6 WEST TER - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
r� Massachusetts State Building Code, 780 CMR, 1'a edition lom
momw
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a !k'Immons
/72 1 One. or Tis'u-Fuindt Onrfhng
l This Section For Official Use Only
(nU\(^J Building Permit Numb: Dale Applied:
^ Signature: kff (P)-�/(J
Budding Commissioner/ pats of Buildings Dale
SECTION 1:SITE INFORMATION
1.1 Pfoperty Addrea: 1.2 Assessors Map 6 Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq(1) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yet& Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system O
Check if esO
SECTION 2: PROPERTY OWNERSHIP'
2.1 gwnerrI.Y f of Ra,,��o ttd:
/vs : Ro -e s c r IL
Name(Print) Address for Service:
9e) R 6 Q
Signature Telephone
SECTION):DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Buildin Owner-Occupieo�0_ Repairs(s)�' Alteration(;) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units1_ Other ❑ Specify
Brief Description of Proposed Work': — IzLa jc=c (..t./ .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Use Only
Labor and Materials
1. Building f I. Building Permit Fee: f Indicate how fee is determined:
2 Electrical S ❑Standard City/Town Application Fee
❑TotalProject Cost (ltem 6)a multiplier t
J Plumbing f 2. Othehe r Fea: f
4 Mechanical (HVAC) f List: �
s Nechamcal (Fire f Total All Fees: f
Suppression)
Check No. _Check Amount: Cash Amount
h
Total Project Cost: f ❑ Paid m Full O Outstanding Balance Due
66 06 6e4
SECTIONS: CONSTRUCTION SERVICES
5.1 L`iccennsegd�Construction Supervisor lCSL) �n y� ' � �
f, ' 1 i 0 ioZ t.0 C• L�nxlVumtwr- Esprtauon Date
Nyae of('SL'H1el(dAeJr (�'�/1 .(1A\J'v9 List(SL Type(fee hl'fow)
Type! Description
Addrr3l
U
� Unrestricted u to Cu FI
R Restricted 1k2 Family Dwelling
Slg ,� _ M .Mason Onl
I'5mre � 5 1 8 3y RC Residential Rootin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
3.1 Registered Home Improvement Contractor(HIC)
n P 1 C) a Q � ''
HIC Company Name or C Regist�NamCe a��. Registration Number
!%!2LCDi; Eapintion Date
Signarwe Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I52. 2SC(Q)
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..........O No...........O
SECTION 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
( 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:OWNER'OR AUTHORIZED AGENT DECLARATION
1, L— .GN (a t fi—o t'y Cn-T- as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
1 s
Print Name
ra
Signature of Owner Aulhoriz en Date r-
(Signed under the pains nalties o rju
NOTES:
1. 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 nfm have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and I IO.R3, respectively.
2 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenVanics,decks or porch)
Gross living arcs(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
Tvpeof cooling systern Enclosed Open
1 "Total Project Square Footage'may he.uhslilutcd for 'Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
klvi www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print L-e",
Name (Business/organiaationdndividual): L 2 e, G1 ,b a LV �`n i�4 [' i tni� {�
Address: I L( 9 tl A t,� S-r
City/State/Zip: qa Phone#: 9 9 8 5 3 l 8 J 3
Are you an employer?Check the appropriate box: Type of project(required):
I XI am a employer with / J— 4. 0 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑Remodeling
2. I ship
a sole proprietor o partrrer- These sub-contractors have
ship and have no employees 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 Building addition
workers' coin insurance comp mscorpor.t
[No P� 5. Q We are a corporation and its 10.❑ Electrical repairs or additions
required.]
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
c. 152, §1(4),and we have no
insurance required.]t 13. Other
employees. [No workers'
comp. insurance required.]
Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
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 sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most 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: q T_� M f L 1 A� J ,w'S C n
Policy#or Self-ins.Lic.#: l I D 9r7 7D l c_ q_ Expiration Date: 03 ( d
Job Site Address:_ ".�.� C City/State/Zip: L-a nn A k r{��
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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature 4 � Date z — l
t
Phone#:
Official use only. Do not write in this area, to be completed by city or town oJrciaL
City or Town: PermitlLicense#
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#:
ISSLLDATE 0713111_009
RODUCER
'dwald F Sennett Inaumce THIS CERTIFICATE IS ISSUED AS A MUTTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
Agency Inc DOES NOT AME1D.E\"TEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
16 South Main Street
/psfi[I[1 MA 019S3 COTVIPAI\ES AFFORDING COVERAGE
N SLIILED -- --
=n Gilmly Contracting Company Inc
ComPANY A A.I.M.Mutual Insurance Co
...
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOIL THE POLICY
PERIOD INDICATED.NOTWITHSTANDING ANY REQUTRE.q'IENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
TO A19CH THIS CERTIFICATE MAY BE ISSUED OR INLAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBIECT
TO ALL TIIG TGRh15,ESCLUSIONS AND CONDITIONS OF SUCH POLICES.LGIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO Tll[Oi IS[URANC[ IOIICI'[RFCi1P[ POLIO'[YPIrAriON
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601097901'--009 06/03/ 08l03/?Ol0?OU9 IIKL �Gc_ EL DISEASE POLiC1'IAtIT 500000
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SHOULD ANY OF THE.\HOVE DESCRIBED POLACRS BE CANCEI l m BPFOLIE THE MIRATION DATE
THEREoF.THE ISSIT40 COAIPANI'1LTLL EAOEAVOR TO FAD,IB AWTp1 NOTICE TO THE CERrMCATE
OLDER NAKED TO THE LEFT,BUr FAILURE TO KUL SUCH NOTICE SHALL IN"SE NO OBLIGATION
A LLu)[UrV OF ANT'KIND UPON THE COMPANY.ITS AGENTS OR RDPRFSENTAT;VES,
01I'lIOA'I IT MAY CONCERN
111 HORIZED REPRESENTATIVE
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A
LEN GIBELY CONTRACTING CO., INC. 99 Page No. of / Pages
149 Main Street _ll�j PROPOSAL
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
(978)531-8234 engaged In home Improvement contracting, unless
FAX(978)531-9304 specifically exempt from registration by Provisions of
Submitted 1 Chapter 142A of the general laws, must be registered
t:M.TO: _$ El-o esC4� _ with the Commonwealth of Massachusetts. Inquiries
about registration and status Should be made to the
qI 4-1514(Cc , Director, Home Improvement Contract Registration,
--- ---- -- - -- - --- - One Ashburton Place, Room 1301, Boston, MA 02108
/I �I (617) 727-8598. Owners who secure their own
construction related permits or deal with unregistered .P..
contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A,
P ONE DATE
/ nEGISTRATIDN NO.
q 7P. �y/s-Gy Z 9/3 /C MA. REG. 100811
JOB NAMENO.
J BLOCATI N
We hereby b specifications tl 1 I work to be performed and matenaIs to be used
-cJ,_timw1--2�.,_�u-_3o I.1, Ja-w�
rc[L ss_ w;tG OP
- 7r' S 4J
Z70. oc, -- Z -- --
i
Constmaion relatetl per - - �- ------ — - - - -
4d6
a.PA,K MI Tr4sti
WORK SCHEDULE
Cool II o b n k order IM1 ter bet a the third day I Ilo g the 'g g f this Ai t les pee f d he
about (tl re) Barring delay caused by c st beyond C I act s o t rh work s be t e b ontraclor II begin the work on or
acknow gas ag a al the sched lin do a ys y V y data).The Owes,hereby
WARRArJTY 9 pp oxI r and roar such dela that are not avoidable b the contract /J�.11 not de cow(in d s Sons of the Agreement
The Contractor warrants that the work fur,shed hereunder shall be free from Bell is material and workmanship for a period ors/ 7 y'`fdllowin leliun antl shsll corner,the requirements of this Agreement.In the event any offset In workmanship or materials,or damage caused by Be Dantradop his subcontractors, mlo9 comp py with
one year after gampletisn of any lob,inclutlIng clean up,the Contractor shall,at his own expense,forlM1wilh remao re air correct,replace,subcontractors
cause libe re.1 agentsels discovered with,,
such damage or such tleled In malerialsorworkmanshle The foregoing warranties shall survive y h p paced.q,replaced
any thwith mat 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:
Payment to be//Z�tle as follows: dollars($ ).
%(S ram)upon signing Contract; �� Q
Namo,f eonlras noesl8,arae Regisea
upon completion of
Streol Atleress
upon completion of
tete P„ne
($ I shall be made brewith upon CI%/S
complelion of work under this contract. Phone rod e,el lD N,.
Notice: No agreement for home Improvement contracting work shall require a down lean —Sa'Bsn
Payment(advance ant for of more than one-third contracting
the total contract price or the Cyr_-�-
total amount of all deposits or payments which the contractor must make.In advance,
a order and/or otherwise obtain delivery of special order materials and equipment, S J
whichever amountis greater,
Not,This proposal may be withdrawn by us II not accepted will / 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 OT SIGN THIS CONTRACT IF THERE ARE AP BLANK-�;PACES.
aignaw,e L ' oale /2 /f+-o? ale,nrer, Date
BOARD OF BUILDING REGULATIONS
i License: CONSTRUCTION SUPERVISOR
Number: CS 094763
Birthdate: 05/14/1943
i
Expires: 0 5/1 412 01 0 Tr.no: 94763
Restricted: 00
THOMAS R DOBBINS
19 CEDAR HILL DRIVE G-
DANVERS, MA 01923
Commissioner
�-\ Board of Buiidin�ong o�and Standards
HOME IMPROVEMENT CONTRACTOR
Registratl9ft, 1008,1
Expiration;_6/23/2010 7r# 268971
;Type: Private Corporation
LEN GIBELY CONTRACTING CO.,'INC.
Brian Dobbins
149 Main Street
Peabody.MA 01960
Administrator