31 BUFFUM ST - BPA-14-97 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
(� Massachusetts State Building Code, 730 CMR SdMor
Revised iLlar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Sector:For Official U Only.
Building Permit Numberr.
Building Official(Print Name) : Signature ,. - - Date
SECTION I:SITE INFORMATION
1.1 Property Address: S� L2 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(11)
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❑
SECTION 2:;'PROPERTY'O WNERSHIPI'
2.1 Ownert of Record:
Name(Print) City,State,ZIP -
_�S FF:�c. 92U45 N38 2
No.and Street - Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupie Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': �>
NF C—
amv
SECTION 4: ESTIMATED CONSTRUCTION COSTS--
Item Estimated Costs: Official Use 1.Only, ,
Labor and Nfaterials
I. Building ; 'I $� I. Building PermitFee S Indicate how fee is determined:
�. Electrical $ ❑ Standard; City/"Gown application Fee
❑Total Project Cost3,(Item.6)x multiplier' x
3. Plumbing ) 2, Other to
S
1. Mechanical (IIVAC) S List:
5. Mechanical (Fire $
Su ression) 'rota!All Fees:S
Check No. Check Amount: Cash Amount:
6 "Ibtal Project CosC S L{
3� l ❑ Paid in Full Cl Outstanding Balance Duo:
- I
sECTION 5: CONS'rRUCI'ION SERVICES
5.1 Construction Supervisor License(CSL) e�y--)
u> 01-I I• _ License Number E.cpiratiou Date
Name of CSL older
List CSL Type(see below)
2--3 Q- l° J u P &1 RRC
pRoofin
Description
No. and Street
ted I Rmmny s u el i1i,000 cu. tt.
�� (/ y✓( d 18c2 Famil Dwelling
City/Town, State, LIP
Cuid Sidii Burning Appliances
Insulation
rele hone d" Email address D Demolition
5.2 Registered Home Improvement/Contractor(FIIC) f `�
MC Registration Number Expiration Date
I IIC Cure y Name ur fll( Registrant Name
Sir Aq Email address
City/Town, State, ZIP F / t Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit mast 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
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 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 Authurind:\gent's Nantc(Liectromc 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 r gistered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under M.G.L. c. 142A. Other important information on tlae FIIC Program can be found at
ww.masc ov:oea Information on the Construction Supervisor License can be found at www.m:us. u�L
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _ —(including garage, finished basement/attics, decks or porch)
tiros; living mca(sq. tt.) _ Habitable room count
Nunberoftircplaccs,-.-- Number of bedrooms
Numbcrofbathroons Number ofhalbbaths
I"vpc of heating sys7un . _ - Number of decks/porches
I}peofcoolingsystcm_ Enclosed Opcn _
1. ""focal I't"wk:t Syuu'a F"ot.I"a oily be silb;tinittd t;)l 1,n1a1 Protect('u;t
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
k1ri www.mass.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):
l.M I am a employer with 12 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 sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ..
slip and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
require
d.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions .
3.❑ q ] officers have exercised their I I. Plumbing repairs or additions
I am a homeowner doing all work ❑ g P
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#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 anew affidavit indicating such.
tContractors 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 am an 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
6010979012012 08/03/2013
Policy#or Self-ins. Lic. #: I Expiration Date:
Job Site Address:, Rti FEy n, City/State/Zip: S_]l.0 -jL, PI
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
nature � S Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
luld UU.L L9 1U : lU : JJ LULL PTU101: ruLLllll'Au4jux 6 Lue VV/OJJI9JLETdgt: 1 VL 1
CERTIFICATE OF LIABILITY INSURANCE DATkUA 24Nf /201zY)
!• THIS CEATIFIGTL I9 I95UED A9 A DSATfER OF NFOWATION ONLY AND CONFERS No RIOHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AFPIRNRtTIVELY OR NEGATIVELY ANENT, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CEATITICATL OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE I3SUING INSUEER(S), AVTHORIELD REPRESENTATIVE OR PRODUCER, AND THE
CERTIFICATE HOLDER.
LNFORTANT: I£ the certificate holder ie an ADDITIONAL IHSVRED, the Polloy(Sesl aunt 110 endorsed. I£ SUBROGATION IS WAIVED, subject
to tnE to.. and ...ditiens of tits policy, oertsia Dolicies may re,mire an ondorseaaat. A stAteaent on this certificate doea not
confer zi0hts to the certificate holder in lieu of Such endoreeaent(s).
vxoovcrx c.mAei
Edward F Sennott Insurance 3%
PMnI[ rAI
Agency Inc EAIc.LNn. sal: I,rc. aa:
16 South Hain Street
Topsfield, MA 01983- cueras:X D[.
NvvJv.(el Aerm.ivc<wnu.e c M ,
wvmea a: A.I.H. Mutual Insurance Co 33758
Len Gibely Contracting Company Inc
23 Winter Street Rear
Peabody, MA 01960-5941
urvxLs e:
mvoua r:
COVERAGES CERTIFICATE NUMER: REVISION NITI••IBER:
THIS I$ TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEH ISSUED TO THE INVITED HANED ABOVE MR THE POLICY PERIOD INDICATED.
NOTVITHSTNIDING ANY AEDDIREIQ]1'I, TERlB OR CONDITION OF ANY CONTRACT OR OTHER DOCNmJT WITH RESPECT TO MICH THIS CERTIFICATE NAY BE ISSUE. OR NPY
PERTAIN, THE INSURANCE APFORDLD BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERNS, E CLDSIONS AND CONDITIONS OF SUCH POLICIES. UNITS SHOWN
MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY NUMEA POLICY EYP POLICY EXP LINIT.
TYPE OF INSURANCE pa•>n1— /m/rml
G40aRKL LIABILITY eACN.RURRNR •f
❑crnlvLl s-L... LceuTY .AHAoa TU axes. $
❑ OLi eneve I—
❑f. In.. nwll ❑IX..A BY.q.aP Ua IAnv o,u vvc.anl 6
❑ ' " Pw.XILL L A.v Twvwr $
❑_ ULxvwL u.neWre 6
(M1N' 1111:-0Ti I.IIT^APPI.RD M10.: '
[
AUTOMOBILE LIABILITY co.Va..11. L[NYT
lea..uaawtl f '
61.rtr JNJvar IP•:PntfJn) f
❑h_�h.l.il Al!)J
❑:'J T.IX.-.Il n:'tl.^. R..I LT [X.ULTIia JRiaentl S —
❑:1I PLG T1"'iP Ipe,R Untl f
❑:MI!R!':.i '.-.11 ❑ R:f.:R Ea.UCCURXLNCv 3
❑e'.<:[:: ::'L ❑ CV.Ct3 VIC .tMiRLWTi f
❑Ce[ll:T ielt 1 ----
MPKETS COMPENSATION ®
AND p@TAYEES LIABILITY -
illB 7'F.^PR:]i^N?APTV635i e.6. uex AOcm[vi $ 500,000
A C:X000TIVU LWIC37' aR3
6010979012012 08/03/2012 08/03/2013 vxLeAve -.vLTCY LHU1 $ 500,000
e.L. .veAle - LA nmwrer $ 500,000
CERTIFICATE HOLDER CANCELLATION
1
Evidence Of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
IXPSPATION DATE THEREOF, NOTICE WILL BE DELMAED IH ACCORDANCE WITH TINE
POLICY PROVISIONS.
urx.wvvva wouaemLr v['`�����
FEB-04-2013 09:4B Sennott Insurance 979 eel 2404 P.01
'ReWI%EN 9,78.867.4900 FAX 978.897.2404 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 DOES NOT AMEND,EXTEND OR
16 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. 0. Box 457
Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC8
ISuREO Len CT e y Contracting CO. , Inc. INSURERA Catlin Specialty Insurance Co
23R Winter Street INSURER.-, Safety Insurance Comany 39454
Peabody, MA 01960 INSURER C:
INSURERD: ._..._ ......-
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 LI
POLICY NUMBER GATE MMI DATE YWD WAYS
POLICYOENERALLMMUTY 3700301537 01/29/2013 01/29/2014 EACHOCCURRENCE 6 11000 00
W TO HEWED
X COMMERCIAL GENERAL LIABILITY PREMISES HeeevNnea a 100.0
CLAIMS MADE u OCCUR MEO EXP(AAY 0M WW)• S 5
A PERSONALSADVINJURY $ IJ ODD 00
GENERAL AGGREGATE s 2,000.00
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S 2 GOO,OO
POLICY JEGT LOC
AVTOMODILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO IEe eeUObNi
ALL OWNED AUTOS BODILY INJURY S
X SCHEDULED AUTOS IPelpMeon)
B X HIREDAUTOS BODILY INJURY
IPm eacAMnl) S
X NON-OWNED AUTOS .J.
PROPERTY DAMAGE B
(PP socidem)
CARAGELIAINUTY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGO S
EXCfiSSrumeamLALIAIDUTV EACH OCCURRENCE S
OCCUR 71 CLAIMS MADE AGGREGATE ,_ B
e _
DEDUCTIBLE S
RETENTION S S
YIORRERS COMPENSATION I TORYLIMITS I I ER
AND EMPLOTERS UAMLIYT --""'
ANY PROPRIETORIPARTNERIDECUTNEQ E.L EACH ACCIDENT S
RI OFFICEMEMBER UCLUDEOT
IMan mIn NH) EL.DISEASE-FA EMPLOYEE i
NNymdas beun0e,
SPECIAL PROVISIONS INYdr EL.DISEASE-POLICY LIMIT e
OTTER
OEBCNPRON OF OPERATIONS I LOCATIONS I VEHICLES I EACLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSLRNG INSURER WILL ENDEAVOR TO MAIL 10 GAYS WRITTEN
Evidence of Insurance NOTICE To THE CERTIFICATE HOLDER NAMED To THE LEFT,BUT FAILURE TO 00 80 SHAM
IMPOSE NO OBLIOATION OR UA0RJTY OF ANY RAND UPON THE INSURER,ITS AGENTS OR
REPRESENTATNES.
AUTHORIZED REPRESENTATIVE
Robert Sennott RP
ACORD 2612009101► ®1988.2009 ACORD CORPORATION. All rights reserved.
The ACORD name end logo are registered marks of ACORD
of If Pages
LEN GIBELY CONTRACTING CO.I INC. Page No.
, Sliieet PEABODY, MASSIACHUSETTS nter 01960 24827 PROPOSAL
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
A 2�7fg- Chapter 142A of the general laws,..at be registered
Submitted /f J��N J with the Commonwealth of Massachusetts.Inquiries
T¢ _ _���-�_." -_ _-. _. _. about registration antl status should be made to the
31 1 pp p �7 Director, Home Improvement Contract Registration,
__ /J V TTO One Ashburton Place, Room 1301,Boston, MA 02108
-- -' (617) 727-8598. Owners who secure their own
�91E/`-f/ /^�� D I 2 u construction related permits or deal with unregistered
contractors will be excluded from the Guaranty Fund
Provision of MIDI.c,142A.
O R Nfk1 a OniE mmISmAm Oqj NO./ o `7 y S Li 3 S z 6 - 5 -l3 MA.REG. 100811
Jou rvnmHNo. JOB LOCATION
e hereby submit Specifications and esumetes for work Ip be performed ana matenlas to to used n
SE :,P. tx�sa-.;, 12-401., ,Q�
,; n««
3 ,�/d/-rx -
Lvn/LS Amu v._Q Gli,rp....y 6.PSlS !"11-.�C. .8 t/ 2JcF pvofl..lr�e�3 lZert-
ot /LOor /s ld {F/t
Po/ GEsh {e =/-ate.ti� e5,-,-.1
�Zc.s� CJT�r,.,4✓l 1 ns"l-g!/ //.r'/t.X C o6 I/e:rl-,�
�kyli�ktl s�t�/_ C�whv.vfrcd� . 4,:4�,,,,gl
F'4W A-C w.i. ,Jo -6 _.
E(D_ w-vE /IJI.T- c� 'Iers-iie_ Lc sold
/`-r/tiT z�_"el /f�J 9Y CJpP r2
JZ;;erlr�./ 1�S�eu .,3a /XY _ /-4sc.a
v f� d G tlz b�Gr< y/
C-.dg -y Bay WI-.:/•1' lzcloled a� A- 7- /M AO—,1
Dart/Jos,-} TTvr,rl_ -7h�—� 7S, c0 ^l�,e /t MT/s._ /
2E//"'la e ., It l pa l� ' 9l7 6 eb �-bES Uh All 0 � �S yy /'I
wZ. 5 iE VIE �i / /J
O 1d�a a 1M1 I'hl In NaO ylately., n gq 11Ay p rah IovC 10 II - Aoro
no, J
�.l�i -a g d l y b by ..verb C Ih x it b IJ1 ��(j�4/�I�I J
ARRANrevold,V e h' n eo 90 pp poll the ntl tY-h vo oeoe by rho coot h Il his pl lO OY all Lf IN/',Ag ay
The
I a h A h
a b ore.....
r ansli p for a PerM 1 YpI I y Ep.dl eilh
b Islander mull Beh l �c/�jrn�/n��� ��yy�M1I/MA��.
jr
Vuror eels or this Agreement.ln the Or an detectworkmanshipor 1 I,or tlamo,. aussby the Conte.. h's suoc clBeclorsywepl�y9oso g (YSascovLraSvei e year allot eompleliin
on 01 eny jot.incluom0 clean up,the contractor shall,of his own evpen e,lorlhwilh remeby,raper,CIXrecl re r ca a to bo remebieb,Y a.diab,or replecab,
surchdeaunto4 uhbel¢Clmmelaie is orv:likearch,The totalingw aeries shall survive any insperlion pertmmotl in coonetlion wills theagrpedupen ad
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum oh )
Payment to be made a5,1 (Ml\ ,.R. dollars($ 6�B
..1s1._L_)updo slynblg emeracU
=ts�"'y )upon More on of �'D asset Aanm„ u,r a:igeu.,l rteple,uol
hi upon completion of
q S )snail to mood fieray.or upon
Comp101ion of woM order this[onlracL Feue'IIO No. -
Nature No afire ent for home improvement contracting work shall require a down %AlI- A
pnymem(aavenco Ceposm of more than one-third of the total commas pane Or me
Ioloi amount of ntl deposits or Paymema which me contractor must make in advance,
ro order anbror omorelse obtain dalroery of special order materials and equipment. —
me wilnarawe is use accept awlme o,,
Acceptance of Proposal I have read both sides of this document and Coe t I prices,specifications and conditions stated I understand
that upon signing,this proposal becomes a binding contract.You are authorized to o l e work as specified. Payment will be made as outlined above. d
You,the Buyer,may cancel this transaction at any time prior o midnight of the third business day after the
date of this transaction.Can ellation must be done in writing.
l DON SI NTHIS CONTRACT IFTHERE ARE ANY BLANK SPACES.
eg,mle,eIe 3 Bigealurn gale
IMPORTANT INFORMATION ON BACK
F
R tit Massachusetts -Department of Public Safety
Board of§uilding Regulations and Standards
License: CS-094763 $
w:t IN
THOMAS B.1m&BINS
19 Cedar 5 Rd Wriva
Danvers MA 01923
Expiration
Commissioner 05/14/2014
Office of Consumer Affairs& Business ficgulation License or registration valid for iudividul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
; �V egistration: 100811 Type: Office of Consumer Affairs and Business Regulation
expiration: 6/2 312 0 1 4 Private Corporatior 10 Park Plaza-Suite 5170
Boston,MA 02116
LEN GIBELY CONTRACTING CO., INC.
Brian Dobbins
23 R WINTER ST. 7w ,PEABODY, MA 01960 Undersecretarya ,IdNot valdture
r