5 WEST CIR - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition Wilbraham
Ja413�-596-2800
uilding Dept
Building Permit Application To Construct, Repair, Renovate Or Demolis
One- or Two-Family Dwellingxt 118
_ This Section For Official Use Only
Building Permit Number: Date Applied: j ` O
Signature:
Building mmissioner/Inspector of Buildings Date
f\ SECTION l:SITE INFORMATION
V/ L Property Address: 1.2 Assessors Map& Parcel Numbers
S � +7S-i
?�I a Is this an accepted street?yes__ no___ Map Number Parcel Number
g Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq f Frontage if)
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 Owner'of Record:
M AIZ-N
Name(Print) Address for Service: -
9 '1 & 5 9 -79 -72-
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildir4pliir- Owner-Occupied Repairs(s) Alieratior.(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:_
Brief Description of Proposed Work': ST 4 C'a rL.A mp Ff
I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
k1.1t.em Estimated Costs: Official Use Only
Labor and Materials
uilding S 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
r-� p Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ r t p cZ.s-= 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) O 9 y—I 63
'L-)D t"t., S License Number Expiration Date
Name of CSL- Holder List CSL Type(see below)
r Ll 4M4 Ili s-� P,-A6Z0 Type Description
Address U Unrestricted(up to 35,000 Cu. FL)
R Restricted 1&2 Family Dwelling
S,,iS5nature M Masonry Only -
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) ) O
—.s .r �t LV C�v^t-
HIC Company Name or HIC Reg ant-Na�mje Registration Number
1 4 0k MA ..3 S'-. l.O n hnoV a\ 46o
�Addres Q
t,�. S'"; ($'� Expiration Dale
Signature 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
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 _--- Date — ----
SECTION 7b: OWN'EW OR AUTHORIZED AGENT DECLARATION
I, L..p„� is t b-p I�Y_ -yT- ,as Owner o Authorized Agen hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
T��b�tI
Print Name
Signature of Owner o Authorized A en Date
(Signed under the pains an ena ties 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(he 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
A
The Commonwealth ofMassaehusetts
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 Lelliblv
Name(Busmessiorganirstionandividualy v Q i t b.p L-V - -.i i 2 ,A e t t /C- Cy
Address: / 4 q M '( ti s-
City/State/Zip:� A h.-,.,✓ ���n C i 9 G G Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a with employer 4. ❑ I am a general contractor and I'
-1-�. have hired the sub-contractors 6. ❑ New construction
employees(frill and/or part-time).
2.❑ 1 am a cote proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These s::b ccntmctors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers'comp.insurance comp. insurance.t
regtrsed.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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.❑ Other
comp. insurance required.]
'Any applicant that checks box#1 rrwst also fill out the section below showing their workers'compensation polity information.
i Homeowners who sul n it this affidavit indicating they are doing all work and then hire outside conawtors must subrrdt 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 thou entities have
employees. If the subcontractors have employers,they must provide their workers'conip.policy nurnber.
I am an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and job site
information.
n
Insurance Company Name: �'j 1 ] v l v �l_ Cc
Policy#or Self-ins.Lic.#:st C i O ri '-1 9 O Expiration Date: Cl-3- �� Q
Job Site Address: S U.) �S� C i CZ I ., City/State/Zip: �A � zn, t t�-1A .
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 it.,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: s- Date:. — �o
Phone#:
Offuial use only. Do not write In th Is 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#:
/ / 31 / 2uub 2 . u9 : 26 Hm 6935 id 02/ 02
ISSUP D.+'CE 07/31/2008
PRO-- "THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
11F>dwa[d'?SetIROC In•`:ra;1Le CONFERS NO RIGHTS UPON THE CERTIFICAT'F 1:0LDER.THIS CERTIFICATE
'DOES NOT AMEND,EXPEND OR.ALTER THE COVERAGE AFFORDED BY THE
AgcDcy Inc 'DOES
BELOW.it 6 South Main Street
opsfield,MA 01983 - - CONIPANIES AFFORDENG COVERAGE
SURED —. .—
Len Gibely Contracting Company lnc '
Jenness Street - '�-COMPANY A Ai.M. Mutual Insurance Co
overly,MA 01915 LETTER
MR!OD
S TO CERTffY TEAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
TG WHICH THIS CcR IIFICA I'E MAY BE ISSUED OR MAY PFRTA;N.THE INSURANCE AFFORDED BY F'HE.POI JC:IE.,DESCRIBED HEREIN IS SUBJECT
TO ALL TILE TSRMS,EXCLUSION'S AND CONDITIONS OF SbiH I OLICIES.LIMITS SHOWN MAY HAVE BEEN RED UCEn BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICYNU:ABER POLICY E PFECTIVE POLICYEXPIRATION LIMITS
LIR -- 'An(MMIDD'YT) DATE(MMIDDIYY)
GINER
GENERAL LIABILITY PROUD
L- COMPIO TE
Y_RODVI CIS�COMPIOV AIi'J,
OCOMIAERCi,L GENEIGL LiABILIT}'
I P`.IISONAL@ADV I`IJURI
O O C"R1S MADE=OCCUR
IP.ICN OCCURRENCE
OWNER'S&CONTRACTOR'S TROT. L.
FIRE DAMAGE(A,ryu:.;m[I
DEL.EXPENSE(Myom pmcnl 1
AUTOMOBILE AABILIT, i .^,MDMED SMILE
LIMIT
L_.-
L^JANT AUR• r BODILY INJURI
nLL O'AT'E AVT.•i lP[ V[r Ie't
.. �SCHEDULLD A["vi
HIRED AUTOS
1 NON O' :D AUTW BOLrLY tr4JT.Y
I oOA1.;.oE;f.�BILITY Ih'=nCeM;
PRnPERTY DAMA GC _ -
EXCESS LIABILITY CACHOCCURRENSE
UMBRELLA FORM AGGREGATE
_ OTHERTHAN UMBRELLA FORM e` ( S Ow
tVORKERS COMPENSATION AND TATUT ORl LIM=. OTHER
EMPLOYERS LIABILITY Ix -
HEPxnPRIETox, ELEACHACCIDE.W 2 500,000
A ARF 5RSe>:ECUn'✓E
FFlCIERS ARE 6010979012068 08/0312008 08!03/2009 EL DISEASE--POLICY L:Mrr 500,000 -
rINCL _ �EXi.:.
LDISEASE--EAr}. 500,000
EWWYEE
COA4MENTSI DBSCRIPT:JN•)F OPERATIONS OR LOCATIONS.
I
n HOULD AI.Y OF THE ABOVE DFSCREEED POLICIES BE CANCELIZI)BEFORE THE EXPERARON DATE
N GELA SI R O N I rHFREOF,THE ISSUING COMPANY WILL ENDEAVUR TO MAn 10 WRITTEN NOTICE TO THE CERTIFICATE
OLDER NAMED TO THE LEFT,BUr FA LURE TO MAD,SUCH NOTICE SHALL IMPOSE NO OBLIGATION
�C10 GIB E LY R LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
49 MAIN ST
I EABODY,NIA 01960 LHORIZED REPRESENTATIVE _
1755
3
Page No. j —ot / Pages )
LEN GIBELY CONTRACTING CO., INC. PROPOSAL p
149 Main Street 18 519
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
(978)531-8234 engaged In home Improvement contracting, unless
specifically exempt from registration by Provisions of
n \FAX(978)531--9301I Chapter 142A of the general laws, must be registered
Submitted U (�O I M�7 with the Commonwealth of Massachusetts. Inquiries
To -- — -/I --1----------- about registration and status should be made to the
Director, Home Improvement
One Ashburton Pace, Room 1301,Contract Registration,Boston, MA02108
(617) 727-8598. Owners who secure their own
construction related permits or deal with unregistered
contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
PHONE DATE REGISTRATION ND.
�47A)97 9- 7°l7 t 9 -Z3-48 MA.REG. 100811
- OB KAMISIND JOBLCCATION
We hereby submit specifications and estimates Or work to be performed and materials to be/uused:
S r�Cf�I R- \ rt'- �� O�n.is �_�AA�i l� �`�z✓ Cl i- r t
�YJ --hL. J
s �— Z 4MID
t �
ualeaIT�� r
Conatruction rested permits:
- -
I
I
WORK SCHEDULE
Cons � not In a vrork or order the materials before the third day following the signing of this Agreement.unless specified herein w" g.Contra for will begin the work on or
aboN (data).Barring delay caused by circumstances beyond Contractor's control,iM1e work will be completed by (date).The Owner hereby
acknow dues and agrees that the scheduling dates are approximate and Nat such delays that are not avoideber by the contractor shall not be considered v olagons of this Agreement.
WARRANTY
The Contractor warrants that the work furnished hereunder shall be free from defects In material and workmanship fora period of following completion and shall campy with
the requirements of Nis Ageemenl.In the evens any defect in workmanship or matimen,or damage caused by the Contractor,his subcontractors,employees or agents.is discovered within
one year after completion of any lob,Including clean up,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied,repaired,w replracod,
such damage or such award e in materials or workmanship.The foregoing warranties shall survlva any inspection performed 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:
t dollars
jPayment to be made as follows: PCJ% 40
1 000 a�
($ L )upon signing Contract,
Neme alCmlrector/DealBnelM Rap 4ent
%is o �^ l upon completion of ._. . .--
west addrese
1 r.
%l$ )uPon completion of _ _ _ _..._.___. . - ..._..
diry/state - Phone
shall be on of forewith upon
%( completion OI WOfk antler thle COnhaCl. PM1one Fede91ID No.
Notice: No agreement for home Improvement contracting work shall require a down SiNrm@y
payment(advance deposld of more than one-third of the fatal contract price or fire
total amount of all deposits or payments which the contractor must make,In advance,
to order act/or otherwise obtain delivery of special order materials and equipment, v
whiolhaver amount is crosier, Note:Th'w proposal may be wllbdmwn q us If not ecwpted w1mm drys.
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 trilinsaction.Cancellation must be done in writing.
D NOT SIGN THIS CONT AC IF THERE ARE ANY BLANK SPACES.
IL
signature on Signmare Date
I IMPORTANT INFORMATION ON BACK
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registra49A.:E 100811
Egpirabon::.-6/23/2010 TrA 268971
• `ie14 Types Piviate Corporation -
LEN GIBELY CONTRACTING;CO'.'INC.
Brian Dobbins '-
149 in Street
Peabody,MA 01960 Administrator
} t BOARD OF BUILDING REGULATIONS
License CONSTRUCTION SUPERVISOR g{{{
Number�:G$y 094763 $I I -
< � ¢4[tt�daje,=05/1Af�993 a �
Tr.no:. 94763 i.
RON
Y.
' T 1OMAS R OBBIWfti,
19 CEDAR-H16L DRR/E�,
s DANVERS, MA 01923 .4,.-
- i Commfesi_oCommfesio_�d
�. ..,..tea....: . .