8 WEST CIR - BUILDING INSPECTION The Commonwealth of Massachusetts RE CE SERYIC $ CITY OF
!� Board of Building Regulations and IN �(13
I ALEM
Massachusetts State Building Code, 730 CMR SMar
�� � �f2evi.red.Wur?0!!
Building Permit Application To Construct, Repair, Rapt"ppppTT rUmdlish a
One-or Two-Family Dwelling
This Section For Officitik Use Only
Building Permit Number: Date pplied:
J
Building Official(Print Name). Signature-`-. Date
SECTION 1:SITE INFORMATION
1.1 ProperlJ �s�ty Address: 1.2 Assessors Map&Parcel Numbers
19 C12cL�
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 Area(sq 11) Frontage(II)
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,§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesCI
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner[of Record:''
N, me(Print) City,State,ZIP
IN ¢Si CtA-,( M Q-1g171-6 IS3
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction ❑ Existing Buildin caner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed%Vork'-: i . Le.. O C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building Sk I &, 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier w�
3. Plumbing S 2. Other Fees: S
d. Mechanical (FIVAC) $ List:
5. .Mechanical (Fire 5
Suppression) 'Coral All Fees:S
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S 1 g aS— ❑ Paid in Full ❑Outstanding Balance Due:
SST
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)_
Tr IDO b t0 a t5 S License Number Expiration Date
Namc of CSL holder
List CSL Type(see below)
No.and Street Type ; - Description
C7 � / U Unrestricted(Buildings u to 35,000 cu. ft.)
)" ,0 ,4 b?7p A � t !N R Restricted 1&2 Family Dwelling
Cityi Gown,State,ZIP M Masonry
RC Routing Covering
WS Window and Siding
SF Solid Fuel Fuming Appliances
9-7 g 53 t 8 -�.3 V, 1 Insulation
Telephone Email address D Demolition
5.2 Registered
Home Improvement Contractor(H1C) 0 i7 o t Expiration
C� 1 b.t+L� 006m T' [ IC Registration Number Due
I11C Company Name or HIC Registrant Name
23 rZLv-w` anti Sv
Id Street ,� ,y d 7 2 Email address
�.�
City/Town,State,ZIP 'rele hone
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 Is§uance 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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.
.v . / .0-e'2-,L19'^)tN
Print Owner's o Ati(xinzed Agen Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
%evvw.nutss.,_ov.'oca Information on the Construction Supervisor License can be found at www.mass.,,ov:/dM
2. When substantial work is planned,provide the information below:
Total floor area(sq. RJ (including garage, finished basemenUattics,decks or porch)
Gross living area(sq. fl.) 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"
The'Comin pgwealth of Massachusetts
Department of lndustrialAccidemts
Office Of Investigations -
1 Congress'Street,Suite 100
Boston,MA 02114-2017
wwrkmass goy/din
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print it fbly
Name(Business/Organization/Individual):_L Q N G b,a� L�/ [2
-0.C.Z—t-u•c.� Cu
Address: i_,J , e 5�-
Ci /State/Zi : , �, Phone k O('l
3 531 3
Are you an employer?Check the appropriate box:
1. I am a employer with ) a 4: ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time). have hired the sub-contractors fi• New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling
ship and have no io These. have�P yaps 8.° Demolition
working forme in any capacity: employees and have workers'
[No workers' comp.insurance comp. insurance.: 9• ❑Building addition
required.] 5:0 We are a corporation and,its 10:0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11. Plumbing
m self. g repairs or additions
y [No workers' comp, riot of exemption per MGL
insurance required.] t c. 152, and we have no - 12•[]Roof repairs
employees. [No workers' 13•❑Other
co rap.insurance re9tgred.]
;Any applicant that checks box c must also fill out the section below showing t Homeowners who submit this affidavit indica theytheir workers'compensation policy information.
=Contractors that check this box must atmchod annaadditionai shy showing tbe'name then of We sub•conbactors'and staoutside co tractors must te whether or not bmit a new those entities have such.vit indicating
employees. If the sub-contractors have employees,they must provide their workers'comp policy number.
l an a to er that is Providing workers coin ensation r
y p p Insurance for my employees. Below it the policy and jab site
information.
Insurance Company Name: •T M M v TV A 4-
Policy#'or Self ins. Lic. #i O 1 0 1.7 4- ')LY1�iPExpiration Date: fj
Job Site Address_� W o C r t City/State/Zip: S q lain
Attach a copy of the workers,cempansatian policy deoiarati page(snowing 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 imprisonutent, as well as civil penalties to 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 tbe.DiA for insurance.coverage.xerification.,;
do hereby certify r nder.the�pares and penalhes.ofperjury that the infprmatran provided above is true and correct
S_i¢nabrrPp y�j� —2 Date:
Phone
O•jlcial 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/Pown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ACORO. - CERTIFICATE OF LIABILITY INSURANCE 0210MUDIYYYY)
02/06/2014
<poucER 915.661.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
-dward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
L6 South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. 0. Box 457 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
fops fi el d, MA 01983 _ INSURERS AFFORDING COVERAGE NAIC#
IsuRED Len Gi sly Contracting Co. , Inc. wsURERA: Catlin Specialty Insurance Co
23R Winter Street INSURER& Safety Indemnity 33618
Peabody, MA 01960 INSURER C:
INSURER D:
NSURER E:
:OVERAGES
I'HE 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.
iIq_6D
H INSR TYPE OF INSURANCE PdUUY FFECTIVE POLIC PIRA N
POLICY NUMBER DATE MINDONYYY DATE fMMJODNYTYj LIMITS
j GENERALLWBIDTY 370030214S 01/29/2014 01/29/2015 EACH OCCURRENCE $ 1,000,00
X COMMERCIAL GENERAL LIABILITY PREMISES Eeacq�irrLy $ 10O,000
_ ] CLAIMS MADE a OCCUR MED EJ(P(Any one person) $ S,000
t
PERSONAL S ADV INJURY $ 11000,000
'— - GENERAL AGGREGATE $ 2,000,00
GENT AGGREGATE LIMIT APPLIES PER:PROTT PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY JE
JEC OC
AUTOMOBILE LABILITY 6221693 COM 01 01/29/ZO14 01/29/2015
COMBINED SINGLE LIMIT
ANY AUTO (Ea eccltlenq $ 1,000,000
I I ALL OWNED AUTOS —�----" --
BODILY INJURY
X SCHEDULED AUTOS (Per person) $ —
X HIRED AUTOS
BODILY INJURY� X NON-OWNED AUTOS (Per acddeM) S
- — —"'"-"--'--'—'- PROPERTY DAMAGE S
_ (Per accident)
GARAGE LIABILITY AUTO ONLY-FAACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGO $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
FI OCCUR C I CLAIMS MADE AGGREGATE $
I
5
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION _
AND EMPLOYERS'LIABILITY Y/N TOftV LIMITS ER
ANY PROPRIETOR PARTNEP/EXECUTIVE❑ E.L.EACH ACCIDENT g
1 OFFICENMEMBER EXCLUDED?
(Mandatory In )NH E.L.DISEASE-EA EMPLOYEE $
II yas,CM i,,
_ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
1
T-
8-SCKIFI ION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
roof of insurances.
:ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
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 OF ANY KIND UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES,
AUTHORLUD REPRESENTATIVE
Robert Sennott/RP
ACORD 25(2009/01) 01988.2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
f
AL�!F& CERTIFICATE OF LIABILITY INSURANCE °ATE'M DDNYYY)
0810112014
THIS CERTIFICATE IS ISSUE
TH
CERTIFICATE DOES NOT AFFIRMATIAS A VELLYY OR NEGATIVELY AMENDY EXTEND, ORANDRALTERR THE TCO COVERAGE AFFORDED BY THEUPON THE CERTIFICATEDPOLI EIS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), 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 WAIVED,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 CONTACT pX
Edward F Sennott Insurance .Ne16 South
ain
Topsfield MMA 1983f
INSURERISI AFFORDING COVERAGE NAIC If
INSURED A.I.M.Mutual Insurance Company 26158
Len 0 ibely Contracting Company Inc INSURER B
27 Winter Street Rear INSURER C
-----
Peabody,MA 019GO.041 NSURER D
INSURER E'
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 POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUIREMENT, 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,
SEEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE I D POLICY NUMBER S LOARS
GENERAL LIA&CITY EACH OCCURRENCE S
COMIAMCIAL GENERAL LIABILITY MgGETO RERYI$�_ f
_7 CUIMSMADE OCCUR MEDEkP(Anyono Pelson) E
-- PERSONAL a ADV INJURY S
_.._ ._—._____._.__-_-._____ GENERAL AGGREGATE S
EN'L AGGREGATE LIMIT AP0.IES PER: PRODUCTS-ODIAROPAGG S
OLICY O- OC
AUTOMOBILE LIABILITY M MI E
ANY ALTO BODILY INJURY(Par Person) $
ALL OMEJ SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accidan0 $
HIRED AUTOS NONOWNED E
AUTOS
S
—_ UMBRELU LIAR OCCUR EACH OCCURRENCE $
EXCESS LOB CLAIMS MADE AGGREGATE -- $
DED _ RETENTION E E
�"t4d'����&�E�i'I�1TL4f4 X �S>Si{rnl�s °jEd'
p a� I��� IiPr�Itl��tcEcunvEl , NIA VWC-100-8010919.2/4A 8/3/2014 6/3/21$ E.L.EACH AcclDour E $00,000.00
(Myaan6d�a�[qo5ry�I yIna NuunnH�d)aa�� �Nuf E.L.DISEASE-EA EMPLOYEE $ 5 W000.00
d6YRIPT(ON OFOPERATIONS below E.L.DISEASE POLICY LIMIT E $00,000,00
r
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Anech ACORD 101,Additional Remarks Schedule,If mom space Is noitoM)
1
I
CERTIFICATE HOLDER CANCELLATION I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE j
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN .w
ACCORDANCE WITH THE POLICY PROVISIONS.
AVTHORQFD REPRESENTATIVE
®1988.2010 ACORDCOOR7P.ORA/TI_OONNN..All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
1 WGIBELY CONTRACTING CO., INC. Page No. I of Pages
• 23R Winter Street 26206 PROPOSAL
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
(978)531.8234 Fax(978)531.9304 engaged In home improvement contracting,unless
www.lengibelycontracting.com specifically exempt from registration by Provisions of
Chapter 142A.of the general laws,must be registered
Subminatl +�Qnn�-t I� — — - with the Commonwealth of Massachusetts.Inquiries 1
To:_ v IQ _—— — about registration and statue should be made to the
Q Director,Home Improvement Contract Registration,
—_CLwr� Cj.GC(-E — One Ashburton Place,Room 1301,Boaton,MA 02100
(617) 727.8598. Owners who securetheir'own ,
C• _fi �1 O'O-7 p� construction related permits or deal with unregistered e —M_�_�—LU —_— contractors wlll be excluded from the Guaranty Fund ; I
T - Provision of MGL c.142A." " '+c,c' -;m•
F NE WTE /I inceniaries Ne:, •17 B f , ��•`
«g/3G//y
JOB NAMEN - +••' 'i- 1 r� JOB LocateN
Sa4M E.
We hereby aulbintspe Icationa end usua les or work to be Desorama aM mat.".to be uwa:
RHOA up— -
_
—C?-F—SUL�C��._�5-. ��l_OJ-Y�-In�f.�,_LQn _L�Q1�
_ /O 350,o _
or.
--�� 7���
WORK SC EDULE
bantrer, Ne xork IN ONB NB 191 b belwe NB NVE Eey bllwl p IM1 .....
..d of t Ag t nIB�0Sp0cll. M1emin wr 0 bepin IM1B we on or ,
roula (aabl.e tl 0 al
ycaused
by dreumalancea Bowed,
y tl C 1 el central
1 IM1 k will be complaleE by� 1.The OwnOr hereby
a6MVNl 066 Bn0 0 Net lM1e eOM1e]II ya01 .pprwlmmeana that such a ley th 1 ra nutwea et b'fe YatlOf ehel�Gl�gpa lee 6 or
Nla Agreement. r
Hvtlen rdwCaWlYNunY Been elWu dO6MWe Wlererepwre]b Ce rOpalRaNONn b d:nrAOle ad.
CnNaC,vNl bocmdebl ats�(��ernen rtIMNH011R)
eha�
WARRANTY
IDe GonuaOOr we,renb IM1eI tl,a work lumlehea bemun0er¢ball be im0lrom earec15In melwlal entl wd'en nd p br a den of bllapinp BomplepO'entl shell mmply wllh
Ino ralulmmenta M Nle A0rt9m0nt In as
went any tlelecl In nnAmenshlp ar mebnala,w aemege c0ueea by Ne Conira<top M6 wbconlmcWre.emplowas crew
0lttwer.a within
¢ucha6mrerar rchtledo.od'sels OalnvmMmenp ITM1e Mm Dint Shell.a;b05hell suMavewen"'Na ectbn pirkinnsreadlln conneclWn we,N as
upon work
o kenteredba.rewired Or reDIaCW.
p 0 Bwerren Y p
We Propose hereby to furnish material and labor—complete In accordance with above specifications,for the sum of: j
dollars($ )
Payment to be made as follow: gomow ell lob lash.
>11 All Oecanteas on ell products from manufarti
h( 3/Z I u gnin0 Conirem;( Ado Permit cost if naetletl.we Dull Permit.
le(i /%1�(.�I )upon wmplellon of Notice: No agreement for home improvement contracting work shall requlm a
down payment(reverse deposit)of more than one-third at the total contract
%(E )upan wmplellon of price or the total amount of all deposits or payments which the contractor must
make.In advance,to order andlor otherwise obtain delivery of special order
shell be mad.knowit upon materials and a uipmenl.
%(E )wmdelon of work under this contract _
NaIa:TMe pr Im%b MNamwT by co is,aces'.."', OaYa' Aa neNra
Acceptance ot.PfopOsal Thai read both sides of this document awlVaccespithe prices,specifications and condbtsms�smtesi 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: . ' - -
'4 DO OT SIGN THIS CONTRACT IFTHERE ARE ANY BLANK SPACES.
sgnmum oma/O slpwwrp
IMPORTANT INFORMATION ON BACK Illiew
_
�I
'! Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-094763 �.
pa IS n
THOMAS P.DOB�IIV a
19 Cedar Hill 019L r
Danvers MA 01923'
Expiration _
Commissioner
05/1412016
t.
.
UVRegistrati
ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only
O
MEIMPROV MENT CONTRACTOR before the expiration date. If found return to:
o:Office of Consumer Affairs and Business Regulation
n 11 Type: 10 Park Plaza-Suite 5170
Expu�lp n. _, 72o-1§7t Supplement Card Boston,MA 02116
LEN GIBELY CONjj d C uiilNC.
THOMAS DOBBIN
s ^
23 R WINTER ST �// �-�•-76+�_-- ` ��.�y�.___
PEABODY, MA 01960 - Undersecretary Not valid without signature
i_