50 FREEDOM HOLLOW - BUILDING INSPECTION (6) The Commonwealth of Massachusetts p4 Board of Building Regulations and Standards RECEIV DA
OF
Massachusetts State Building Code, 780 CMRINSPECTIONAI ER�FM
�ry Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Q'04r�is rh.i A ID 20,o
One-or Two-Family Dwelling ��•
This Section For Official Use Only
Building Permit Number: Date plied:
Building Official(Print Name) Signature - Date
SECTION 1:SITE INFORMATION
1.1 Propert t ddress: 1.2 Assessors Map& Parcel Numbers
n) epx. l—- oLLvw
I.Ia Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 0 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(R)
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:
"Lone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
1. eA R v 6-re In t .v r, 6Z Y -S A Lo n1 MA D 1 9`7-p
Name(Print) City,State,ZIP
T; D P-
o eS�n.r+7 �(OLLp W �? �✓� �1717
No.and Street "telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupie Repairs(s Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': 11 w�zJs�3,r✓f o
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 01g1p OO I. 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 (I-IVAC) $ List: -# -- i�
5. Mechanical (Fire $ —
Suppression) Total All Fees: $
3 �� b Check No. Check Amount: Cash Amount:
6.Total Project Cost: ' $ t 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ,7r 3 ' )
\ • %(� License Number Expiration Date
Name of CSL Flolder
List CSL Type(.sce below)
No.and Street Type Description
,/� U Unrestricted(Buildings u to 35,000 cu.ft.)
C]-O Y - i r P'v i fl R Restricted 1&2 Family Dwelling
City/Town,State,ZIP I M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
4 8 S3 P34 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
J. �.L2 G t h.el v e 12 1 _ a r
� -'' HIC Registration Number Expiration Date
HIC Company Nine or HIC Registrant
LA
N tree[ Email address
City/Town,State,ZIP 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 ........e,=El'' 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
no
Print Owner's o Authorized Agent ame(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
(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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned, provide the information below:
Total Floor 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
DepartmentoflndustrialAccidents
Office o'Investigations
600 Washington Street
Boston, MA 02111
5a�:,s✓ www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibiv
Name (Business/Organization/Individual): L 4!N G t bQ L Y Ct„r,2AC77w s CO
Address: 9
City/State/Zip: pPhone #: 99 'a- S'L k 9 QL 3 __
Are you an employer?Check the appropriate box: Type of project(required)
1. I am a employer with I �D_ 4. ❑ I am a general contractor and.1
employees(full and/or part-time).* have hired the sub-contractors h ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y aP tY• 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 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' 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 hue outside contractors must submif a new affidavit indicating such.
tConuactors 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-contractors have employees,they must provide their workers'comp.policy number.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name: /A e M . N 0-1 v A L Sn<c , C
Policy#or Self-ins.Lie.#: 6 D ] Cl q-7 -- D O 1 3 �_ Expiration Date: g 3 a
Job Site Address:_ SQ V,� O LLr,t,7 City/State/Zip:_SQt,m l�
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.
Sienature: _ Date: jam, 1
Phone#- 2
Official use only. Do not write in this area,to be completed by city or town offuial.
City or Town: Permit(License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
1. Other
Contact Person: Phone#:
ACORQ CERTIFICATE OF LIABILITY INSURANCE F DATE(MMODN"Y)
02/06/2014
PRODUCER 978.887.4900 FAX 979.897.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
16 South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. 0. Box 457
Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIL#
INSURED Len Gi bel y Contracting Co„ Inc. INSURERA Catlin Specialty Insurance Co
23R Winter Street INSURER : Safety Indemnity 33618
Peabody, MA 01960 INSURER C:
INSURER 0:
INSURER E:
COVERAGES
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.
INSR DD' POUCYEFFECTNE POUGYEXPIRATION
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MMIODNYM DATE MWD LIMITS
GENERAL LIABILITY 370030214E 01/29/2014 01/29/201S EACH OCCURRENCE It 1,000,00
X COMMERCIAL GENERAL LIABILITY PREMISES Ea oaurrorlce $ 100,000
CLAIMS MADE rj-
I OCCUR MED EXP(Any one pwecn) $ 5,QQQ
A PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO S 2,000,00
POLICY PET LOC
AUTOMOBILE IJABIUTY 6221693 COM 01 01/29/2014 01/29/2015 COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) S 1,000,00C
ALL OWNED AUTOS BODILY INJURY
B X SCHEDULED AUTOS (Per Person) $
X HIRED AUTOS BODILY INJURY
X NON-OWNEDAUTOS (P-aabenl) S
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHERTHAN EAACC $
AUTO ONLY: AGO $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
S
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION WCAND EMPLOYERS'UABIUTY TORY LIMITS ER
ANY PROPRIETOFUPARTNEWEXECUTNE/� E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? I_J
(Mardatory in NH) E.L.DISEASE-EA EMPLOYE $
If Yyes,desaibe w
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1 S
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
roof of insurances.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Robert Sennott RP
ACORD 25(2009/01) 01988.2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
M
a�coRd' CERTIFICATE OF LIABILITY INSURANCE
07 6 Bps,,
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H Y is
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BYTHE
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S);'AVTH
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:It the certificate holler Is an ADDITIONAL INSURED,the policy(Ies)must be endorsed. 11 SUBROGATION IS WANED subject to `
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER 01634.001
Edward F Sennott Insurance ,No.
18 South Main Street "--
Topsfield,MA 01983 INSURERMI _
. A.I.M.Mutual Insurance Company 33788 '.
INSURED - -
Lan Glbely Contracting Company Inc
23 Winter Street Rear - - -
Peabody,MA 01660-I1941 .
NSUIERF-
COVERAGES 'I CERTIFICATE NUMBER: 1 1 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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;iHE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1 _ I{ 1
VNI TYPE OF INSURANCE POLICY NUMBER. (• 4 LIMITS
GENERAL LIABILITY �.• 1 I, EACH OCCURFIENCE f I.
{J !
COMMHiC1AL GENERAL LABILITY r1 f+ . •1',�.'r a
CLAIMSMADE OCCUR. ) '`••••� tI `•,•'.✓ MEDIXP .
(MYana Pmral) a
PERSONALa ADVINAIRY e -
GENEIMAODREGATE P - -t
INL AGGREGATE LIMIT APPLIES PER PROOUCTS-COMPAOPAGG-Pou 1
CY C -
AUTOMOBILE LIABILITY IEUMir—
ANY AUTO BODILY V UURY(Po pmmn) a
ALL VM® SCHEDULED
ID
BODILY[NARY(PW ecdd $
ALL O A AUTOS
HIRED AUTOS NON OWNED -
AUTOS :
1
UMaRELLAWB OCCUR EACH OCCURRENCE e'
IXCESSUAB CWMSMADE AGGREDATE - t ..
DED RETENTION 1 P
ZROMFORK - X IV
A � iFE N NIA VWC4004010879-2011A 8/312013 BI3/2014 EL EACH ACCIDENT a 600,000.00
(Mwto dary In N�H�)W� EL DISFASE•EA EMPLOYEE Y �` 600,000.00
MEOW`f$A'OF OPERATONS e.w . . EL DISEASE-POUCY LINT $ 500,000.00
DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES~h AOORD 101.A6010onel Remarks SChemds,0 mom spot to!"Wed)
CERTIFICATE HOLDER CANCELLATION
'ISHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOP,A NOTICE WILL;:BE 4ELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
. AUTHORMED REPRESENTATIVE > u
1 Ad 1988-2019,ACORD CORPORATION..All rights reserved.
ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD ,,�,
• LEN GIBELY CONTRACTING CO., INC. Page No. of Pages
23R winter Street 25969 PROPOSAL-
+-t'b. ""PEZODY,MASSACHUSETTS 01960 -
E- All home Improvement contractors and eubcontreatore
(978)531.8234 Fax(978)531.93044�\!t\!\ —,` engaged In home Improvement contracting, unless
www.leOglbelyCOntrecting.COm 1N specifically exempt from registration by Provisions of
_ Chapter 142A of the general laws,must be registered
Wbmined / 2- V 6 C with the Commonwealth of Massachusetts.Inquiries
T.:.�/—121 l` —.I N SK y_ about registration and status should be made to the
Director,Home Improvement Contract Registration,
0 M ! 0 tl o W One Ashburton Place,Room 1301,Boston,MA 02108
-- - ---- (617) 727-8598. Owners who secure their own
construction related permits or deal with unregistered
0 contractors will be excluded from the Guaranty Fund
Provislon of MGL c.142A.
GHONF DATE / ,/ REGISTRATION NO.Sl8 - 36 9- 9�r*] /N - !u- /( MA.REG.300811
Joe—hav), Jae LOCATION
...-- — ------ S.eu n-,` tir B vd
VB hOrOby submit BDBCIIicellOnM eB1 ma1B B OM far murk b0 p0r1m 100tlM toB m016161B hat %a0: n
1 N.Q. W—/ 6 �'e U3 Mfl
ill k-ovvP - 'U Olc( __—nov6�9- I+vfl6 W;nttlowP 1 rsratl
1-2,(f a fl knS1-t a w i nl!) u wS 1 ) i i F4 C ly �ef2 6 y_S T ton
11aSS (/2 S C /1C5eNS -
Ti l� =i^ Se rf'f�5 _
11
I Sv /9Yz� /fND -( 0-3u%J l- -�� _--5_/_���5---
— D
1.
GX� 1/2-x a0 1� TOL —
-- - --- ------- —I -- Q l onslruclidn related permits:
-_ irmuS�aa� , C'ondo Y��0 L) --
WORN eC ULE I--•_.—__—__ -
Vo c �y,qe o 4 Oemra Ne NiWt say IalwAne the a,,to, r a Nia AarOamOn,unleaB speared homm wnlln8 et tll of
in Ina work on or
u0om (a B Ina used by dmumatencea Oeyond'Do Nenors comml,me work wnl be compleleE by l0 ne owner nereby
aamha peee,gas...Me,Me scheduling dates are amemon¢Ie am that such delays that are not eroltlOEle by the contraM,shell bemnLOe evb IWs AANWNt.
WARRANT
The Cohnna r warrants Net Ne vroM lumlehpl hereunder shalt he Irea from deleN In Walmial and waMmensnlp An weed of 4 ram ,.a end flwll comply It
the lerylremenle of N4 ABreemenl.ln tlw Buenl any detect N worxmenahlp or mobtleb,or Wmepe[saved Oy,We Contractor.Ma eu%onl n,emplgees cr agents,4 uxmared within
no year after wmpletlon of Min
Irrdudlrp clean up.Ne Conh m r shall,at Ma wen saran e,forthwith remedy,repaid comm,rep4ce, r aausa to so remedial,m(airm,or N'Amad,
each damage anuch delM In mmi at,..MmenMlp.The lorepan8 we,renYea awll survhv any inspection perlurme0 in connection with he agreed-upon reek
We Propose hemb to furnish mat rial and labor-complete In accordance with above specifications,for the sum of:
dollars($- /2)0. o 0 ).
Payment to be made \ � T
I-���Yi/
%(s mean signing Contma�-I�- Name co -'Iiwwmm NW un
%is )upon cpmpon lean Q Bvee�Am e - ^ ---- ----- _--
%(s—)upon completion of lstsw Phone
—%Is )shall be made forenth upon _ _ - _.. _ —
c'omplefte of wmhl Whom Ihla cOnlmcl. arm lb No. t(}
Notice: No agreement for home improvement contracting work shall require a Oman the ne a }.
payment aid....deposit of mom Nan one-third of the total contract price or the I�5
total amount of all dm essil8 of payments which the contractor must make,N advance. Ill 1 r
m order and/or otherwise obtain delivery of special calm materials and equipment, r p.
ryh cheveramounl legaale r. O.Thi9 c ale W IlM1drewn C,axeralmomedwrwN days. rk
Acceptance of Proposal I have read both sides of this document a eccep he rice pool n t ations and conditions stated.I understand
that upon signing,this proposal becomes a binding contract.You are authorized o do a war as specified. Payment will be made as outlined above. 1
You,the Buyer,may cancel this transaction at any time pro torrid night of the third business day after the °
date of this transaction.Cancellation must be done in writing. t
OT SIC THIS CONTRACT IFyTaHERE ARE ANY BLANK SPACES.
serarvr. 06� !wra oath r
IMPORTANT INFORMATION ON BACK 1i
I
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction -0947i3
License. CS-094763
THOMAS R DOBBIN ---
19 Cedar Hill Drive `1 y
Danvers MA 01923 �� \
Expiration
Commissioner 05/14/2016
re pnomoawreoea/!/o�'C� raa�r�/rm�//� License or registration valid for individul use only
Office of Consumer Affairs& Business Regulation g y
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumers 5170s and Business Regulation
-T. gistrauon 100611 Type:
xpiration 6/23/2016... Private Corporation 10 Park Plaza-Suite 5170
,is g_-; Boston,MA 02116
LEN GIBELY CONTRACTING CO:;INC.
Brian Dobbins
23 R WINTER ST. - g
PEABODY,MA 01960 Undersecretary Not valid wit ut signature