3 LOCUST ST - BUILDING INSPECTION 10
The Commonwealth of Massachusetts CITY OF
� Board of Building Regulations and Standards f��}..S�C1�ENI
4(!� Massachusetts State Building Code, 780CMR101b AUG Z5 R s Sl for 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
On Building Permit Number' Dal Applied:
Building OlTicial(Print Name) Signature Date,
11 SECTION 1:SITE'INFORNIATION`
i.l Property Address: 1.2 Assessors Map& Parcel Numbers
Map Number Parcel Number
I.la Is this an accepted street?yes_ no
P
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Propose)Use Lot Arca(sy tt) Frontage(R)
i.S-Building Setbacks(R)
Front Yard Side Yams 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:
Zone: _ Outside Flood Zone? Municipal C3 On site disposal system ❑
Public O Private O Check if es❑
SECTION 2: PROPERTYOWNERSHW`
2.1 Ownerl of Record: C t A M A
fJ V N ^P J
�me(Print) City,Slate,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction Cl Existing Buildin wner- )coup eepairs( Itemtion(s) ❑ Addition ❑
Demolition ❑ AccessoryBldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': 't' r
L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OfDcial Use Only
Item Labor and M1laterials)
1. Building S Cjstj oa� 1. Building Permit Fee:$ Indicate how fee is determine):
❑Standard CitylTown Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3.Plumbing S P ether Fees: .$
4.Mcchmtical (I-IVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Su ressiun)
Check No. 110 Check Amount: Cash Amount:
6.Totai Project Cost: S SC> — O/Paid in Full ❑Outstanding Balemce Due:
1,N) As n_ T"c' .
mRiLt� it 2
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) JF-1
r
License Number Expiration Date
-
Nmne of CSL Holder
List CSL'rype(see below)
w Type. __ - . Description .
No. ;md Street
U Unrestricted Duildin a to 35,000 cu. ft.
V-4 Le3c:;,Y� d (ti I CI �J R Restricted 1&2F:uni1 Dwellin
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
Sf Solid Fuel Bruning Appliances
Insulation-
Telephone
nsulationTele hong Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 2 Z>6 >Z, .l e 6� Z l�
G,-b-e[—V K'z r A-7 HIC Registration Number Expiration Date
f IIC Company Nnme or IIIC Regislmnt Name
T'r,e S v
No tree[ Email address
— _Cityffown,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,[ 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 Isbuance of the building permit.
Signed Affidavit Attached? Yes ......... No...........O
SECTION 7at OWNER AUTHORIZATION,TOBE.COMPLETED.WHEM "
OWNER'S AGENT OR CONTRA CTORAPPI .IES FOR BUILDING PERMIT`
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(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.
Co c.r�f ' ` ) gz (6
Print Owner's u u irize Nnme(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
(tot registered in the Home Improvement Contractor(HIC) Program);will LIgul have access to the arbitration
program or guaranty fund under NLG.L.c. 142A.Other important information on the HIC Program can be found at
seww.mass.eov;'oar Information an the Construction Supervisor License can be round at www.mas� .
2. When substantial work is planned,provide the information below•.
'rolal floor area(sq. ft.) .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. RJ 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
1. "Total Project Square Footage"may be substituted for"Total Project Coil"
SLS
LEN GIBELY CONTRACTING CO., INC. Page No. oiPages
23R Winter Street 27286 PROPOSAL
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
Submitted I n with the Commonwealth of Massachusetts. Inquiries
To: . _.Q U I_iI - T �.. -_. - _ ... about registration and status should be made to the
• _-7C+, One Ashburton Place, Room 1301, Boston, MA 02108 Director, Home Improvement Contract Registration,
.-��l _ 4�_Qc
_.!. j�S'I",
- ---- --'-- -- - -- (617) 727.8598. Owners who secure their own
,/L1/( - O n construction related permits or deal with unregistered
Icy') I r I'T -1 contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
P/yONE ppl QQppGATE REGISTRATION NO.
�7(lV /5_/(
S � S MA.REG. 100811
Ma Ate' JOB LOCAT ON
S-4M c
W.,I:?by submit citations and estmatirs,for work to be perforni of in smile w be used
F01/ -
3 rs�_
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- -a�--alb P r s.-_ A �1�_��s s �A—
feta , hh
Gas Z ,7o»
fl�lr✓x t�4_yS e\ssuue 30X 5(1 " 40-
iso, YPS
WORK SCHEDULE � --_—__
Convect tM1 work or order the materials before the third day lollawmg rite signing of this Agreement,unless specbietl M1ereln wrli 1l r ill b in the work on or
about— idetpl.Barring delay caused by circumstances beyond Contractor's control,the work will be completed by ill... he Owner hereby
mcknowl gas ofd agrees that the schetluling dates are appmaimater and that such delays that are not avoidable by IM1e contractor sit a on itlered as molalions of IM1is Agreement.
Hidden rotor wMitpns not seenat Oma otworvle llatare required tow repaired In oNermcomplamthl Wntmet,MIIWwmpletetlat$ per man hour(MAN HOUR).
WARRANTY
Tho Contractor warrents that the work furnished hereunder shell be Iraq traintlelecis in material and workmanship for a period of Ilowing comDlelion end shall comply win
the requirement.ml this Agreement.In the event any defect In workmanship or materials,or damage Caused by the Coniracto,his subcontractors.employees or means,Is discovered within
one year after completion of any job.Including clean up,the Contractor shall,at his own expense,Iorthwifh remedy,raper,correct,repl...........to be remodmd,spared,m,eplace4
sucM1 dame,.or such defect In materials or workmanshlp.The loregoing wromakes shall survive any inspection performed In connectlon with the agreed-upon work.
We Propose hereby to furnish material and c replete accordance with above specifications,for the sum of:
Af>'(Y / dollars($ GO ),
Payment to be made as follows: remove all lob trash.
All guarantees on all products from manulacturer.
%($ Upon signing Contract; Add permit cost if needed we pull permit.
upon completion of Notice: No agreement for home improvement contracting work shall require a
down payment(advance deposit)of more than one-third of the total Contract
($ )upon mmpletion of price or the total amount of all deposits or payments which the contractor must
make,in advance.to order and/or otherwise obtain delivery of special order
% ($ )shall w made forewim upon m `ipment,
completion of work under this contract.
Nate:This proposal may be withdrawn by u;it net accepted within dayspH sal signawre
Acceptance of Proposal I have read both sides of this document 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 Gone in writing.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signawm _1C!�?25�7+z Z Dawsgnmum oaf.
i IMPORTANT INFORMATION ON BACK