'` • tI Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
I "lilt rU CII.1II Still,I'vI+,i l' q;C
License: CS-094763 }art
THOMAS R WWBINS
19 Cedar HBUDrive sryl y
Danvers MA-01923
91 1 Expiration
Commissioner 05/14/2014
License or registration valid f
Office of Consumer Arrairs& Business Begulation W'intliv idol use only?; "AME IMPROVEMENT CONTRACTOR before the expiration date. 1f found return to:
F Registration: 10pg11 Type: Office of Consumer Affairs and Business Regulation
expiration: 6/23/2014 Private Corporatici+ 10 Park Plaza-Suite 5170
Boston,MA 02116
LEN GIBELY CONTRACTING CO., INC.
Brian Dobbins
23 R WINTER ST.
PEABODY, MA 01960 ----- .- ---_---
Undersecretary Not valid w' ut Ignature
r