7 GRAFTON ST - BUILDING INSPECTION •
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
�y Massachusetts State Building Code, 780 CMR, 7"edition Wilbraham
Building Dept
(� Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
V� One- or Two-Family Dwelling Ext 118
This Section For Official Use Only
1P
Building Permit Nu er: z Date Applied: •Z� `
vV Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
r`1 Ge.a FT
O,✓ Sr
L I 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ner'of Record:
LSIv,., b�2 -7 G2aro •. S�
Name(Print) Address for Service:
q'7 3 &- i,% 83�
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': 'r"rzi b E00 1-1 d-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:_
5. Mechanical (Fire $
Suppression) Total All Fees:$
6. Total Project Cost: $ (,J p p Check No._Check Amount: Cash Amount:
1 r Jr — ❑ Paid in Full ❑Outstanding Balance Due:
V1h1VQ 0b
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) O q V 1 6-� r_�=/
O%o%,�, b'CLC License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
I U a M A I AD ������ Type Description
Address _ U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Si nature M Mason Only
41Q 5 Z 3y RC Residential Roofing_Coverin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning A221iance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) / 0 t? g I
HIC Company Name or HIC Registrant Name Registration Number
I CZ
9 MArZ ��-
Address
g ��C A 91 R S 3 ga3y I Expiration Date
Signature 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 .......... ❑ 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.
Signature of Owner Date
SECTION 7b/: OWNER'—6R AUTHORIZED AGENT DECLARATION
1, 1 n-tL .�.o�—r 4.®' ,T`- ,as Owner or uthorized n creby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
-P,1),:ib -, ,,
Print N,
Signature of Owner o uthorize gen Date �-
Si ned under the ains and enalties o er 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 not 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 I IO.R6 and I IO.RS,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 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
If www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legiblv
Name (Business/organization/individual): -,,7 Q i i by L-Y Q..- 2 A
Address:
City/State/Zip:?p A �J4 c i 9 G O Phone#: q ` 5.3 t 3 �(
Are you an employer?Check the appropriate box: Type of project(required):
1.R I am a employer with tW. 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).*- have hired the sub-contractors
2.❑ I am a sc le proprietor di partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These scab-ccrtractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.t 9. E] Building addition
required-) 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
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
insurance required]t c. 152, §1(4),and we have no
employees. [No workers' ]3.❑ Other
comp.insurance required.]
'My applicant that checks box#1=at also 8a out the section below showing their workers'compensation policy information.
t Homeowners who subrrdt this affidavit indicating they are doing all work and then hire outside contractors must subrmt a new affidavit radiating su&
tContractors that check this box roust attached an additional sheet showing the name of the subcontractors and state whether or no thou entities have
employees. If the subcontractors have employees,they must prmide their worker's'comp.policy number. ' .
I am an employer that Is providing workers'compensation insurance for my employees. Below is the polity and job site
informadom n
Insurance Company Name: f t �_ tijj v i u g L 1 s . Cc.
Policy#or Self-ins.Lich#:. Ft Q i C Ci `1-9 r I Q C, O 53 Expiration Date: C 9 - U'3- C 9
Job Site Address: City/State/Zip: 1 .4 1 O
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 itnprsonment,as well as civil penalties it 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: \ � ,e._ Date:, 0 S'
Phone
Official use only. To not write in this area,to be completed by War 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#:
}
R I `: ,- ISSUE DATE 07/3//2008
PRODUCER -
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Edward F Sennott Insurance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
gency Inc DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
16 South Main Street
opsfield,MA 01983 COMPANIES AFFORDING COVERAGE
INSURED
Len Gibely Contracting Company Inc
8 Jenness Street COMPANY A A.IN. Mutual Insurance Co
Beverly, MA 01915 LETTER
THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
LTR DATE(MM/DWYY) DATE(MMIDD/YY) LIMITS
GENERAL LIABILITY GENERAL AGGREGATE T
=COMMERCIAL GENERAL LIABILITY PRODUCTS.COMPJOP AGG.
PERSONAL E ADV.INJURY
_=CLAIMS MADE=OCCUR
EACH OCCURRENCE t
=OWNER'S k CONTRACTOR'S PROT.
FIRE DAMAGE(Anyone ting
D MED EXPENSE(Anyooa parso)
AUTOMOBILE LIABILITY
COMBINED SINGLE
LIMIT
ANY ALTO
ALL OWNED AUTOS BODILY INJURY S
SCHEDULED AUTOS IRT Perron)
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY
GARAGE LIABILITY (PenaidaM)
PROPERTY DAMAGE
EXCESS LIABILITY EACH OCCURRENCE
UMBRELLA FORM AGGREGATE
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND STATUTORY LIMITS OTHER
EMPLOYERS LIABILITY X
E PROPRIETOR/ EL EACH ACCIDENT S 500,000
A ARNERStEXECUTIVE
FFICIERS ARE 6010979012008 08/03/2008 08/03/2009 EL DISEASE--POLICY LIMIT
INCL �EXCL $ 500,000
EL DISEASE.-EACH 500,000
EMPLOYEE
COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
ANGELA SIRONI HEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL ID WRITTEN NOTICE TO THE CERTIFICATE
OLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION
/O G IBE LY OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENT/IATIVES.
149 MAIN ST
PEABODY,MA 01960 AUTHORIZED REPRESENTAI IVE
i
CEN GiBELYCONTRACTING CO., INC. 20356 PROPOSAL
149 Main Street
PEABODY,MASSACHUSETTS 01960
All home Improvement contractors and aubeontractors 1
engaged in home Improvement contracting, unless
(9787 5313$234 vI
FAX(978)531-9304 specifChapter lly
exempt from rel lam,m by Prov registered of
submitted
?l 1 Chapter Com of the sansei lam,must be rinquiries
To: lJ0.n/1. 1 UInJ V// with the Commonwealth s of s should se m inquiries
the
about registration end status should be made to the
Director,Home Improvement Contract Registration,
-- t!-f-r^— f=^-- -•3333----3.33_3 One Ashburton Place,Room 1301,Boston,MA 02108
(617) 727.8598. Owners who secure their own
construction related permits or deal with unregfstorad
contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
vNoxe w*e aealsiBAnon xo.
(4761 7, 3'? 3 3 0 9^ MA.REG.100811
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aw y@er aXwaampkllon W arN lam.InUludln9 Clean uR in.
CMlteddr Rhell,et nls awn recreate,hatMAM remedy,repair,eMract,e(Neee wens (e W eemeWetl."orwo,pr replarad,
auCN tlem@ge or nada datxl in metexara orwoM1rrensnlp Tba bragdngwdfreMnessMY eumvearry t^sP@xbn pedwmetl M anrlecWn will)Ina agraadupon wnrk.
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
-� Payment to be metle Be fallew,
dollars
t
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kk Qk t,,,lA�-)upon compete,of_g�.2� sisal Aed.q/
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reamrsv
} N No agreement for hdnla ImprrngmoM canttectkg work shuN repave a tlavn
pe adrenin Moral d reare than ams trhrd of the Brad epnit0el price or 1*—
Mete Be onecos w parnmeMs where are coneorn.r mull melee,in advance • /� —
arder and arms obleln doth er,of soarer an.,maledals end eaulpmen\, .,/�
xore:rmv pmpew maymwlMarewnqusnral lra@WedwYMq my I
ADceptance roposai I have read both sides at this document and Spatial the prices,specifications and conditions stated.I understar
that upon signing,this proposal becomes a binding contract. You are auhorized to do the work as Specified. Payment will be made as outlined about
You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after
the date of this transaction.Cancellationmust be done in writing.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Seroww � pea IO�Oq sronnure _ � saw
IMPORTANT INFORMATION ON BACK 10
------------
� GT/+e �o-uvnow,rea/.G�S o�./�aaaaa{uaelfa i
-\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration:
on: 10010081111
lug Expiration: 6/23/2010 TrC 268971
Type: Private Corporation
LEN GIBELY CONTRACTING GO.,INC.
Brian Dobbins
149 Main Street
Peabody, MA 01960 Administrator
c T�te 'r0onb�nanuieaUA 0
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number,. CS 094763
Birthdate:105/14/1943
Expires; 05/14/2010 Tr.no: 94763
i
Restricted: 00
-
THOMAS R DOBBINS
19 CEDAR HILL DRIVE
DANVERS, MA 01923
?
Commissionw