46 WINTHROP ST - BUILDING INSPECTION Commonwealth of Massachusetts aryOF
Board of Building Regulations and Standards SAL NI
Massachusetts State Building Code, 730 CMR Revised Mar 2011
a Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Sect' ' For Official Use onl
ton
y ..
Building Permit Number: . Date App
Building Official(Pont Name) Signature Date
SECTION L SITE INFORCNIATI
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
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 ft) Frontage(ft)
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❑
8
ECTI0N2:, PROPERTY'OWNERSHIP�'
2.1� Owners of Record:\ /�
i ) AVin HA ALo � S6b 'L, rz. 1 /r1 0 '1/a 01 �( 3b
Name(Print) City,State,ZIP
->, n .Se-(A L S� (o0CC30 WSZ4
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply),
New Construction ❑ Existing Buildin Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Dzmolition ❑ Accessory Bldg. ❑ NttmberofUnits Other ❑ Specify:
Brief Description of Proposed Work: i� Iri l- e e 1
�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use 11 Only,
Labor and Materials
1. Building 9 i L go o� 1 Building Permit Fee S Indicate how fee is determined:
❑ Standaid.City/town Application Fee
?. Elaetrical 5
❑ Iotal.Pioject Cost' i. ,(Item b)x multiplier x
3. Plumbing y 2. Other Fees: S
1. Mechanical (HVAQ S List: -
i. Mechanical (Eire
sli: ression) S total All Fees:
® Check No. Check Amount: Cash Amount:
Total Project Cost: S O IGR V C�® 0 Paid in Full 0 Outstanding Balance Duo: ---—
r
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL) q y ,b a� 5— / �4 I It
License Number Expiration Date
Name of CSL I[older
List CSL Type(sae below)
Z � � Type Description
' (-,i.1 c'ti IT' `a7°rr-'��t—�Q•4 �tai�Y .
No. and Street
U Unrestricted Duildin s up to 35,000 cu. tt.)
lea bvb R Restricted 1&2 Foraly Dwelling
Cityfrown, State, ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
cle hone Email address D Demolition
5.2 1Registered Home Improvement Contractor(HIC) 9 D (f) & f � _Z _lCfr
G (-b� 'LY Cati-T- HIC Registration Number Expiration Date
I IIC Company Name ur HIC Registrant Name
nd Street Email address
�.A MA
City/Town, State,ZIP 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 .......... 13 No........... ❑
SECTION 7a: 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 Name(Electronic Signature) Date
SECTION 7h: 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.
_L..vr_v .� t 6- 1-V Lt�. Y ---2 �- z 3
Print Owncr's o 'Wtlwrized Agent s I v 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 find under M.G.L. c. I42A. Other important information on the FIIC Program can be found at
wWw,mas5.110v/ocu Information on the Construction Supervisor License can be found at w,vw.mass.eo�':IL
2. When substantial work is planned, provide the information below:
Total floor area(sq. R.) — — _(including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) _ _ Habitable room count
Ninnberoftireplaces-.---�--- Numberofbedrooms ------_--_--_--
Number of bathrooms Number of haltvbaths
fvpe of heating systcnt _--_- ---- ----_,__-- Number ufdecks/ purrhes
----------
f}Pe of cooling sy;lcm ---- [inclosed ._. _- —Open — -----
1. '-I'ot,tl 1)1 Ct Syu;ro Footn,,e" may be substituted t;,r..lot:11 Project Co;t"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
U'r 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (BusinessiOrganiution/Individual): 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):
1.® I am a employer with 12 4. ❑ I am a general contractor and I
employees (full and/or part-time).
+ have hued the sub-contractors 6. El New construction
2,0 1 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' !
❑t 9. Building addition
[No workers' comp. insurance comp, insurance. I
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.) t c. 152, §1(4),and we have no 12.❑ Roofrepa repairs
employees. [No workers' 13.0 Other
comp. insurance required.)
•Any applicant drat checks box#1 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.
tContmctors 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 subcontractors have employees,they must provide their workers'comp.policy number.
I out an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
inforutation.
A. I .M. Mutual Insurance Company
htst$ance Company Name: P Y
Policy# or Self-ins. Lie. #: 6010979012012 Expiration Date: 08/03/2013
Job Site Address: y �, (..y e 57--"- City/State/Zip: S A 1l'lt4_
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Pailure 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
mature II_Nr_7 � 0_12v,� Date ` �-5— 3 _
Phone#:
Official use only. Do not write in this area, to be completed by city or town offtcialt
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
-.FEB-04-201$ 09:48 Sennott Insurance 978 887 2404 P.01
VG/v+/GUAs
L�RODUCER 978.887.4900 FAX 978.697.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Edward F. Sennott Insurance Agency. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
16 South Main Street ALTER THE:COVERAGE AFFORDED BY THE POLICIES BELOW -
P. 0. Box 457
Topsfield, MA 01963 INSURERS AFFORDING COVERAGE NAICB
YSURED Len Gl e y Contracting CO. . Inc. INSURERA Catlin Specialty Insurance Co
23R Winter Street .u.ERe! Safety Insurance Codpany 39454
Peabody, MA 01960 INSURER C: _
INSURER 0: ._..._
INSURER E.
,`OVERAGES
THE 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.
TR NS TYPE OF INSURANCE POLICY NUMBER "TTEOYMI DATE "0011TT'T/YON LINTS
GENERAL LIABILITY 3700301537 01/29/2013 01/29/2014 EACH OCCURRENCE 3 1,000 00
X COMMERCIAL GENERAL LIABILITY _ PREMISES EA29anrnal_ $ 10010
CLAIMS MAOE u OCCUR MED EX►(My cm wwn) 3 5.ON
A PERSONALAADVINJURY S 11000.0001
OENERAL AGGREGATE i Z.000.00
GENL AGGREGATE LIMIT APPLIES PEN: PRODUCTS-COMP/OP AGO 3 2100.00
POLICY jE LOC
AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT
ANY AUTO (EA ealdenl)
ALL OWNED AUTOS BODILY INJURY S
X SCHEDULED AUTOS (PeTPMAAn)
B X NIREOAUTOS BODILY INJURY
3
X NON-OWNED AUTOS IPA eocw") ....
PROPERTY DAMAGE S
IPxaccridAm)
CARAGEMABILITT AUTOONLY-EAACCIOENT S
nANYAUTO OTHER THAN EA ACC S -_
AUTO ONLY: AGG S
EXCESS!UMBRELIALIABUTY EACH OCCURRENCE 3 ...
OCCUR CLAMS MADE AGGREGATE S
DEDUCTIBLE
RETENTION 3 3
WORKERS COMPENSATION TORv LIMITS ER
AND EMPLOYERW LIABILITY YIN u
ANY PROPRIETOR ARTNEIUEXECUTM �E - E.L.EACH ACCIDENT S
OFFICERIMEMBER EXCLUDEOT u
VEL.yAMMmy In NH)
DISEASE-EA EMPLOYE 3
SPECWL PROVISIONS ealav ELDISEASE-POLICY LIMIT 1 S
OTHER
JESCRIPTION OF OPERATIONS I LOCATIONS f VEMICLE3/QCLUGMS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRBEY POLO DE BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE RTSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS wwrmN
Evidence of Insurance NOTICE TO THE CERTIRCATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SMALL
IMPOSE NO OBUDATION OR LIABILITY OF ANY KIND UPON ME NSURER,Ire AGENTS OR
REPROBENTATNES.
AUTHORIZED REPREEUENTATn
Robert Sennott RP
ACORD 28(2009101) 01988.2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
L
tue IJul 24 IU : lU :55 ZU12 From: Poulin,Robert To: 997853193aBhge 1 of 1
CERTIFICATE OF LIABILITY INSURANCE ATF.IMb uvz a24/2:,.Yy, -�
uiz
THIS CERTIFIGT£ IS ISSUED AS A NATTER OF IHPORNATZON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATC HOLDER. THIS CERTIFICATE
DOES NOT AFFIR=TIVELY OR NEGATIVELY AMEND. e%== OR ALTER THE COVERAGE APPORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 13SUIM INSVRER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, RED THE
CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIQXA INSURED, the poliey(ies) must be e[Idoroed. If SUBRWATION LS WALVED, Soh).ot
to the t... aESL eoedikieas of the Policy, certain polieiva .1 require as endo....t. A stat®set an this certificate doe. not
confer rights to the certificate holder In lieu of much andoraement(s).
vvucLR DDYTAR
Edward F Sennott Insurance R.,
PXCNE iAx
Agency Inc N"_/c' • L.L1, 1"/ •el:
16 South Main Street
va.'"A
Topsfield, MA 01983- cuarcaa To
IxveuD(vl amoeollw cweAAci Jc p
Len Gibely Contracting Company Inc
xsuma A: A.I.N. Mutual Insurance; Co 375E
23 Winter Street Rear -- -
Peabody, MA 01960-5941 INDDua D: _
iXIVRX is
IX6UPER F:
COVERAGES CERTIFICATE NIJIMER: REVISION NUMBER:
THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW Hi VE BELL ISSUED TO THE INSURED NAHED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTHITHSTANDING ANY REgV IRv1aN'r, TERN OR CONDITION OF ANY CONTaALT OR Om@R DOCN6NT wITH REBPELT TO mic" THIS CERTIFICATE WAY BE ISSUED OR HAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HS2WIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. L1>IRS SUGHN
MA'Y HAVE EMEN REDUCED BY PAID CLAIMS.
r• TYPE OF INSURANCE POLICY NIISBLR POLICY PTP POLICY EST LDNITS
DLIC E Un/w/ivr,l
GENSRAL LIABILITY
eACX OccawW Ce '$
O71: In..-Alt 71%1.m P....'N,E e[e:,iraneel $
eiP m IAm on. P�.Xanl i
0 Peasvxw L Aov mJlm* $
�', aa:Xr avT lair^um.nD nA: Arm.LDATe a _—__
{
AUTOMOBILE LIABILITY ..IS.. U.LIMIT S
FlJJ. .... lee ec4UenC1
nA-, . 111 Al 11 BODILY INJURY H-perm) S
�::;.I T.Ix;.11 A1:'rl:J aODILT INJYRTIpei J[elUentl $
❑tIV1U M�'i9
' Ipe[ ,m S
�'J"r-.2a'1TJ.uRA'a 6
':Tl (?TIP BAQ...... S
�iL CV,LVY 4/d:L AWAYGATC S
a 1:E"ILI:I I'iA $
6
WORKERS COMPENSATIONAND EMPLOYEES LIABILITY
MG -.L PR:3rOR/?AAI:NEIS/ E.L. Laces 11Luvui { 500,000
A EXVI:TIVO OP([CI'S �RI ____
P%°1 6010979012012 08/03/2012 08/03/2013 B.L. DIMAS. -POLICY LnaIT i 500,000
.L, vnusc - u nolAneL [ 530,000
� J
CERTIFICATE HOLDER CANCELLATION
L
Evidence Of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EEPIRATION DATE THEREOF, BOTTOM WILL BE DELIVERED IN ACCORDANCE WITH Tit
POLICY PROVISIONS.
vrxoeu[D xaevvinnJv[i�����
'.e1r afdtLI CON"I"RACTING CO., INC. Pace N. �_ol
23R Winter Street �Pages
PEABODY, MASSACHUSETTS 01960 24581 PROPOSAL
(978)531-8234 Fax(978)531-9304 FProvIsronOtMGLp
me Improvement contractors and subcontractors
ged in home improvement contracting, unless
www.lengibelycontracting.com fically exempt from registration by Provisions of
Submitted ter Coo42A of the general laws,must be registers,
To: �/�v1�. I�t the the Commonwealth of Massachusetts. Inquiries
q r"I dretion and status he Id be made to the
tor, Home Improvement Contract Registration,
shburton Place, �G
�1 // // // 727 Room 1301,Boston,MA 02108
/_'SryOVrN/1/aP1 8598. Owners who secure their own o
r /�4, C/ y 3 0 uction rallied permits or deal with unregistered
ctors will be excluded from the Guaranty Funtl G
ge.NE ion Of MGL c.142A. O
D I ��I �� `/ f4TE gEGISTgPTIOX NO. '_
MA.REG. 100811 m
rt
IOCFiION
JOa I
Wv'I,er¢by soonerSp¢CiliCalipop
antl S
pslirllat¢s IOr wpA Ip bC pOr/p,mptl antl malClials to po usCtl: / L� 1/4 a �� rN
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J or/P pit 2c.^
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ilrveoul.s-r �)y�
Illrr" yU �V vp�e e!Ina malorlaly oolo,e In¢Ipirp tlae,allowing Ipe signing of Pis Rpre6menl,unless spocilipo porei
J e aria eg—loot Ina scpOdyling 67f¢9Yare ase opy circumslan¢s beyonO COnlraclors control.Ill.work will be eomplarpp boor
11 p on or
In/,kTY3 PP im...no la.,ou.Eulays In.,ore riot nvoyab',py the eapeonclw sp Ol bo conSl P6onsipllhi9 oomenrlopV
Cp lo�ninos Of fors ynlraclor wartpn151ha1 Ina walk lurnishoo nerounbor shall pe neo IrOm tleleCl3 in malarial¢n0 workmansplp for a and reopen
ol.
9 p,tlon 1 evo ytl l roc p u d 91 Ilo�ft^by h C 1,_ OlTox n9 111 b h'II Con
gOr soon Yran.1 IUdiYk 0I C li. ni N paper Poo Ye y pVwn
n p.To y9p y ssnlls enY- o be tl ,l renewed oe Otl ri lN,
a r5pectl p odY rmed n tonne'n 1 are.tl be rearpl arr,cnd
f PfOp OSE hereby to furnish material and labor'complete In accordance with above specifications,for the sum of
nenl lO ba matle aG fOOW' /^
upon completion ad < l�� Nam-of tarlear.O.Orar e,d,yr,,m
sii.a nndrraY
-=R )upon¢omplmmn If
_eo is '11.11 be road.IO...on upon OY/Bale ' oho,
uOyea tips of work Orion,Inie contract. /
NO Cm l/ an IO NC
tl(adv'Gnc onl can npma improvement conlractlny work moll raGu re O duwrl _e beppsill of more Inun one"InirO pl Ipe on.
Cortrracl price or theniren
mount of all deposil3 or paternally wpich re connector must make,in up or I.
"and/or onperwiso ordain Oalivery of special order matenals and oGuipmonl, o0 5 w
'vP�fy4LL9walE[
mrT„. a eo or'lly n I,or r ra_oren whom
�ptance of Proposal have reatl both sides of This id a t OnI antl a pt he prices,specifications and conditions stated I understand
tans Buy this proposal becomesi bintling contract. You are aulhorizatl to do the work as specified. Payment will be matle as outlined above.
the Buyer,may cancel thel transaction at any time prior to midnight of the third business day after the
of this transaction.Cancellation must be done in writing.
DO NOT SIGN THIS CONTRACT IFTHERE ARE ANY BLANK SPACES.
/� tt LrG AJs�"� `,b IMPORTANT INFORMATION ON BACK
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
1111,11 LM1011 bUjk 1�Istil
License: CS-094763 Y'v
THOMAS R. D6]BINS
19 Cedar HULDri", X f:
Danvers MA-01923
11% Expiration
Commissioner 05/14/2014
Olt-ice of Consurnermfitirs& BUSIUM IlCgUhniOa License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 100811 Type: Off-ice of Consumer Affairs and Business Regulation
Expiration: 6/2312014 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
LEN GIBELY CONTRACTING CO., INC.
Brian Dobbins
23 R WINTER ST.
PEABODY, MA 01960 Undersecretary Not validut ignature