13 WEST AVE - BUILDING INSPECTION — --- I'lie C'ummunwealdi of bt:usadnuelts
Board of B S'\Ll:\I
uilding Regulations and Sl:mdards CI'L OF
s Massachusetts State Building Code. 7SB CNIRHeviwd
L, ..
Building Permit Alviication 'ro Construct. Repair. Renovate Or D. nolis a
One-or rnw-Farb/• D:nvllhnq
Phis Section Fur OIT ul Use Only
Building Permit Number: Da a Applied:
03 /
lluilding Oilicial(Prinl Nmne) Signalum Dale
SECTION I: SITE INFORNIATION
1.1 Property Address: 1.2 Assessors.Map S Parcel Numbers
�--
12 (Al, 9 AA� -
I.la Is this an accepted slreel? ,es no Map Nunther I'urcd Nunstecr
1.3 Zoning Information: 1.4 Property Dimensions:
Lnning District I'ropuscd Use Lot Area IN Ip Frontage(It)
1.5 Building Setbacks(fl)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Requirvd -Provided
1.6 Water Supply:(M.G.1.c.au.§54) 1.7 Flood lone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal s)stem ❑
Check it' es❑
SECTION3: PROPERTY OWNERSHIP'
rou
wnerl of Record:
r � Ez es �L12as -sL.AV, �A1.�n. IMA
('ity.Slaw"ZIP&2� tt_1r7
and Slnel I'dephune Fmuil Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Buildin wner•Occupie Repairs( Iteration(s) ❑ I Addition ❑
Demolition ❑ .accessory Bldg.❑ 1 Number of Units_ Other ❑ Spccily:
Brief Description of Proposed \Vork':
'dam' PY d Q�Vi 0(L's,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofliclal Use Only
I Lateran \latrrialsl
EEO
S �� I. Building Permit Fee: S Indicate huw Ice is determined:
EEO U:,
'. Iilectrieal S ❑Standard CitylTarsn Application Fee
❑Total Project Cush I Item 6)r multiplier
I'IumM°g S �, Other Fees: S_
J. \fmmnical iII\' \('I S List:._ -.--- ------ / -.-_ . . .
j \Icch.mir,ll iFire — --- - — //
`u vc;monl S rotal .\II Fces;
('heck \u. __('heck :\mount: ('.Ish \inouni:
Tel l Project Cuvt ❑paid in Full 0 Owsl:mding Bal.mce Duc:
SE( [ION S: ( ONSI'RIIC'riosi sERV If Es
5.1 Cons I rue Iiuu Su pen is or Liccnse(C'SIJ � k4��-
I Icense V'uulbcr f\piraliwl llale
,•\.Iliw III C.vl. I IPJef
Vp
-
No
tt AA // ll I htrestricwJ I IludJin s li to IS,Illlq cu. It.l
SLL._�L.b li R¢.+Iricl¢J Idl'� Pdmil D\\.Ilin
C'ilyiroan,Stole.Lll' %1 Masonry
RC Itoolin Cascrinit
...—. VA %Vindow.uldSidin
SF Solid Fuel Ihrming Appliances
1 Insulation
I'de hone Ifmail address D Demolition
4.1 Registered III^umt Improvement Contractor(11IC) 0 D R' ) ?
---.p/' h ,-bm L V D�+"(`� III(:Registration Number E\p�iruliunoVile
I IIC Cool Nanw or I IIC'Regislratp,Nante
Z3SLUr y
td$Ircet Email aJJrcsa
City/Town, State,ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 157. 15C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atftdavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION In.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 Nulna(Electronic Signature) Date
SECTION 7b: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 application is true and accurate to the best of my knowledge and understanding.
I'rimD\sner'sor: whurim Ngents towlHeclrunic.tiignanlro) Dale
VOTES:
1. .tn Owner\shu obtains a building permit(a do his-her own work,or an o\vner who hires an unregistered eunirac(ur
(nut registered in the Hume Improvement Cuntmctur(HIC)Programl,will nrf have access to the arbitration
program or guaranty fund uoder.M.G.L.c. I42A. Other important information on the HIC Program can be lhund at
I Information on the Construction Supervisor License can be found at,\\\,\ 111.11; •J,H Ill+
\tlien substantial\wrk is planned,preside the infunnmion below:
rUWI Door area(1+ 11.) - (including garage, lmished basement attics,Jacks or porch)
Gross li\ing area l sq. it.l .___. _ _,,. . -. Habitablerountcount
\anther ul'lirchlaccs Number os'bedrooms
\mil her ofhalhrooms . . \unlbaufhalfhaths
1'\Ile of healing s)ilea \anther oI Jecki- porclws
I\I,e ot eJUling i\Ilelll I Ile!„+cd 111+ell
I "I on.d Ilrolco Square l'oot,we I im K:+uh,l ltaed for•'1', I.il Project 01it-
l
LEN GIBELY CONTRACTING CO., INC. Page No. of Page:PROPOSAL
23R Winter Street 28725
PEABODY,MASSACHUSUSETTS 01960
All home Improvement contractors and subcontractors
(978)531.8234 Fax(978)531-9304 engaged In home Improvement contracting, unless
www.lengibelycontracang.com specifically exempt from registration by Provisions of
/ Chapter.142A of the general laws,must be registered
Submitted /� - with the Commonwealth of Massachusetts.Inquiries
To:_V—�� Zukl/S..CB_ ._ _—.. about registration and status should be made to the
'7 ,l Director,Home Improvement Contract Registration
I-3 �[_o_C Y'�1/4e, One Ashburton Place,Room 1301,Boston,MA 02106
(617) 727-8598. Owners who secure their own
C /1,I A7 conetructlon related permits or deal with unregistered
(—r•`R Q 19-TO--,— contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
PHONE MTs REalem,Lnawao,
�f3�7C'i_)617 7 �j�)� MA.REG.100811
(,10a NAwA�. JOB LOCATION
AMA
We hereby aubMl¢Iaeci116eVom wW eeumetea air wcrk to be DerlprmeE MmaIam",la Me
11A
If V
—�9. e�'S _ Pi ,n r �D 7x/APT 00.E _
OP
PLz'-�c9)-1A1� --
__
rat _anr Jc�. -.�c� _s acs-o Lp-
ConslruNo9 ralaletl DDerm�i`� / �'-
_�2C.-t]�_CtS_vT� ^��0.� n�P—�sfcu�..
WORN SCHEDULE '"'-�—"-'--"—
ConV of IAe woM d IM1e malerkla bears the Chid Uey bYowinp the slBnire d 0ia ABreoment,unlms eppcllietl neraln ml g for willyBain the work on s
gbout (U61e1,Barrine tlelay ceueetl Ey circumslanc6a eeycntl CAnlradola cpnlrol,lne work will be compIBIBJ bygl}ho Owmr herBb
Ckn BpgBe mCeg BB Ih01 VIB 6CM1BEYIIny oBIaBVB epgNXlma1D BIItl IM1V SYC1l tlelaye lM1V em not BYd0a0IB by CreCM1R<tOr¢M1eII nM EB Co Br D INls PSroemanl.
WAHRANtt
TM1e GonVecwr weRenU Ihal the wBM1 IurniaM1OO Iwrevntlor sM1ell be Iree Irom Uolocls In material antl wohmanaMD kr a perlo0 lollowing Bpmplellon antl shall comply wn
IhB requlremenls of Nls Ayaerram.In ilia wem arcy Celed in woMmanshlp or mebr�els,or tlHmege teusM by Ne Conlmcmr,M1is su Vetlore,emplgees ar eBenls,is Discw.10 wiVu
one year ener completlpn of any pb,Irclutllna dean up,the cgmmdor edit,el his oxn ex�nm,IonhW.N remedy,repalp cprred,reDlam,or sauce lobe remetlie4 rapaeod or replaces
smM1 OamaBe or Bush eeleel In meletlals orworMmanship.TVa bneolnB warrenYea ellell¢u any inapDBlbn pOrlormetl in mnnOClian wllM1 Ne aOreetlupon vrork
We PrOPO9e hereby to JJ Ish m Cartel aapd I bor—comp ate in cordonc`e/With a ova sp cifications,for the sum of:
f()S� 11�5�(M�jQn OG�' (-1]CTVl7A ll l$ ).
Payment to be made as follows do as
:
%(e v5`-'_' )upDn al ours ace
X(d �/ N d on no,�l am �--
)upanCorealelNrl'8r
B Ml Atltlr •' ..".
%(s.)upon comp101 on of
Ch/SIDI PnanO
shell be made brew a upon
wmpleoon olvroM under life soared. pnm - no ml iV In,
Nellke'. No agreement for home improvement cenlreding work shall r.,quiro a down la BrBel�mun ..�
Payment(advance daposlU of more Ivan one-laid of Ino sche contract Drice or the
fetal arreml of all deposits to paymmb which mescal must anal in edvenm. �_—
lo order and/or otherwise obtain delivery of special order materials and equipment, oriied SiBaBlum
wh'cherer emn m
Nob:TMa pmpOaal may Oo vnW,awn tyes"anchloa,,ohn oar.
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.
A� DO NOT SIGN THIS CONTRACT IFTHERE ARE ANY BLANK SPACES.
sgnl_ .(144 IA_ eels IIZ slpnaw,a oma
IMPORTANT INFORMATION ON BACK IN-
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
UV
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/C'ontractors/Electricians/Plumbets
Applicant Information Please Print Legibly
Name (13usiness/Organiz tioMndividual): 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: Type of project(required):
I.® 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.F] 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'
com insurance.[
required.]
p' 9• Building addition
workers' comp. insurance
required.] S. ❑ We are a cotperation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L[I Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other _
comp. insurance required.] _
Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy informoltion.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors 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 sub-contractors have employees,they must provide their workers'comp.policy number.
I ant 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. #: 6010979012012 Expiration Date: 08/03/2013_
Job Site Address: City/State/Zip:
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification. _
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature ` _ Date:
Phone#: Jt'
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):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
t
JAN-24-2012 14:35
F'...... EArP • .• S_e_nn_o_t_t I_ns_ura_nce _ 97B H137 240I r. 01
• 01/24/2012
PRODUCER 978.887,4900 FAX 978.987.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
'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
P. 0. Box 457 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Topsfield, MA 01983 INSURERS AFFORDING COVERAGE d
INSURED Len Gibely Contracting Co. , Inc. IN$uAERA Catlin Specialty Insurance Co _
23R Winter Street IN$uasae. T 119038
Peabody, MA 01960 Na
IDREa
wsuREa D: ��
INSURER F..
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTVVITHS"fANDING
ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE NAY 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.AGGAEGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
WLTF NSA TYPE CF IN BURANCE POLICYNUMBER P ICY EFFECTIVE FOUCTEXYIRATION
D TE MMIODfIYYY GATE MMIOO/YYYY uMiTS
GENERAL LIABILITY 3700301015 01/29/2012 01/29/2013 EA�CNAiO��CCURRENCE S 11000,006
X COMMERCIALGENERALLIABILRY 9 S(Ea TE"
PREMI EB EE omirren<e { ___1QQ r Q_
CLAIMSMADE TOCCUR NED EXP?Anya pi, N ) 3 5100
A PERSONALaADVINJURY $ 1 000,00
—V...., GENERALAGGREGATE 3 2 000.00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCT$•COMP,OP AGG 3 2,000.00
POLICY PRO LOC '•" _ .`.
JEC7
AUTOMOBILE LIABILITY _
ANY AUTO COMBINED SINGLE LIMIT S
(Ea ewdwd)
• ALL OWNED AUTOS i,.----
j BODILY INJURY
B X SCHEDULED AUTOS (Pw Pown) {
X HIRED AUTOS
BODILY INJURY S
X NON-OWNEDAUTOS (PA,A Idm)
FHOPERTYOAMAGE 3
(Po,ectldanl)
GARAGE LABILITY AUTO ONLY U ACCIDENT {
ANY AUTO
OTHER ONLY: EA ACC 3
I AUTOUTOONLY: AOG 3
EXCESS IUMBRELIA LIABILITY EACH OCCURRENCE 5
OCCUR U CLAIMS MADE AGGREGATE E
OEOUCTIOLE
I I 3 � 3
WORKERS COMPENSATION ::... _.
AND EMPLOYERS'LIABILITY YIN TOR,LIMITS
ANY PROPRIETOR,vARTNERJEXECUTIVE❑ E.L.EACH ACCIDENT 3 _
C OFFIOERAIEMBER EXCLUDED?
it a.dAryM NMI LOISEASE-EAEMPLOYEE J p;{
Il yFY AL PR A under
SPECIAL PROVISIONS hMCN E.L.DISEASE•POLICY LIMIT I
OTHER
DESCRWTNJN OF OPERATIONS I L UCATONS I VEMICLES I EXCLUSIONS ADDED BT ENDORSEMENT I SPECIAL PROVISIONS
EVIDENCE OF 2012 RENEWAL COVERAGES.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE 06SCRIDEO POLICIES BE CANCELLED GEFORE I HE UlllW TION,
DATE THEREOF.THE ISSUING INSURER WN.L ENDEAVOR TO MAIL 10 UAYS WRIT ILN
NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT,BUT FAILURE TO OO$0 SHALL
IMPOSE NO OBLIGATION OP UEMIUf OF ANY RIND UPON THE INGURER.ITS ADEN TG OR
REPRESENTATIVEG.
AU iRORQFD pEPPEEENTgiIVE
Sennott Ins. A enc
ACORD 25(20gB107) 0 i888.2008 ACORO CORPORATION. All righLe muorvvd.
The ACORD name and logo Ore registered marks of ACORD
'i:ue uul L4 lU : lU : .7J [U1L erom: Voulln,kobert '1'O: y9 /Mb:319JLPiage l oI 1
A . CERTIFICATE OF LIABILITY INSURANCE °AIF `�)
o�"'" D'))
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, 74IS CERTIFICATE
DOES NOT AFPIRMATIVELY OR NEGATIVELY MEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AFO THE
CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(iea) must be endotaed. I£ SUBROGATION IS WAIVED, subject
to the term. sad ..edition. of the policy, ..stain policies may se]Iuise an .adoraemant. A •t.tase.t on this certificate does not
confez rights to the certificate bolter In lieu of such endoraement(e).
PROLucnR cov
Edward F Sennott Insurance X{1Ci
vx°.,
Ax
Agency Inc ePi�.LNe x.a, a/G. eel,
16 South Main Street "°°PILBI
"WUCe[
Topsfield, MA 01983-
xeuuslLl AnoaPl Rc cweMc[ Lc L
A.I.M. Mutual Insurance Cc 33756
Lent Gibely Contracting Company Inc
23 Winter Street Rear
Peabody, MA 01960-5941 ,xxXMP n:
IMLVMP 8: l
]XiUVER 1': f
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS W TO CERTIFY THAT THE POLICIES Of INSURANCE 1I5M BM HAVE BEEN ISSUED TO THE INSURED MAPED ABOVE FOR THE POLICY PERIOD INDICATED.
NOf'NITH..ANDING ANY REgUIREKEWI, TaPN OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MICH THIS CERTIFICATE MAY BE ISS.0 OA HAY
.Bl'A1N, THE: LNSUPA CE AFFORDCD BY THE POLICSBS DESCRIBED HEREIN IS SUBJECT TO ALL THE TEXMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN
NAY HAVE BEEN REDVCED BY PAID CLAIMS.
POLICY t . m POLICY EFE POLICY E%P LDIITS
" TYPE OF INSURANCE °N'si/rw, /w/rvrrl
GENERAL LIABILITY ePCx eccuPANL< S
❑GlM[VG].ti CSt3i:.L ]:.9:LItY °.VP°8 x°Mx[E°
P0.p[[LPlee.eeeveemwl S
❑�' .n.in..YwrL ❑Ix..et Xln[YY IA,IY C,u 0.avanl [
O v[M°[u f APV]e 1
VLNLML AGUMFAiBJ� I
(i Nl". .:.iPl:-01Z 1.X"^ ACGI.Il;i M1k:
AUTOMOBILE LIABILITY COY01 nnB e[vcv.L L]NIT [ I
❑!JY!Y`I:1J r lee ecu Jen[)
BOnILY IMJVBY (p°[pCa'fOn) $
❑::ATR-.11 4'\)` a.DILT IWIVAYIpa
ANDEMPLOYEES
e°CLGan[I 3
�H[PLL r�L`:'i.X (Fe[,xlCanLl I I 1
3
❑'MP.0.!':.l':.11 ❑ c:r..1R BACK V[GUµNLXGL S
❑BF:L::` L.,� � CLry[Vy W1;L PW0.LWTL [
I
ANDS p. COMPENSATION ® w -
@LOYQ9 LIABILITY
I:IB ?F.il'P.=3ti�R,/?AA.i:IBdLi E.L. Lux uun[Ai 6 500,000
LA
C<ECI"TIl/B 'IFIEC33' iA3
--I
inc. ® er."-I 6010979012012 E L. w[LAL[ -POLIot LI.IT 3 500,000 {
08/03/2012 08/03/2013
e,L, XT¢ASI - 1.I oOL Tll 1 500,000
it
I
i
j
i
CERTIFICATE HOLDER CANCELLATION
1 _
Evidence Of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EEPNIATreN MTE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
i
1
X.XXA].GX ALxx[:uen,vL`����� J i
l
7 Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Cuu tru ti.n Sul .ni�. r r�r'��
License: CS-094763
�.r A
THOMAS R DABINS
19 Cedar RULZrive
Danvers MA-01923 '
ITL I
^�N7rrNt Expiration
Commissioner 05/1412014
Office of Consumer Affairs& Business Regulation License or registration valid for inJividul use only
per+=-I.OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
�,egistration: 100811 Type: Office of Consumer Affairs and Business Regulation
! -Expiration: 6/23/2014 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116 l�
LEN GIBELY CONTRACTING CO.,INC.
Brian Dobbins _
23 R WINTER ST.
PEABODY, MA 01960 _- _-- --- ;w7,ZgUndersecretary Not validlure
r