48 WINTHROP ST - BUILDING INSPECTION . 1
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish
One or Two Family Dwelling
Tbi`s Section`For Official Use'pnly
Building Permit Number
Building Official(Print Name) Date
}
SECTION 1 SITE INFORMATION ,
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
!_/.. R LJ t .-1 r
L la 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
I E 1
1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private ❑ Check if yes❑
":° SECTION`2:;PR00RT3"OWNERSHIP' ` z
2.1 Owner'of Record:
.SC-lR t en ( Hoc te, L,o rn
Name(Print) City, State,ZIP
y 8 w 'iti.It P k2 fix R�$ 5 8'7 2v,2,D
No. and Street Telephone Email Address
SECTION 3:.DESCRIPTION OF PROPOSED WORKZ (check all thata"pply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ 11 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'': 7T r2 b ✓ F' � c� OQn� �"'
SECTION 4: ESTIMATED CONSTRUCTI,ON COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1. Building $ 0 315 1 Building Permit Fee $ Indlcate how fee is determined..
❑.Standard City/Town Application Fee
2. Electrical $ ❑TotalProject Cost'(Item 6);xmultiplier x
3. Plumbing $ 2 Other) ees
4. Mechanical (HVAC) $ List: " l ��
5. Mechanical (Fire $ Total All Fees. $ .[
Suppression)
Check No Check Amount Cash Amount
6. Total Project Cost: $ i U3 75 �� 0 Paid in Full 0 Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES
r5AColns:t�ru�ction Supervisor License (CSL) t (-7v 1y
k License NumberExpiration Dale
CSL Holder
pList CSL Type(see below)
r_e (b.�aan StreetSype -r. Description'
U Unrestricted Buildings up to 35,000cu. ft.
R Restricted 1&2 Family Dwelhn
City/Town, State,ZIP M Mason
ry
RC Roofing Covering
WSnNumber
d Sidin
SFBurning Appliances
CJ 3 $ 3 y I
Telephone Email address D
5.2 Registered Home Improvement Contractor(HIC)
q ( l -23 -1
I-�-o w.� t(� Z.-� Cpf,T n Number Expiration Date
HIC Company Name or FlIC Registrant Name
rid Street Email address
City/Town, State, ZIP Tele 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... ❑
SECTION jai OWNER AUTHORIZATION TO:BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT:
F1, aswner of the subject property,hereby authorize
on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER` 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 uthonzed Agent's Nt(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
wwwamtss.gov/oca Information on the Construction Supervisor License can be found at www.mass.eovidos
2. When substantial work is planned, provide the information below:
Total floor 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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
ti www.nlass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/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. El am a general contractor and t I 6. ❑ New construction
employees (full and/or part-time).
« have hired the sub-contracors
2.❑ 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'
(No workers' comp. insurance comp. insurance.t 9. Building addition
required.] 5. corporation We are a co oration and its 10.❑ Electrical repairs or additions
❑
3.❑ I am a homeowner doing all work officers have exercised their l l.❑ 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 NI must also fill out the section below showing their workers'compensation policy infomettion.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
1Contractors 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 sub-contraetors have employees,they must provide their workers'comp.policy number.
I ant au employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A. I.M. Mutual Insurance Company
Policy#or Self-ins. Lic. #: 6010979012012 Expiration Date: 08/03/2013
Job Site Address: yl?" City/State/Zip:. 24,2n, NA D \ Ct -0
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: � ��+ o Date
Phone#:
Official use only. Do not write in Ibis 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#:
JAN-24-2012 14:35 Sennott Insurance 578 8E'7 2404 r'. Ji
01/Z4/2012
PRODUCER 978.887.4900 FAX 979.897.2404 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 DOE NOT AMEND EXTEND R
16 South Main Street S O
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. 0. Box 457
TOpsfield, MA 01993 INSURERS AFFORDING COVERAGE NAIC 4
INSURED Len Gibely Contracting Co. , Inc, nBugERA Catlin Specialty Insurance Co_
23R Winter Street INSURERS. T �19038
Peabody, MA 01960 INSURER C'
IN 3URfiR
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTYJI THSrANOI NG
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 CONOI T10N5 OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LLTR IHiA TYPE OF INSURANCE .. POLICY NUMBER POLIOTEFFNCTIVE POUCYEXPIRATION
DATE MM/DORYYY DATE(MIADIVYYYY1 LIMITS
GENERAL LIABILITY 370030101E 01/29/2012 01/29/2013 1 EACH OCCURRENCE 6 1,D00,0T0
_
X� COMMERCIAL GENERAL LIABILITY v , EB ES76Rda Tuw _ 3 __ 100 0
CLAIMS MADE ❑X OCCUR —J
ME E%P(Any vw pPrYonl S S.00
A PERSONAL L AOV INJURY S 1 000,00
GENERAL AGGREGATE 2 600 00
GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOP AGO E -- K000!0U
POLICY PRO- -
JECT LOC -
AUTOMOBILE UABIUTY _ Y
COMBINED SINGLE LIMIT S
ANY AUTO (Ed SUldar,D
�•• ALL OWNED AUTOS BODILY INJURY
X SCHEOULEDAUTOS (Pci PPIPPnI S
g X HIRED AUTOS --
fiDOILY INJURY S
X NON-0WNED AUTOS (Per ed[IdeWl
_-••— FROPERTY DAMAGE
(P.,3ccdeni)
OARAOELASILITY AUTOONLY EAACCIOENT S
ANY AUTO EAACC i _-- ---__-
-- I OTHER THAN
AUTO ONLY: AGG S _
ESCESS(UMBRELLA LIABILITY EACH OCCURRENCE 3
OCCUR U CLJMS MADE AGGREGATE
1
DEDUCTIBLE
—.—Jaim
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN TORY LIMITgy- ER --M, - ._
ANY PROPRIETOIUPARMER/EXECUT)VE❑ E.L.EACH ACCIDENT 8
C OFFICERIMEMBER FXCLUOE07 --
IMAndauwyIdNH) E.L DISEASE-EA EMPLOYEE 3 P,1
II O.do$,Aw urger _
6PECIALPROVISION3W. E.L.DISEASE-POLICY LIMIT I S
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISM NS
VIDENCE OF 2012 RENEWAL COVERAGES.
�
CERTIFICATE HOLDER CANCELLATION 1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE LWZTiONI
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 UAYS WROI EN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO Oq 6O SHALL
IMPOSE NO OBLIGATION OR LWOILrrY OF ANY KIND UPON THE INSURER ITS AOENIS OR 1
REPRESENTATIVES.
AU THOND:ED HEPREDEHT4DVE
Sennott Ins. A enc
ACORD 2512008/01) 9)1988.2009 ACORD CORPORATION. All Tights resu"vd.
The ACORD name and 1090 are registered marks of ACORD
SennotI InSur-ance
CERTIFICATE OF LIABILITY INSURANCE
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23 Winter Street $¢far
I Peabody, MA 01960-5941 cbviIZAGNJ (MRTIPICATS NUHRER: REVISION Nl4r03BR:
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WEIR PR4VIBIORB.
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Page No. of Pages
- "'LEN GIBELY CONTRACTING CO., INC. PROPOSAL
23R Winter Street 24296
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
submiited `'�� ` ' y - with the Commonwealth of Massachusetts. Inquiries
To:_ �.l f/—S�rfM C ?dQ-f` about registration and status should be made to the .
Director, Home Improvement Contract Registration,
/Ili (. ),n One Ashburton Place,Room 1301,Boston, MA 02108
7 YJ—W (617) 727-8598. Owners who secure their own
�,I �^ construction related permits or .t with unregiGuaranttered
y
.)QULH if contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
PH/ONE ee DFTE // REOirsteaION NO.
1 �777��Z /Z/..J��Z - - MA.REG.100811
J 'INPMFMo. JOa L00ST.
&XIM (7
we hereby submit Bpestioefmna am estimates for work to be pedurmed end maladals to b0 used: �.
`�x_z.(_ra,7:�F-Zs - .-�-••(�eJw,p_I,rJ.00�-F aF�er.�,.;y«.,l�o_�.ar�e.,—
— IASpec cl:-- f4l1,-tt aLa'a./9/00f-0o �y9 airoJ-7,
_
—crr 1��Gr1�(F��A r .7 �� 10�37 , do .
Up-43zrr-
1uu"oak ` I-c°PPv- JUanf�.�-
dK�.. I'—G.Lt I-u,..�111�_�D.n.IvM �o ai✓.r1�oo . ` Z_�50_(_0 �
Construction related permits:*- f
"Alt Nola
_ -
-."aConlre III b0 w 1k or ortler IM10 melatlals belore IM1e 111iN tlay lollowing Ne signln9 0l NIs Agreement,unless spetllietl nereln wn, � Ir r II O gin the work on or
aooul (tlate).earrin8 tleley causeE by dreumstancee DByond Comract015 comrol,Itle woM will be Complele0 Dy The Owner hereby
ecknewl gas d pr Ihe1 Ne SChatlullnB tletes era appre%imelBaM IFa16ud10elaya list ere nal avdtleDle b,'the Wnl2VYw a1,aII WI De Cp sMeretl es violet, IIMh Agreement
mply
Tre C TY /(
TM1O COnVaClor xarrenls IDet In0 waA IufnbhBO nereuntl0l BDell OB tree Irom belects in meleflel end xorkmanBM1lp tar a pariM of " IOIIOwing COmpleliOn anE shall comply wit'
,he requireller com 1 11 Ag 1 any otDl loclutlin tleen up,Ne Lo 110c1araelleA,ret hlatlowle.00Nt Eamepe cause!W PayCe Oelr Icorhmcis re lose,aroceusaloobe mmreOgled 15opuVotlworr re lacod,
uthydamepo0 uCh dale[,In malarlelB Or workmanship.lTe brepoinBw rmnllea shell euMve B,b'hwl�'armetl p grBedupOn woA. p
eM sp peNorm�ln connection with lhoe
We Propose hereby to turn' ms serial and .bar-compete in accordance with a peciI cations,for the sum of:
dollars($ )
Payment to be made as follows: Z�ermlswn�t
kO.Gr iJ��im,^ *J(E =-)upon spnle CoLne /oe Ig dRepiB surest Ndd es(s�)upon complelonSsuss --' - Iron.is�l comp be made roplellonefwo PIroM FBderal lO N..
NotiCe: No agreement for home Improvement contracting work shall recalls a down Fort.,
an
payment(advance deposit)of more Nan one-mire of Me total contrast pN I
tole) mount of all deposits or payments witch the 0-howdor must make,in a ante, at a
w order and otherwise Obtain delivery of spade)order mateNels entl equipment,
chevaramO nt B eater m.:11i,woq.tlm.yeewide. callmllvoswredwrh d.ys.
Acceptance Of Proposal I have read both sides of this document and accept the places,specifications and conditions stated.I understand
that upon signing,this proposal becomes a binding contract.You are authorized to do the warx 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 NOT SIGN THIS CONTRACT IFTHERE ARE ANY BLANK SPACES.
sister— orearra La.
114 Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Gull�Ir❑011 II Snlh'I'1 I�ii 1' > P '
License: CS-094763
I Is
]IS
THOMAS R U&BINS r '4
19 Cedar HBIArive
Danvers MA-01923
J '
Iit " Expiration
Commissioner 05/14/2014
�%�r Y%nuuu on�oro�/�r�n.��iJ.;ur�2,r✓/.' -_ .
Office of Consumer Affairs& Business Regulation License or registration valid for individul use only
„ OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
l,egistration: 100811 Type: Office of Consumer Affairs and Business Regulation
s` #xpiration: 6/23/2014 Private Corporalia; 10 Park Plaza-Suite 5170
�:_, ��' Boston, MA 02116
LEN GIBELY CONTRACTING CO., INC.
Brian Dobbins .-
23 R WINTER ST.
PEABODY, MA 01960 Undersecretary Not valid w I iture `
1