8 WINTER ST - BUILDING INSPECTION (2) a� as __/
1 7 I'he Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 730 C-NIR SALENI
'L. Re rised,I h it-21)l l
Building Permil Application To Construct. Repair, Renovate Or Demolish a
Our-or To-o-Familt Dn ellin,\r
This Section For Off I Use Only
Building Permit Number: U e Applied:
Building 011icial(Print N:une) Sibtlaturc Date /
SE ON 1: SITE INFORAIATION
I.1 Property Address: 1.2 Assessors Alap& Parcel Numbers
I.la Is this an accepted sl eet?ye no Nlap Number Irarccl Numinr
1.3 Zoning Information 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area Is It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yurd Side Yards
Rear Yard
Required Provided Required Provided Required Provide)
1.6 Water Supply:(( G.I,c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal s m ❑
Check if es❑ P W" )stein
SECTION2: PROPERTY OWNERSHIP'
2.1 Owneru of Recor
_ rA S a u LL 1 rs It_ S A(� -1.1 /I'I
N;une(Print) City.State.ZIP
No. and Street Telephone E nuil Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Buildin w Oner-Occupie pairs(s Alteralion(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ I Number of Units Other ❑ Specify:
Brief Description of Proposed Work-:__ ai ��r yk_ Qr�n
SECTION 4: ESTIAIATED CONSTRUCTION COSTS
licm Estimated Costs: Official Use Only
(Labor and .\laterialsl y
I. Building 5 gel 1. Building Permit Fee: 5 Indicate how fee is determined:
'. Electrical 5 ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier _
.1., Plumbing 5 1. Other Fees: 5 P x
-------
J. Mechanical 01\'ACI S Lisl:
i. .\Iechunical (Fire _ —._--
5u>>ression) S Total :All Fee—
s:Total Project Cost: 5 Q
- ------- -------
Check No. ('heck Amount _ Cash :Amount _
❑Paid in Full 0 Outstanding Bal;mee Doc:
SF.CI'ION 5: CONSTRUCTION SF.RVI('ES
5.1 Construction Supervisor License(C'SL) Cl I
--- ---
`T-"���,`�t License Number Pcpiratiou Date i
N:une ol'CSI. I!alder
L 1st C'SLI)pe(scvhclow)__
i-
Z�.�__�_S._✓__f.n-S__.--_ �--- 1'}Pe Ikxripliun
No. and Street
/� II I Inrestricted t Buildings ti it)35,000 cu. 11.)
V J._9 �,-O R Restricted I', I.amil Dttellin
01% fueu,State.ZIP M Masonry
RC Rooting Ctnerin
WS Window and Siding
SF .Solid Fucl Burning.%ppliances
qZ 9 3NA 1 Insulaliun
ielc hone h:muil address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ! c, b P,1L7 -7
f!--, o�tJ G u fo Lf Chi e I IIC' Registr;Itiun Nuinl+cr Expiration Dule
I IIC Compan) Name or I IIC RegistrantC Name
am' _
N Suuel j.
Email address
(/,A L>t9f!>D 3� 1� S �14a7
City/Town.State,ZIP relc hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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.
Print Owner's Nwne(Electronic Signature) Date
SECTION 7b:OWNERI 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.
Print Owner's or(:.: ut torirc AgvnCN , aI Electronic Signature) Date
NOTES:
rprograin
n Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
nut registered in the Hume Improvement Contractor(HIC) Program),will nu have access to the arbitration
or guaranty fund under I.G.L.c. 142A. Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at tt>s tt.ioass 1;os ,ht.
hensubstantial twrk is planned, provide the information below:
flour area 1 sq. ft.) (including garage, finished bascment.attics,decks or porch)
Gross firing area uy. ft.) Habitable ruum count
\umber of lireplaccs__- _ - _ _ .-- Number of bedruonts
Num her of bathruums _ Number of half hatlu
I')pe of heating system _ ._ _. `'umber of decks, porches
I\pe ofcouling syStem ... _ _ Fncloscd _ _ . --Open
3. "I'alal Project Square Puottgc- m;w he substituted fur"total Project Cost"
I�
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass,gov/dia
Workers' Compensation 1 ,surance Affidavit; Builders/ContractorslEleetriciansfPlumbel s
:applicant Information Please Print L eilli ,
?\arf1C (Business/Organization/Individu I):
:address: '
ry _r
q%State/Zip: Z 129A , 0 k Rk(yhone #: q ❑ g S .� �_ '>_ �__.._
.v e you an employer? Check the appropriate box: Type of project (required):
I am a employer with I -Z 4• ❑ I am a general contractor and 1 6• ❑ New construction
employees (full and/or part-time;: + have hired the sub-contractors
= ❑ I am a sole proprietor or partner• listed on the attached shoat. 1 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8• ❑ Demolition
working for me.in any capacity, workers' comp. insurance.
9. ❑ Building addition!
[No workers'.domp• insurance 5. ❑ We are a corporation and Its
required,] officers have exercised their 10.❑ Electrical repairs or
:.'D I am a homeowner doing all war. right of exemption per MGL 11,❑ Plumbing repau s or ac,'•it:,
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof remius
insurance required.] t employees. (No workers' 3,❑ Other
comp, insurance required.] ------ -
';ny applicant than checks box Nl must also till o t the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicatin they are doing all work and then hire oubidc contractors must submit a new affidavit indicuur,g rash.
:.onuactors that check this box must attached an dditionai sheet showing the name of the sub-contractors and their workers' comp, policy infcm::n'un.
wn an employer that is providing won cers compensation Insurance for my employees, Below is fit policy and;ob
IRrormation. -
usurance Company Name: ,Z ' v
Policy # or Self-ins, 1,ic. #: V �l �' (, (� I (] C� r7 Cf 6 1 'j rs s t Expiration Date: 9 _3-- -,
!. Site Address: O WvV. o� �T City/State/Zip:_-
:vttuch u copy of the workers' compel.;ation policy declaration page (showing the policy number and espir:jtivn
Failure to secure coverage as required u':der Section 25A of MGL c. 152 can lead to the imposition orcriminal pen.Ihb;s ;
ime up to $1,500,00 and/or one-year im-4sonment, as well as civil penalties in the form of a STOP WORK ORDER anci u. f::•.:
up to $250,00 a day against the viola! r. Be advised that a copy of this statement may be forwarded to the Office oC
:,:esugations of the DIA for insurance overage verification.
.... ..... .
o hereby cert(fy under the pairs and enallies ofperlury that the information pro vider//above is true arid correct
nanlre Date [� Z
--
OVIcial use only, Do not write in th s area, to be completed by city or town official
ji
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Del. irtni 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing lmpcsto:
6. Other
'.f Contact Person: Phone#:
rYvvlAV� --- �r a�� r. , u Av�reer ve Pei��Per, e. , •�• Sl17 till! G4L14 r.'rJ1
""' ""'"� 07/28/2011
1aDcsR 97,8.887.4900 F/ft14.978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION--
dd a�tiy F, Sennott Insurance Apw$cy, Inc. ONLY AND CONFERS NO MMYS UPON THE CERTIFICATE
6 South Main Street "MOW THIS CERTIFICATE DOES NOT AMOND;EXTEND OR
ALTER'THE COVERAGE AFFORDED BY THE POLICIES BELOW,
0, Box 4S7
DPsfield, MA 01993 INSURERS AFFORDING COVERAGE NAIC #
�uNeD Len GT y ontraet ng o ne. '-----
INSURTERA A.I:M.
2 R Winter St. IN$uPERe
Peabody, MA 01960
INSURER D:
7VERAGES
HE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWFTH5TANDIHG
,NY REQUIREMENT,TERM OR CONDITION OF AMY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR
.NAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
-OL1CI E S.AGGREGATE LIMITS SHOWN MAY HAVE SEEN.R901j"D BY PA10 CIAIMS.
'.jN3R TYPE OF INSURANCE POLICY NUMBER Y T
LIMITS
CENERALI.IASAJTY EACH OCCURRENCE 3
�— CO RCNL GLNERA LIABILITY nce 6 --
CLAIMi MADE CCCUR NED EXF Ww perwn) 6 --.--
PERSONAL S ADV INJURY 3
GENERALAGGREGATE 3
GENL AGGREGATE LIMIT APPLES PpJL Pfl00UCT9.COMPIOP AOO 6 —^---_
_ POLICY PRC- LOG
AVTOMOBILE WBBJTY
(E donq HOLE LIMIT
ANY AUTO ee a 6
ALL OWNED AUTOS BODILY INJURY --_-----I
SCHEDULEDAOTOS (PY,pmm))
H RED AVT06 BODILY INJURY
NONOWNEDAUTOS (Per aIddenO 6
_... .._ _. .,_ PROPERTY DAMAGE
(Pw wi0en0 6
DARAOE LIABILITY AUTO ONLY.EA ACCIDENT 4
ANY AUTO .. ... ..,..... ....._...
EA ACC i
THAN
w;IN: AGG 3 ---�
EXCESS/UMSRE"L{ASARY EACH OCCURRENCE_ 6
OCCUR n CLANS MADE AGGREGATE
DEDUCTIBLE — 6
RETENTION I —
—
i
4NW PEMP�io ESSA TY VMG601O97901xO11 08 03 ZO11 MN 08 03/2012 7( T ER _ _
AY PROPRIETOWPARTNENEXECUTIVF{Y1 E.L.EACH ACCIDENT i SDO,DD j Iyn FYIda"MBE)FXCLUOED7 LJ E.L DISEASE-EA EMPLOYEE 6 500,00_
SPEC PROVISIONS Wbw
01MFJi E.L.DISEA$E.POLICY LIMIT 3 $UU U
::0.WT10N OF OPEMTM)M6/LOCATgNO/Y®BCLFa/Fl.fOLNM,DNB ADOGD BY p1DONBSMpfT/iPECMI PRONSIOILT
RTIFICATE HOLDER CANCELLATION
SHOULD ANY OF TINS ABOVE DBSCRUBPD POLICE$BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING WGURER BALL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NMICE TO TNECEIRTINCATE HOLDER NAMED TO THE LEFT,BUT FALURE TO DO 90 SHALL
IMPOSE NOOM JCATRON OR LYIBHRY OP ANY KIND UPON TNN INSURER,ITS AGENTS OR
Evidence of Insurance ALnMOMWIRpnR WAY09
Robert Sennott
ORD 25(2001M01) 0 1986400 ACORD CORPORATION. All dohis ru$Irvdd.
The^CORD nalne and logo we reglatered narks of ACORO
J FIN-24-2012 14:35 Sennott Insurance 9'78 887 24FJ4 P.01
r .. .. .Ar _ �. _ - .- �. _ _ — - - —_- -�_.�. _ .. _� .� - _. -. _ _ _ 01/24/2012
;4 PRODUCER 978,887.4900 FAX 978.887.2404 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
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. 0. Box 457 —
Topsfield, MA 01993 INSURERS AFFORDING COVERAGE ! NAIC t
INSUKEO Len Gibely Contracting Co. , Inc. InaURERA Catlin Specialty Insurance Co
23R Winter Street INSURER S. 19038
Peabody, MA 01960 WSURERC:
INSURER
INSURER E ^J
COVERADES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANOING
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 CONDO PIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I ADD I
LTR NISAC TYPE OF INBVIIANCE POLICY NUMBER P ICYEFFEL'TIVE Pou"EXPIRATION --
DATE IMMJOO/Y)fYVj DATE JMWD0 YY`tj LIMITS
GENERAL"OIL" 370030101E 01/29/2012 01/29/2013 EACH OCCURRENCE S 11000,00
X COMMERCIALGENERALIIABILITY PREMI ES EeS o�aur�ra�¢e T 100 000
CLAIMS MADE FX OCCUR ME EXP(my NM,PorePn) S 5.000
A PEASONALAAOVINJVRY s 1 OOD,OU
GENERAL AGGREGATE f 2,000,00
GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS_COAw/OP AGG 7 2 OOOIOO
POLICY PRO- '_ .�—
JECT LOC
AUTOMOBILE UABIUTT COMBINED
ANY AUTO Ed 9cc dwt)SINGLE LIMIT Y
ALL OWNED AUTOS
BODILY INJURY
X SDWOULEDAUTOS IPWpPIwn) f
B
(
X HIREDAUTOS-� 6001LV INJURY I f
X NON OWNED AUTOS (Pal acelderv)
-• FROPERTY DAMAGE J
GARAGE LIABILITT AUTO ONLY EA ACCIDENT i
ANY AUTO OTHER THAN --_——
EA ACC f
I AUTO ONLY: AGG f
EXCESS/UMBRELLA UABLLITY EACH OCCURRENCE J
OCCUR u CLAIMS MADE AGGREGATE -- f
OFDUCTI BLE J
WORKERS COMPENSATIONAND EMPLOYERS'LIABILITY YIN I TORT LIMIT4y. ER
C OFFICERIMEMBEER EXCCLUDED7 ECUTIVF❑ IE.L.EACH ACCIDENT
IMUIda[Ory In NHI CL DISEASE-EA EMPLOYED
IIyyw,.dswIw,,rd%r -- _
SPECIAL PROVISIONS bMdw EL DISEASE•POL,C'LIMIT f
OTHER —'
DESCRIPTION OF OPERATONS J LOCAOONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
VIDENCE OF 2012 RENEWAL COVERAGES.
I
t
CERTIFICATE HOLDER CANCELLATION _ J
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I HE EXPaIATION
DATETHEREOF,THE ISSWNO INSURER WILL ENDEAVOR TONAL 10 UAYS WRITTLK
NOTTCE TO THECERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE To
SD B."
IMPOSE NO OBLIGATION OR UAUILrrf OF ANY KIND UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Sennott Ins. A enc
ACORD 2 5 120 0 9101� 9)1988.2000 ACORD CORPORATION. All rights reserved.
The ACORD name and logo am registered marks of ACORD
Page No. of / Pages
LEN GIBELY CONTRACTINGCO., INC. '2n8r PROPOSAL
0
Street
23R Winter Street l
PEABODY, MASSACHUSETTS 01960 .
All home Improvement contractors and subcontractors
(978)531-8234 Fax(978)531.9304 engaged In home Improvement contracting, unless ^ m
www.lengibelycontracting.com specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered o
Submitted T r f ff J with the Commonwealth of Massachusetts. Inquiries
70: __.T�'IG.n.-_�_I�!O_r/---_—_.,_ —.._.._ __..__ about registration and status should be made to the
Director, Home Improvement Contrast Registration, o
II _� One Ashburton Place, Room 1301, Boston, MA 02108 Is
(617) 727-8698. Owners who secure their own m
construction related permits or deal with unregistered B
- SC•k, M.._MJ_�__--_________—_._._._..__ contractors will be excluded from the Guaranty Fund
/ Provision of MGL C.142A.PHO I
�9N7k
701I MTE / REGISTRATION NO.
" 33- G�/ /L� MA.REG. 100811 f
,08 1"73 33-3 ?oil JOBLOCATION
We hereby submit specifications and estimates for work to ad performed and materials to be used:
—
t a
in
_1-�.Z..�.Pfn
Ox
.�M/ _ tI
V �9 7,,a� �t -')xNrsCall
�DNr� r
JA r //�J�� //[L(
ORKW 5 E IU
Con qor II net be
- rk or order the materials before the Ihla"i led following rho slgning of tnls Agreement,unless spacitied herein Bfe q cfor III three the work on or
ape (rate).Barring delay caused by circumstances beyond Contractor's control,-.the work will be compleretl by te).The Owner homby
asis led s and agrees t al the screening dates are approximate and that such delays that are not avoidable by the examseor shall n��ot//be corral// as N ns of this Agreement
The Contractor warrants that the work furnisher hereunder shall be free from detects in material and workmanship for a period of�z/._I.A.11owing completion and shall comply with
the reyuiromants of this Placement.In the ereM any defect In workmanship or materials,or damage caused by the contractor,his subcontractors,panel a r or agents,la tllacomretl within
one year attar 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,or replaced
such damage or such detect in meledale or workmanship.The foregoing warranties shall survive any Inspection performed in connection with the agreed-upon work.
We Propose hereby to furnish mat r I and labor_cane late i1 arc_Ends Ce with above specifications,for the sum of:
G t"i -J O 7 / / 5 S\__I dollars($ ).
Payment to be made as follows o,Z Of 15 /5'
%is upon slgning ContracbC - - --- -- -- ---- tl
`^ � N IC Im<to l0 Ip etl Rog61 I I
($:)V` )upon compatten of
($�)upon completion of .. ____ -
Ciryl$mte � - � -- Plwna
% ($ _)shall be made brewlthupen _
completion of work under this contract. Fro mIT15 No.
Notice: No agreement for home improvement contracting work shell require a n 'Nam of$a sman
payment(advance deposit)of more than one-third of me loml contred pri or the I .-
total amount of all deposits or payments which Me dent radpr must make advance, wt red SI news
to order and/or otherwise obtain delivery of special order materiels d equipment ,
whichever amount is greatgy hkprnposelnry as wlNder br us It hot accepted WtHe tlays.
Acceptance of Proposal I have read both sides of thi ' menl 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.
/ADO- NO(T�T SIGN THISCONTRACT
�fIFTHERE ARE ANY BLANK SPACES.
Gate 6 �_L` le as um Gate '
IMPORTANT INFORMATION ON BACK Bib-
-
I
I
Massachusetts - Department of Public Safety
Board of.Suilding Regulations and Standards
C0n4,tractionSupenisur .
License: CS-094763
E'rTs 40 f
THOMAS Ii.1a6BINfLN
19 Cedar r1 Pam'
Danvers 11
V
�iC t6Pa Expiration
Commissionerr 05/14/2014
_.........._......_.------ ..._ _.._._.._._..__......
r Affaarew�Business
Regulation
la
Office of Consumer Again&Busisess Reguledoa License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistratlon 109611 Type: Office of Consumer Affairs and Business Regulation
1 - xpiration 612W2014-; Private Corporation 10 Park Plaza-Suite 5170
g Boston,MA 02116
L_N GI8[LY CONTRACTINGYCO INC.
Brian Dobbins
23 R WINTER ST.PEABODY, MA 01960 ---
Undersecretary Not valid w' ut ignature