003C FILLMORE ROAD - BPA-09-253 ` The Commonwealth of Massachusetts I
► Board of Building Regulations and Standards H)R
r �� MUNI( IIIAH IN
�. ' Massachusetts State Building Code, 780 CMR, 7 edition I .
l of
W Building Permit Application To Construct, Repair, Renovate Or Demolish a Rrr,�r,/hunuu,
One or Ttnu- , v riling 1 ', )8
This S tion For ffici I Use Only
Building Permit Number: to A plied:
Signature: 511Rlo
Building Commtsswnen hnpc or of tldmgs Date
SECTI : SITE INFORMATION
1.1 Pro rty.,ddress: 1.2 Assessors Map & Parcel Numbers
1- LL 2< ��
I.la Is this an accepted street'?yes_ no Map Number Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq A) Frontage(it)
1.3 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Fj
Provided Required Provided Required Provided
M.G.L c. 10. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal s stem ❑
❑ Check if esO P y
SECTION 2: PROPERTY OWNERSHIP'
. f Record: Me— KY L Fs L f>
L i►+ o 2-e Ia
Name(Print) Address for Service:
G -1 i? 5 9ti
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied Repairs(s Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': es it e=e 'f=Ro(off L,4 c t a (A J �*bc'VArJ
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building S I. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. electrical $
❑Total Project Cost (Item 6) x multiplier .a�
3. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) b List:
5. Mechanical (Fire $
Suppression) Total All Fees: 5
c, ci,� Check No. Check Amount: Cash :\mount: I
6. Total Project Cost: S 2, t a b Q ❑ Paid in Full ❑ Outstanding Balance Due:
i
ea Ocvel f r6e jv�_ I
SECTION 5: CONSTRUCTION SERVICES ,
5.1 Licensed Construction Supervisor (CSL) im
�6 3 S� li i t�
V--- C)® 4J b v:� ber Expiration Date
Nana of CSL- Holder e(see below)
1 � i � Ma, v SrQDa � � o1
scri stun
�ddr restnciedlu to }5.Wo Cu. F(.t
stricted I&' Fmn Dssell,n
S1 namrc`� �7 son Onl
3y sidential Roofing Cuserm
Telephone sidemal %V,ndots ind Sidrasidential Sohd Furl l3unu tie :1 s+han..• In,killitwn
idential Drnnohoon
5.2 Registered Llome Improvement Contractor(tIIC) ' Q o O t (
HIC Comppany Name or HIC Registr�nt,Marne Registration Number
o _
6.
4ddr
aGi ] 9 5 3 1 91 4 Expiration Date
\�� [tee
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 9 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure tit 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' OR AUTHORIZED AGENT DECLARATION
I. as Owner or Authorized Agent ereby declare
that the statements and information on the foregoing application are true and accurate. to the best of my knowledge and
behalf.
LE JNL� c:,
Print Name
Signature of Owner or A`thorized Agent Date
(Si tied under the pains and penalties of perjury)
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 110.116 and I WAS, 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 ISq. Ft.) Habitable ra,m count
Number of fireplaces Number of bedrooms j
Number of bathrooms Number of half/ba(hs
-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 Conunomvealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
ulr� wwminass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legiblv
Name (Business/Organization/Individual): i i P l 1� Ct - t 2 ,0.r i -y C- C L•
Address: / t--i c. M -1 t - s --r-
City/State/Zip:7e A h:.�,4. i'`)xt C / / 6 O Phone#: q ` .5 1 3 4
Are you an employer? Check the appropriate box: Type of project(required):
1.M I am a employer with �y. 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole pr^prietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-ccntractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
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 I I.❑ 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' 13.❑ Other
comp. insurance required.]
•Any applicant that chats box#1 must also fill out the section below showing their workers'compersation 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.
IContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contactors 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: ? ti`I f J v i L l ,s Cc
Policy#or Self-ins. Lic. #: E; C I C ci ' 1 7 r,, I Q c,, G : Expiration Date: O-3- c 9
lob Site Address: -3 fe F, LL-,-v, y-, kz City/State/Zip:Sa L,o ," 114 rA I'T
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required trader Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 31,500.00 and/or one-year imprisonment,as weIl as civil peralties it the forty:of a STOP WORK ORDER and a fine
of up to S250.00 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 ofperjury that the information provided above is true and correct
Signature: ` , i :Cz =—>� 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#:
11 / LUUb 2 : UY : 2b HIVI 69i5 Id U21 / U1
1 WWI
ISSUP Ri.iTE 0713112008
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MAI'l'ER OF INFORMATION ONLY AND
jEdwerd?Sennot:InrrR:lce CONFERS NO RIGHTS UPON IM CERTIFICATE;:OLDER.THIS CERTIFICATE
South
M ')OES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
IAA I.POLICIES BELOW.
�Iti South Main Street "
Ops6eld,MA 01983 COMPANIES AFFORDENG COVERAGE
INSURED '- -- -- - .
Len Gibely Contracting Company Inc
Jenness Street cONPANY A Ai.M. Mutual Insurance Co
eveily,MA 01915 LETTER
c— ROw
Rq. 9t
a{n� :cx:N.� v4:` � i•f' �, .Y.' + rr
THIS IS TO CERTIFY TEAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
j PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
TO WHICH THIS CcRi IFICA TE MAY BF MST IFD OR MAY PFRTA.IN.THE INSURANCE AFFORDED BY T;-IE.POE ICIEI DESCRIBED HEREIN IS SUBJECT
-TO ALL THE TSRMS,EXCLUSIONS AND CONDITIONS OF SLCI1 I OLICIES.LIMITS SHOWN MAY HAVE BaN RED OCEP BY PAID CLAIMS.
V TYPE.. -- ! PDATE(MMtDDI VE PDATE UM
--
Tl'PEOFINSURANCE POLICY NUMBER LIMITS
LT0. DATE(MMfDDIYY) DATE(M MIUDIYY)
CENEPAL LIABILITY GEMEMLAOGR.LAfE
PRODU�PArJJ.
O COMMERCIAL G ENERAL!.IABII.)TY
PSRS'ONAL@AUV IMJLrR!
OO CLAIMS MADE=OCCUR '--
k CHOCCURRENIS
f OOWNERS&CONTRACTORS I ROT.
FlRE DA MA OE IAn,L.i I0
MEL EYPEN^E(Myom ymm)
ALTOMOBILk bWBILITr----�— L. .;.LMBINED SINGLE
LIM,
ALL ALTO
ALL OWr1 hUA__ !BODILY INJURY
T SCHEDULED A,-1.
HIRED AUTOS
NON Ow!ZD ALTOS so:dLY Itl:Ual'
I PR(TERTY LAMAOL
UCESS LIABILITY _ EtCI}OCCURRENCE
1� r
OMBRELL.A FORM (AGGREGATE �J _ L
OTYERTHAIU UMBRELLA FORM
WORKERS CONEPENSATION AND - i- PS ATLTORY LIM OTHER
EMPLOPERS LIABILITY Ix
E FROPRIE1 EL EACH ACCIDENT S 500,000
A A11-1s1E>:EcvrvE
rRCIERS ARE_ 6010979012008 08/03!2008 08/03/1009 jEL DISEASE—POLICY L:MIT S 500,000
1 L DISEASE-FA^_:. 500 OOP
r ( EMPLOYEE
_y—
' COMMENTS!DESCRJPT::)N•iF UPERA7i0NS UR LUCATIUNS.
I
T10
i
I
7A Yo . ..5
_b "Y
ROULD MY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
A N GF.LA S I R C1 N I THEREOF,THE ISSUING COMPANY WILL ENDFAVUR'TO MAIL 10 WRITTEN NOTICE TO'THE CERTrFIGT
OLDER NAMED'1'O THE LEFT.BUT P'AD,LTE TO MAIL SUCH NOTICE SHALL REPOSE NO OBLIGATION
10 G IB E LY R LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESFMATIVES.
i I
49 MAIN STJ /'I
FABODY, NIA 01960 _ AUTHORIZED REPRESENTATIVE
1755
of I Pages I
Page No. �— —�
n 182a2 PROPOSAL
LEN GIBELY CONTRACTING CO., INC.
149 Main Street
PEABODY, MASSACHUSE17S 01960 All home improvement contractors and subcontractors
engaged in home Improvement contracting, r
(978) 531-8234 specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered
FAX(978)531-9304
with the Commonwealth of Massachusetts. Inquiries
Submitted: M,ka `,/_ -_. -.-_. -- - about registration and status should be made to the
To __ a=eJA— -- ' - Director, Home Improvement Contract Registration,
One Ashburton Place, Room 1301, Boston, MA 02108
v (917) 727.8598. Owners who secure their own
construction related permits or deal with unregistered
Q1_4_7 --------- contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
DATE REGISTRATION No. MA REG. 300811 i
ONE
S4 4 in/c1 �1�� --
J JD0 LOCATION
JOa NAM., S 4,44
> 7
We,h0 opy eubmltspecldgmona add a 'metes for yy to be perlormed nd marshals to be used: — --_ --- — —- -----
r
rx r•2dac:-�s_.—�r`_�P___.Ll.__z�_u—tk._.,,_��—L.t Lc..( fi_e__n—J-------
--- -sue-
4�,,, -
---
ermits:
Construction related p - ------ --
-f—
1 'll beg IM1 work or
WORKeO µEDUCE (tl le).Th O eM1 by
(Antrect g 11 n01 n IM1B wok or ostler le materials bolero he lhrtl day 1 II g Yh Bning of IM1Is ggreemanl unless ap0c I' d M1 el 1 °I"'.Agreement.
about (dale).Barring delay causatl by circumstances beyontl Ccnlraclers control me work will be co pl 1 d by
aAnowl es end a eo Ihel IM1B uhedulin tlales are epproximat°antl hat sucM1 tlela s tM1al are not ev0ldable q'Na ConVaclor shaS°I be 0°'ollcwlnaacomplelion antl shulscomply with
WgRMNTV M1is subcontractors,empbye.,or agents b discovered within
TM1e Conlreclor warrants IM1at IM1B work turoished hereuntler shall ba Imo VpOmo tl�led5 In malarial antl workm°nsM1ip loepd pe0c�rrecl,re lace,or cause to be remedied ri palred,or replaced,
lh0 requirememe of his Agraemeol'llndluding clean duB1Blhe ConVacmrsshall,altisown°npensa9brmw5lM1 emted Ddae6Glor p
one year etler<pmDlegon of any lob, P
such damage ar sucM1 detect In materials or wVrkmenshtp.The foregoing warranties shell survive any Inspection performed In connecfron with the agroebupon work.
We PrOPOSe hereby to furnish material and labor -complete in accordance with above specifl dollars(s r the sum
Payment to�bje�'ymbaq as follows: L
%(9 )upon signing Contrl Name o om od esig^also
°k Ig v C� )upon completion of Street Address
Ig )upon completion of GIIY/Slate - - - Phone
Shell be made fo n upon &�^ ——� Fed.arl to No.
h(s )completion of workrk a antler this contract � a
Notice: No agreement for l om0 improvement contracting work shall require a down 1417 Nyman
payment leWance deposic of moreame which-third ontractorof the lmust make,-compact ativancce or he, Au -agna
tend amount of it deposits or peym says.
to order antl/or onemse obtain delivery of special ortler materials end equipment. Nme:This,nooesl may Ee withdrawn by us it nut a crested within
...hrM1 remo t'= reefer
have
the
ions slid
ons
d.I understand
Acceptance of
Proposal
r Ppososal becomes artimdmgtcooVacL fYou are auth this orized to do hnt and te workrlas specified, Paymentw�beti made tas outlined above.
uponsigning.
You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after 1
the date of this transaction.Cancellation must be done In writing.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. _—
O�D/ oat.
Dale .`+ignOWre
IMPORTANT INFORMATION ON BACK 11111-
sgnawm
I
' �/re 1°iomma�wieal/� o�./�aoaac�uoelA � ...
.� Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registraggri 100811
EXPiration'_6123/2010 Trill 268971
/Type: Private Corporation
a1 _PI?,
LEN GIBELY CONTRACTING:rO INC.
Brian Dobbins /
149 Main Street
Peabody, MA 01960 - "'l Administrator
{ ✓m 10&.mp9t!!/6RI.[/L O�✓YI NAfC�d �'' {
iarv
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISORNumber ,CS, 094763da ,3
F 1 0 14/�20;'('g Tr.no: 94763 i
THOMAS R DOBBINS
CEDAR HILL DRIVE
DANVERS, NiA 0192V--' I -
Commissioner