281 ESSEX ST - BUILDING INSPECTION (8) The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CM[R)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
c ------oro Of ficiid Us
BuAdi e,Only)his Section
----- 7 '
n'g A 'rmit Number: 04tc'�Zp ii
e pli6l", ,_' ', T T 0 h*' ress ii,not available)
SECTION 1:LOCATION and Lot#for locations for which street dill
,(�ieaseindicateffl ck# a
S '4 0 k 9_l —%
No.and Street City/Town Zip Code Name of Building(if applicable)
�'7SECTION 2!PROPOSED.WORK
Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below
Existing Building2a-1 Repai�j Alteration 11 1 Addition 0 1 Demolition 0 (Please fill out and submit Appendix 1)
Change of Use 0 1 Change of Occupancy 0 1 Other 13 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No IJ
Brief Description of Proposed Work: �?_g
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING REN 0 ADDITION;OR,
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) [3
Existing Use Group(s): Proposed Use Group(s):
,
SECTION 4:BUILDING HEIGHT'AND AREA'. .
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 54 USE GROUP(Check as`applicable) . ,
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 1:1 B: Business 0 E: Educational 0
F: Factory F-1 11 F2 0 1 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
1: Institutional 1-10 1-2 0 1-3 0 1-4 0 M: Mercantile 0 R:: Residential R-10 R-20 R-30 R-4 0
S: Storage S-1 0 S-213 Special Use 0 and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE,(Check As applicable)
IA C3 IB E3 IIB 0 IIIA 13 IIIB E3 IV 0
-
SECTION 7:SITE INFORMATION-(refer111.0 for'detai*I s onea ch item)",I,tj o 780 CM
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone 13 Indicate municipal 0 A trench will not be Licensed Disposal Site 0
Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: NU,Historic Commission Review PrLvoss:
Not Applicable Structure within airport approach area? Is their review completed?
or Consent to Build Yes 0 or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:— Occupant Load per Floor:
Does the building contain an Sprinkler System?:—Special Stipulations:
0 61140 A 001 4%elkt
,SECTIONS;PROPERTYOWNERAUTHORIZATION
Name and Address of Property Owner �+
NAa-vFrz�RIJZcc 91 �s3a��' J /ILo OV4lZ3
Name(Print) No.and Street U"r'i City/Town Zip
Property Owner Contact Information:
Z D`L
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10 CONSTRUCTION CONTROL(Please fill-out Appendrx2) + ,
,
If buildin is less than 35,000 cu,ft.of enclosed s`ace and/or not under;Construction Control then check here L7`and ski Section lO.'1)--
10.1 Registered Professional Res`onsible for Construction Control
is
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Con 6act6
/ i. b Lr St
bnFJY
Company Name
_F 12661"- CS
Name of Person Responsible for Construction c--� License No. and Type if Applicable
'�;l 2. W a bow P'IA O t-i 6n
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
��••. SECTION 11iiVORKERS'CO\tl°ENSATION INSURANCE APLIDAVIT M:G.L.c.1527 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
`SECTION 12r CONSTRUCTION'.COSTS AND PERMIT FEE - ` '
a
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ -7 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipal' )
5.Mechanical Other $ Enclose check payable to C
6.Total Cost $ 3 1 —7,j (contact municipality)and write check number here
`• SECTION 13:SIGNATURE OF B"� U„ILDING PERMIT • '
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 arcurqte to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to'fill out this.section upon application approval
s .. -... '^ :. . ._, •, '.. .,. - - , a .'..Date, :;.
The Commonwealth of Massachusetts
a__ Department oflndustrial Accidents
[ Office oflnvestigations `
=! 600 Washington Street t
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Inforinatiou Please Print I e ibl '
Name (13usiness/Organization/Individuaq: Len Gibely .Contracting. Company
Adrlless: 23R Winter street
Peabody, MA 01960 978 '531 -8234
C ity/State/Zip: Phone.#:
At you au employer? Check the appropriate box: Type of project(required)
1.® I am a employer with 12 4• ❑ I am a general contractor and I
employees (fill and/or part-time).
have hired the sub-contractors 6. ❑ New construction
L] 1 am a sole proprietor or partner- listed on the attached sheet. 7. El
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. ❑. We are a corporation and its 10.0 Electrical repairs of additons
3.❑ 1 am a hmncownei'doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
j insurance required.] t c. 152, §1(4), and we have no
employees._[No workers' 13.0 Other ____
I. comp. insurance required.] I
'.Any applicant that checks box At must also fill out the section below showing their workers'compensation policy information.
' !-iomzossasers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employces..If the subcontractors have employees,they must provide their workers'comp.policy numtier.'
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
A. I .M. Mutual Insurance Company
Insurance Company Name: p Y
6010979012012 08/03/2013
Polioy t,' or Self-ins. Lic. tt: - _ Expiration Date:
Joh Site Address:a_8AAF__q4_e_,a_ ( it,rT�
Attach a copy of lire 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
tine 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
luvestieations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties ofper/my that the information provided above is true and correct.
Date
11hone 1i__"1
Offrc•ial ase 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/Towm Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: - Phone#:
rtb-tJ4-�b13 09:48 Sennott Insurance 978 887 2404 P.01
A-e v.v• AAOIM �• _ _ __ _ —_ _ _ � --- -- --- - — -
A' V(./LIT/LU 1]
KODUCER •978.887.4900 FAX 978.887.2404 THIS CERTIFICATE 15 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 4S7
Topsfield, MA 01993 _: INSURERS AFFORDING COVERAGE NAICIf _
ISu—RE Len GT b e )F Contracting Co. , Inc. INSVRERA Catlin Specialty Insurance CO
23A Winter Street INSURERS: Safety Insurance Conpany^ 39454
Peabody, MA 01960 INSURERC: _ _
INSURER 0'.
WSURER E.
:OVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWrIHSTANDING
ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WnH 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.
iTP NRRD TYPE OF INSURANCE POLICY NUMBER ATf I E ATE( EXPIRAYYY1 _ LIMITS
GATE YMIDWYYYY pgTE MILVpl"TIO
GENERAL LIABILITY 3700301537 01/29/2013 01/29/2014 EACH OCCURRENCE b 1,000 00
X COMMERCIAL GENERALLIABILPV PREMISES FA eecurrenee S 100,00
CLAIMS MADE u OCCUR MED UP(My orre Pereon)' $ " $1000
A I PERSONAL a ADV MMRY $ 1 000 00
GENERAL AGGREGATE 3 21000,000
GEN'L—AGGREGATE LI MITAPPLIE$PER: PRODUCTS COMNOPAGO 3 2,000,0O
POLICY JEC LOC
AUTOMOBILE UADIUW COMBINED SINGLE LIMIT
ANY AUTO (Ea a[elEenl)
—
t
ALL OWNED AUTOS BODILY RV
X SCHEDULED AUTOS (per PertHYj
��DI 3 __
X HIREOAU1`OS BODILY INJURY
X NON-OWNED AUTOS (Per ecaStel3) S
PROPERTY DAMAGE 3 ---- `
(Per sw'darn)
� GARAGE LIABILITY AUTO ONLY.EAACCIDENT b
I "
DANY AUTO OTHER THAN EA ACC $ _
AUTO ONLY: AUG 3
EXCESS I UMBRELLAUABILITY EACH OCCURRENCE S
L OCCUR CLAIMS MADE AGGREGATE _ $ ---_
IS
DEDUCTIBLE
RETENTION S
WORRERS COMPENSATION I
TORYLIAIITB ER
AND EMPLOYERS'LIABILT' Q ANY PROPMETCRIPARYNERIEXECUTIVE - E.L.EACH ACCIDENT 3
CFgCERIMEMBNR EXCLUDED?
wMnrweorY In NH) EL.DISEASE-EA EMPLOYEE S
pyo IAL dearibe under
$P ECPROVISIONS 116dY E L DISEASE.POLICY LIMIT b
OTHER
,EES RIPTION OF OPERATH)NS I OCATION?!VEMX:Lti9l EXCWBIONSADDEDGY ENDORSEMENTI SPECIAL PROVISIONS
^ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES OR CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL 10 DAYS WRITTFA
Evidence OP Insurance NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO W SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORRED REPRESENTATIVE y�—
Robert Sennott RP
&CORD 25(2009/01) 01966.2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
JUL-24-2012 10:42 Sennott Insurance 978 887 2404 P.01i01
y
CERTIFICATE OF LIABILITY INSURANCE °"'E0"n4/2012Y'
ialb enTIrICATN IR Isavan AS A m rNR Or nIT01Sg1'ION DNLT AM CONTNRS NO RIDIIYR UPON TNN CNRTIr1CATN NOLDIR, TN19 CTRTIPLGTR
DOE$ ROT ATTIAMATSVNLT OR RNINITIVNLT Am=, EYTSM OR ALTER TNN LVVNAAST ATTORpiv Or TNN POLICIES OUM. TNIe aIRTITIL'ATR OP
I.NSVRANCr DOe9 NEI CONSTITVTN A CORTRACT BNTNNNH 7" I6SVINe INSOMR(S), APTNOMZW RHPRESEPTATM OR PROIAl"K, AM rml
CRR2T rwl NOLDER.
iNPORTANT: I£ TAO o .tLfi.&" holder ie An ADDITIONAL INSURiO, the polloyliGO Due! I,e eneereed. IP eVBflORATION IN WATVND, eDbl.ot
to thn term, AXIS aonditi. of the policy, eerkain pO1LOLes Day rogoina An endeeeoPeok. A ntatemeht on thi• oertl£LCeto doe. not
Deafer rtghte to the oertlfLPAtn holder in 1Leo of .uah Dodoreesent(e)
• rcvF [�
Edward r Sennott Insurance FAr
Agency Inc .u11Yin d•r: W.. w,r.
16 South Main Street
Topsfield, MA 01983- eovevA m1.
IYYOP2Y1Y1 A.rYaic wv,NY,[ ue 1
1°fln'0 LmuA.: A.I.H. NAltuai ineuranc¢ Co 33756
Len Oibely Contracting Company Inc Y...
23 Punter Street Rear r:—�
Peabody, MA 01960-5941 flog",P,
urvem I
coVRRACrBB cHRTIMCATE NUMBER: REVISION NU R;
SN:", IS To MMATIPT nLS TM POLICM OF ®AL9ANQ, LIST=RIPLOV HAW :a$DND TO THC INSURED NAVID Mon I=TIVE Po1ICT PERIOD, IMIMTM.
"DIVIMSTA=INa ART RrwlN . TOM OR, CONDITION or AM CONTRACT OR OT wcteaeT WITH REBEECT TO Tlnrrn "IS mUIrICATE NAY B6 IAAIIID oR W
PIMPTAIN. TNC INSU11,49GE u ORD=SY TM POLSIES DNMCRRVO HEREIN I9 eVAJLGT TO ALL THE TEI039, Z=%,51006 AND CONDITIONS or PVCI MIMICS. LWT6 3101+N
ffLY IUVL DroI PtOVCYE RV PAIR C ,
PoLrC INIDrII P°LICT hrr POLICY M LMTTO
TYPR or TNSUwwCr �K/„•n wwnsm
OpiLINL LTARILCI'Y IAw n_oa•[Yv
�rv,eutu owuw. LAbl UTY °u0ai re
FPP'I,n
��cui W,t ❑OCCM MO YYY a•'V°^�Vs•anl f
Q .WCY4 4
[Laww[ unYt AFFLI,I a,. oeRvi.mev 1
�:nn.F:♦ �1'Y ♦�W" ,.ODVGr'e -CO!/PF .m 3
A 75C ILA LIA9I1 TT CpilYF • ,.mr I
❑— run, 10 MYaW
nar
rrPly IvaT IPr nranl r
❑.°:.aYsn nlrcoa
�3ClannsP auto, soonr mmlvr Ax,wna ,
Y OYr¢ v,n,P, 1
OInPm 4V1C IYrt•YaYYI
' ❑MIN-[YM.n n.:n1. ,
1
�vXPreLu 'W U,mm nal aamudKL 1
� Qvnz.r[ Dine Q e AammlT, , _I
PSOA;n91I I j
❑F9T[1lTFON [ ¢
NONiJt➢ EN$ATION
[.F
pAD n1PL0Y6S3 LIAR 6ITY
TN9 FAOPRIETOR/Y/,R'fN$RP/ 911 ..['il 1 100:ODD
EFEMTIVI UFNCSPS ARR
A
❑ inCl ® excl wrPLly unr , SOD,ODO
6010979012012 00/03/2012 08/03/2013 1 J.—j
oI...• n wterm 1 500,000
CRRTIEICATH NOLDSR CANCLa[LATION
Evidence of Insurance '"°"'a °r °f'E�°YL pucRDl® OL:`� Dr wIClAT amRc TNr
oenwASY oaTz TIEA=e. NOTlOr MILL Sc DD,LIVAONa IN ucAPnnu¢ TnTx TIM
POLxtY PNC1'SSIaIE.
TOTAL P.01
• l I `i}} d f ) n" c �. i..1 a { I 'ofnJ}et� r PeA�N4 Y_ of -`60� Pages
LEN GIBELY CON �TRACTING CO., INC _ ± �+ ln�'a
4: ' 23R Wi'11,Street, z- ° +- '
t PEABODY MASSACHUSETTS01960 - " 24425 '+, PRO-POSAL
i
i "� ° ± 1'F •'? '� + , n AII'h'om0 Improvement contractors and.aupdontractors
v, ""'; (978)S37 8234r Fe (978)531-93e4 .4;. engaged In;homellmprovament contracting, unless
pe
4 �`�' sysvvi.lengibelycontfecting com'� 4>•r scaically exempt from registration by Provisions of
"` ChapteAp142A.of the general laws,mustl.tie registered -
9ubmiarTed V '/2�._:1�f _ %/ with.the Commonwealth of Massachusetts..Inquiries
To _ ]- /d�!' _ r--r, _ ' about ragletratlon'anC status shouldbe made to the
lit
""`•� "�/"-t-- LL Director, m Noe Improvement Contract.Registration,
UW 1 r 2o�, One Ashburton ce;Pla Room 1301, Boston,MA 02108 '
rt•r _n Im p, (6/A) 7V,-859Ba:Ownefe-Who.secure.their own
�a lB t h 'rO/ /7 g conetruc p tlon related armitaor deal with unregistered
contractors raft l e excluded from the.Guaranty.Fund "
gqy i + ! K s Provision of MGL'o.let - r
aheaEpn '1 � _ OgTE"+'. q4 PE019TPwTOX NO
�tl/ T��oZl.rh /g6 /1 ` {J s'+ i +. .h1A REG 100811 yef.
XuaEmn..q f y +,us;". y.'tt roe toceinory Wahe bJ b Icpedlire0 Iq Bmet ato warkbba perbrmed arltl mennels bud tl:� +�{��xy y 1) h't3,,;t��- x
W) �(]w 4 �,.:
do
F
WiKcQow10,
:</ '
y:�?�d w� a-
-k- - --- - --
r _
Cti6�6.y_ Sri-,, G'/ass -_r6i� 'Sc�e�� / ) l¢ ^
s�lslaS } oR� sT.__G�eciJ _ Co/oL /ems
1 j
a.
r
C nslmctlon red permlis x
n lL �'� /gall
-e us:.
s _-� e In 1 n e ro In mlro aav I'll 'q In B e m this it 1 wa.."no.n mre �apI��','b a m k
b 1 )o at..
aby m hd eC 1 I111 k attlby�p�/'yB�'''I]TB O I "y
vesmi l ep M B N IX bOE IlnB tlal r0 pp 1 tlBul nU Hp'her WB01 . 1 10 n Mb C e mp UT Ilhl (,g
WhflMNTY ''beat/ 1 1iM1IIh kI was
Orin wobe Ireh ell tII tl M1mytheb cbar ommand,
bll IB p1 MiII d -h
IM1oreq emenb of mb Pgreomont In Vw erenl any tleteel In wvrkmanaNpo me nls,or dameBeceuaatl by Ilia Can12c10,M1lc so et rs.employvvs gnls,aesmvoroe vilni
na yOvl eXal rome ii=of any Ivb,translational up,.me aOnIRCIw.511011,al his^con amorse,br within roped,;Cprrael,leplata:-a cause a nv nr atrad.rapaime,0r replaced. .
such tlamape of arch maps In met.rear u,Mmeriship.The brepolnB Werra^Ilea shall svrviv any lnapeclloa pmamed( ma. :1 wIlh"Is.11. upo^work j
We Propose hereby tofurmsh material and labor'-complete in accordance with above sponfications,for the sum of
Payment to be made car follows t dollars($ / I OZ )
4 ya i
%IE ) po Onl Bc Imcl -
E y ,r :.� N W Cpib W 09ap M Ppya M
.14
3. J sand.—
no s}ouon of
'shall be de foemlh upon a'
—xis
is :).component fworkand has bass.
componente7i-ry "
NoneO N agreement fah mpmasmenl connecting work sh II require a down no of —
i payment ledvaneo deposit)or more Nan ona-Nird of me total confect price rr NB
bond that 0l II depose.O they b whish N de 1 must make I dvrand.orderto d/ otherwiseobtal deWOry arpcal order sterile d qul,ount.' -0-' -
whch^ n runt t.•t 3 :eE e G ki"
ry Ire ma h n ce ee wilxn eaY=
Acceptance Of Proposal"rhev`e read both sldes'of m ptl id document an ac apt ces,'speclfisetions and conditions stated.I understand
' that upon signing,this proposal becomes a binding contract.'?so are authorized to o the work as specified.Payment will be made as outlined above.
I You,the:Buyei,rnayeancel this transaction af'any time prior to midnight of the third business day after the
s' date of this transaction.Cancellatlonmust be done in writing.
DON!
Q.TjSIIGN THIS CONTRACT IFTHERE ARE ANY BLANK'SPACES.
IMPORTANT INFO RMAT{ON ON BACK.Pill
, „ ,d.^ ....
sitMassachusetts - Department of Public Safety
Board of Building Regulations and Standards
("m.ri uAi,m Sul,cn i"Il ;
nX
License: CS-094763
I' n,
THOMAS R DOYBBINS-
r
19 Cedar IIiILDrivre ;.�
Danvers MA-019Z3
ld
J.�• -��9rP nt Expiration
Commissioner 05/14/2014
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:
5
Registration: 100811 Type: Office of Consumer Affairs and Business Regulation
Expiration: 6/23/2014 Private Corporation 10 Park Plaza-Suite S170
`��1 Boston,MA 02116
LEN GIBELY CONTRACTING CO., INC.
Brian Dobbins .- 7w .
23 R WINTER ST.PEABODY, MA 01960 -UnJersea'etary Not validture
C