8 BARNES AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
'1 Board of Building Regulations and Standards CITY
111 ` Massachusetts State Building Code, 780 CMR, Vh edition FRevised
F.SALEM
✓unuuryBuilding Permit Application To Construct,Repair, Renovatetar Deisha
One-or Two-Form! welling
This Section r O tial Use Only
Building Permit Number: Dat Applied:
Signature: r 4 /
Building Commissioner/Inspector u uildin Date
SECTION 1: T INFORMATION
i.l P pe Address: 1.2 Assessors Map& Parcel Numbers
L'7QfG i.v c fs-p'
l.la is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: /.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) 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?
Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Oaert of Record-
�t:a t -
Name(Print) Address for Scrvice:
tore ;k> Y-i ���
Si
Lina Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check aU that apply)
New Construction❑ 1 Existing Buildingpj.Owner-Occupie epairs(s) O 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Worlt': r,i,.:^ ! 2»eg 1"
SECTION 4: ESTIMATED CONSTRUCTION COSTS
tftildin$
ps
Official Use Only
s y
1. Building Permit Fee:S Indicate how fee is determined:l ❑Standard City/fown Application Fee
❑Total Project Cost'(Item 6)x multiplier xg 2. Other Fees: Sical (HVAList:cal (Firen Total All Fees:5
Check No._Check Amount: Cash Amount:
6.Total Project Cost: 5 9 0 c'v ❑paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) -� S- 114 I
,j,p10 t Ai3 Li—cense umher — Expiration Date
Name ol'C'SL•Ilolder
/1 List CSL Type(see below)
1 t-F 4 M t.t� T Pn d fvn
.4JJrcss
rvpe Description
U tlnnstricted(up to 75,000 Cu.Ft.
R Restricted I&2 Family Dwelling
Signature M Masonry Only
s a 3 RC Residential Rooting Covering
relcphone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regbtered Home Improremeot Contractor(HIC) ) g 1
L a � r lin op f CV-Cr F— [
111C Company Name or fIIC Registrant Name Registration Number
1 �► �Yn'iar.� �� a booms
4(�-Z3- 12—
AJJre
Expiration
p
imtion Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(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..........O No...........O
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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, as Owner c AuthorizedAgen hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name 12 - / -
Signalurc of Owner o w nriz fluent Dale
(Signed under the pains and penalties of 'u
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 of have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 half7b2ths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
J. "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
www.mass gov/dia
Workers'Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers
Auolicant Information / I Please Print Legibly
Name(BusineWOrganization/Individual): L ,p,:e/ G L 6 P L`l`' y v�m 4 G x k�G,: Cie
Address: ( %.-1 9 M A i ; j -S-r
City/State/Zip:_o,A b ci,d Y MA Q V ct Jip Phone#: 9
Are you an employer?Check the appropriate boa: Type of project(required):
1.❑ I am a employer with CJ_ 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time)-* have hired the sub-contractors
2.❑ I am a sole proprietor or partner listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 9. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp,insurance 5. ❑ Weare a corporation and its 10.
roquired.] officers have exercised their ❑Electrical repairs or additions
3.❑I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c.152,§I(4),and we have no 12.❑Roof repairs
insurance required.}t employees.(No workers' 13,C]Other
comp.insurance required.)
*Any applicant that checks box#1 must also fin out the Mlion below showing their wmkcn'cmapcualme policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contnctms must submit a new affidavit indicating such.
'Connector,that check this box most attached an additional sheet showing the name of the subcontractors end their workets'comp.policy information.
I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site
informadon.
Insurance Company Name: f't L 'U T l: q 1_ ,M;7
Pohcy#or Self-ins.Liic.#: 6y a 1 a r' \ l7 Expiration DazOe: tg` C7 3-- i 1
Job Site Address: R E A r7,so 7 �-a' _City/State/Zip: . �„p_,err ✓I f,�
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 cerdfy under the pains
sand penalties ofperjury that the information provided above it true and correct.
atn Sigure:_ i. .CC__ ti ea�— `.Date:
Phone#: 3
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permlt/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
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ACORD. CERTIFICATE OF LIABILITY INSURANCE
o1/za/2010
PRODUCER 978.837.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MA 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
P. 0. Box 457 ALTER THE COVERAGE AFFORDED BY THE POLIgFS BELOW.
Topsfiel d, NA 01993 INSURERS AFFORDING COVERAGE NAIL 8
INa1nR Len Gibely Contracting Co., Inc. INSURER,: Catlin Specialty Insurance Co
149 Main Street INSVRERW Merchants Insurance Co.
Peabody, MA 01960 INSum
INSURER a
WSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW NAVE 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,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
L TYPEOFISUBIINCE POLICY NUMBER
LIMITS
aERERALUARKM 3700300250 01/29/2010 01/29/2011 EACH OCCURRENCE f 1.000.001
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GENtAOGREGATCLIwTAPPLUMPec PRODUCTS-COMROPAGO f 2000
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Evidence of Insurance DATE THEREOF,THE WWW MUR INIAL,MOSWORTO MAI. 10 DAYsamar /
NOTICE TO THE CERTIFICATE HOLDER NAILED TO THE LEFT,MIT FAILURE TO DOW SHALL
WOSBNOOBU r4NORUAMMOPAWKWUPW)THEMWV^ITBAaMMOR
REPRESENTATIVES,
. • AUTHORIZED RBPREBSNTATTVE
Robert Sennott
ACORD 28{2049101) FAX: 610.341.7691 0 i988-2009 ACORD CORPORATION. An Flghm nBBrved.
The ACORD name and logo are reglabfred ma*s of ACORD
Page No._�_91 r Pages
.� LEN GIBELY CONTRACTING CO„ INC. _
149 Main Street � j4 j;3 PROPOSAL
PEABODY,MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
A (978)531-8234 engaged In home Improvement contracting, unless
FAX{478) 1-82 304 specifically exempt from registration by Provisions of
Chapter 142A of the general laws,must be registered
Submitteedd J_two°\ Or���CL with the Commonwealth of Meaeechaeaus. Inquiries
G-V C1 r about registration and status should be made to the
�y Q.r hP f A tie Director,Homo improvement Contract Registration,
(✓ One Ashburton Place, Room 1301, Boston, MA 02108
(617) 727-8598. Owners who secure their own
�Q M � 61
��CI construction related permits or deal with unregistered !I
1..tN1 contractors will be excluded from the Guaranty Fund
- 11 Provision of MGL c.142A.
PHONE
JOB NAM NO. -ZZR .1isho arawN
1 sod wcnnory p MA.REG.,100811
OAiE
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We nOIdY/subm6 Sp¢ciflCe40na and aC'Yma1a5IMwell 1060 pellDlmeq a0tl malella5 to be 4Sae.
� J Ga 0lt/ /
e��r. �, a 1-�-• dam.,- �� .�u ���+�1. ry a; l
dt. 6?of "k--, ,` C f
yIfo,61<
}construction reiategoar M1-
WOJK' E/n`tial 1'�
c0nuat',t��jwjll q 1. x'wk m OYfbi Ih0 mateta4 Wb,01M"am Oey IUIWvma me algll"g d 1N6 A4mdmBtll.UnI0a5 6pacele0 6¢van n w01 pBgln IM cork On 0,
aCam..) & ,dre.earlm8 tlahY c¢OSGd b9 emcumslanws beWnd com,6tlars wnu01.ma wod wIP 6e comPloted W sale).IDs Owner Hamby
pu,hva,`Udaaaa, Ngl he he scheduling dales are national and the pucn delays that are r a,aadable W mar C0n0aM0/anall Hoe c0 OgOtl W00p5011hI6 A8r00,pBnt.
'JARANTY
iTha,C."alOrwanA".mar'me wamWash.MmundOYareas hexoelmmdaleue"—",at qW wwkmensNo kpape'we at awkwap Caresser mb sraa(areas arm
,he tegVl,m,anoand.6 AgN0meI.M1I1108vpo8ny a,MOlG summer nlpermatBr-h w,.Ta. cmom areep ra,shClM.la.mrcbm.or
Is bpt5whared, eased
,U yOBY pl,er OpTPleliOn 01 Brly I.
II ra;1 l olPoan up,IM10 OOnbP010r shell,pl his Uwll e•pOnStl,IUrinWilll remedy,rOpal�.0orracl,f¢pIaOB,or<ax6010 bB IVm001¢q,assail10PIBOBa
bu¢n damage O�swh deYecl In malaldls Dr WOYkmanshlp.The IoregOing wananles sh'WI survive mry InsPO¢IiOn padoll+letl'm ednneclion wile m¢agreed-uWO Werk.
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
dollars{$._ )-
Faymcnt 40 6e matle as Idbws'
_ N 3 �,{�.�,�,t/�� )Iwon signory corpracl; �
�j��. ,. �� /j Namom m.0 pro:o%,w m
is l Upon emnall or.�"_
l5 1 upon wmplBfoo M
/ cIvr
I Ir 1 shall be mase Iwemin
(� cmpwhanawureundennlscommrr Phannlele / Gne,olto No.
Ni- N9 qe/memen119r homd irrtpmaapWOl cBNrd¢ting woYk stall ropul[eaaowa no Be—, /J
payment(advenw deposit)at have than one-rtird of the mmi damosel Fnce q,
IT
IOlelamount Ol all deposit or memenls whish the eonastapt must mahC.in atlVtln<e, gyr,y,UrO
10 Orpar and/Or otherwise Obtain di of spectral order materials and equipment.
W 1LYheV11 9ledif Nae'.rats"a"m stay to wlma"'by us 11 a11m`a10"�—.—Bay+.
Acceptance of Proposal I have read both sides of this document and accept the prices,specifications and conditions slated.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 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
dealg
2 r_o start rc_.. OUIe
IMPORTANT INFORMATION ON HACK /►
Massachusetts- Department of Public"Safcq
Board of Building: Regulations and Standards
Construction Supervisor License
License: CS 94783
Restricted to: Oq,
THOMAS R DOBBINS
19 CEDAR HILL DRIVE °
DANVERS, MA 01923
Expiration: 51142012
f'unmdssiuner Tr#: 23757
1 .
/fe �aomtino�weo!!/f o�✓�amac/u�elQ „
Office of Consumer Affairs&Bmines Regulation
HOME IMPROVEMENT CONTRACTOR
Reglstration olgo811 Type:
Expiration 812312012 Private Corporatioi
lug .r--,
LEN GIBELY CONT�iA 7,1iJ�a Cl] ;SNC.
4
Brian Dobbins
149 Main Street
Peabody, MA 01960
Undersecretary
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