7 GOODELL ST - BUILDING INSPECTION Ti!5-- IL� - 135 Z 5 & cr- 4 3 2
The Commonwealth of Mass
�p Board of Building RegulationsTaiilRvICES CITY OF
y /$ Massachusetts State Buil MR SALEM
Revised Mar 201/
Building Permit Application To Construct, ����jjjj�� �r%vaj' (kKQZolish a
One-or Twa-Famil}h` we
This Section For Official Use Only
Building Permit Number: Date lied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
7 GoaoeL-L 5—
L I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use L.o[Area(sy Rt) Frontage Qt)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
_D.S,,rt. L Rcb C1 a SAC, ,, MA
Name(Print) City,State,ZIP
r7 CroO9oLL S< 7 77 ? Q37
No.and StreetTelephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Build in wner-Occupi Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':_ —r t h 4 LC
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ goo 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 6->D ❑ Paid in Full ❑Outstanding Balance Due:
M A,t-'Co To &6ktiy �PI zi
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
l bCfl yr..ls License Number Expiration Date '
Name of CSL Holder
( ^t ! � v, '1 List CSL'1'Ype(see below) U
Imo.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
/t^A
a "Z .l \` R Restricted M2 Family Dwelling
Citylfown,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
L e� C, cb. LVi t- �b� � ` '� �'� HIC Registration Number Expiration Date
FIIC Compan Name or IiIC Registrant Name
t.tJ f 2j\o r'
N�nd Street Email address
��bno�✓LJ,4 b 1 4 (�
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 .......... ❑ 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: OWNEW 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.
O—e_cr c� , 14 ^ 1
Print Owner's o ent Authorized Ag ame(Electronic Signature) Date
NOTES:
1. 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
Awy .mass.eov/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 CosP'
i
The'Commotr!weaith Of MassachuseM
Department ofindustria[Accidents
Office of Investilgations,
I Congress Street'Suite 100
Boston,MA 02114-2017
wivmmassgov/dia..
Workers'Compensation Insurance Affidavit: Builders/Contractors/Elect I ricians/plumbers
Applicant Information Please Print Leetbly
Name.(Business/OrgaaizationdndividuW): �— e. v Lr . b P l��/ o,y i R AQ e.r I
Address: 2 i J _e z S t—
Ci /State✓Zi : t�Q G . Phane#: q'� $
3 $") 3
Are you an employer?'Check thi appropriate box
1.®,I am a employer with / @- 4. 1 am ageneral contractor and I e ofproject{required):
employees(full and/or part-time).* have hired the sub-contractors 6. [�New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. �Remodeling
ship and have no employees These sub-contractor have 8: '0 Demolition
working for me in any capacity, employees and have workers'
[No workers comp,insurance comp. insurance.* 9• Building addition
required.] 5.0 We are a corporation and its 10 Electrical repairs or additions
3. I am a homeowner doing.all work officersHave exercised their 11. Plumbin g repairs or additions
myself. [No workers' comp. . right of'eiemption per MGL 12•Q Roof repairs
.insurance required] t c. 152,§1(4),and we have no
employees. [No workers' 13•❑ Other
comp.insurance required.]
'My applicant that checks box#1 must also fill out the section below showin tr workers coin am ation it - -
.. d .. P. Policy
t Homeownps who submit this affidavit indicating they are do' all work end then
hue outside contractors must submit a new affidavit indicating such.
*Contractors that this box must attached an additional sheet showing the name of the subcongactols'and state whether or not those entitles have
employees. If the sub-contractors have employees,they must.provide their workers'comp,-policy number,
lam an le er that Is rovidln workers compe ._ ,o
P y P 8 nsatbn insurance for my employees. Below is the po/Jcy and job site
in ormattan.
Insurance Company Name.—A T M , "/ v'rV A L
Policy#or Self-ins. tic. #: (/(t/C._i t5 d b O I t 3 rV7 4—_)6l4FiExpiratidn Date:
Job Site Addreen
ss: G o.> p Z $ City/State./Zip
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 D]A for insurance coverage:verificatio L,. r
I do hereby certify under the par U and penalties.of perjury that the information provided above.is true and correct
SitmatvrP tZ ��. R U Date.[ �
Ph ne 2
OJflcW use only. Do not write in this area,to be completed==offkcial.al.City or Town: PIssuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Pown Inspector 5.Plumbing Inspector6.OtherContact Person:
ACORQa CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDUIYYY„
02/06/2014
bl<coucEa 978,887,4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
,Ld•ward 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
P. 0. Box 457
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.-1 ops f i el d, MA 01983 INSURERS AFFORDING COVERAGE NAG#
------------
suREO Len i y
23R Winter
Contracting Co. , IDC. INSURER& Catlin Specialty Insurance Co
Street INSURERS: Safety Indemnity 33618
Peabody, MA 01960 INSURERc: ---
INSURER D:
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.
iN,al1ppo0'L� __________ _
RA
_rR INSRD TYPE OF INSURANCE POLICY NUMBER DATE YUL WDO/Ylrn^fY if DATE MMlD Y OMITS
GENERAL LABILITY 3700302145 01/29/2014 01/29/2015 EACH OCCURRENCE $ 1,000,QU
_wwwGrTX COMMERCIAL GENERAL LIABILITY PREMISES EaEa re s_
----1QQ,000
..- CLAIMS MADE aOCCUR MED EXP(Any one person) $ $ QQQ
A — —
-- ---- PERSONAL 4 ADV INJURY It 1,000,000
GENERAL AGGREGATE $ 2,000,000
.._._..__. __
GENT AGGREGATEPIRMOIT APPLIES PER __....__-_
PRODUCTS-COMPIOP ADD s 2,QQQ t000
POLICY JET LOG .___.. ._...
AUTOMOBILE LABILTY 6221693 COM 01 01/29/2014 01/29/2015 COMBINED SINGLE LIMIT
I ANYAUTO (Ea accident) s
5 1,000ito 0
_X IALL OWNED AUTOS BODILY INJURY
SCHEDULEDAUTOS (Per person)
HIRED AUTOS
_X _-
BODILY INJURY s
I X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE
(Per accident) s
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT s
Z ANY AUTO EA ACC s ----------
�__1 OTHER THAN ____.._.._.
AUTO ONLY' AGG
EXCESS I UMBRELLA LABILITY EACH OCCURRENCE s
I OCCUR CLAIMS MADE AGGREGATE
g
r�
I i i UEUUCTISLE S
lr7 RETENTION $ $
WORKERS COMPENSATION ----------I
AND EMPLOYERS'UABIUTY YIN TORV LIMITS ER
AN't FROPRIMBER EXCLUDED? E.L.EACH ACCIDENT a OFFICER/MEMBER RIETOR EXCLUDED'!
(Mandalory In NH) E L.DISEASE-EA EMPLOYE s
IIyya5 cew"a _
SP EC'AL PROVISIONS below E.L.DISEASE-POLICY LIMIT s
OTHER --------
JFSCRIPTONOF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
P ofroof 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 SO STALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR—
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE y0
Robert Sennott RP
ACORD 25(2009101) - 01988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
< LLN GILIELY CONTRACTING CO., INC. '.,C 1V° —/-01 Y spas¢
w L 2 Street 26016PEABOOY,MASSACHUSETTS O PROPOSAL
�lam
All home Improvement contractors and subcon{rectors
/ (979)531.8234 Fax(978)531.9304 engaged In home Improvement contracting,unless
' www.longibelypontracting.com specifically exempt from registration by Provisions of
Chapter 142A of the general laws,must be registered
8ubminae with the Commonwealth of Masaachusetts.Inquiries
TO. -/.Q,-I a - -1-n--C� �-Q------ about registration and etatuo should be made to the
' - 7 Director,Home Improvement Contract Registration,
One Ashburton Place,Room 1301,Boston;MA 02108
n 7 (517) 727.0598; Owners who secure their own .
Sa / M'4 (y�1G construction related permits or deal with unregistered
contragore will be excluded from the Gus ranty'Fund
Provision of MGL c.142A.
P.E Dea I REe1"VON..
-7- iv /l N MA.REG::100811
Bw Nrm Emo.
Joe l.ocATloN
SAfH �
W�bye I¢Podpcetlom erd eepmebe br eaMbbe PorbmadeM meledW bbewM: ... .. . . .... _,�.
14�
--I-Cz=rwa �wrrv=�a�.+�1ec�l 11__1PalIS_3_._0 I er_4
—U 1 26
—�C N rry-Q! YS _ 1 cl f�jE M ICI r_� l_ --0d
q 80 --- ---- -
--------------------------------------------
*on
comracmr t ua won w pme m iBn s bW a u.mire oar alpwmp w alpmnp d InN Aa a c l spec nee nareln wd I pr win b 1 m x i eeoa'�_(aemt.ea lye 1 y ea by dmamWnces oeyone commdau wmrol the work will be omplebe W�(eerel.ino owner hereby
edmowloea ee aNBlure xlredwNp else ere epprmimaie one wteacn dove Mel are nd aaweadawm.comrecpralwll rnnamrea letpnadlms Amo.man,. ;
rvieOen mlwwrduwamp soar dare desarele Metare rpdreepNrepexpin wPolbawrlxele NacmaW.Mn bewmppbpelE— .,_DBr mennpv lMANrvWRI. e
WAggANTY
Tne CmVadw warmnb filet IM1e wwk Wml¢Ilbe M1ereurWer¢hell bB Ir¢e Irpm eelaclB in material en0 worxmenalAp br a petlCd al yQ bllw;lne cOmpl011on and sM1ell Comply with
IM1e rBqubemen1e 01 Nb Ap LIn NB agnl erry select In wpMmeruhlp or malBrUle,ar some's uWae by Ne COnOxton M1la euECcnlraclwa,emplgeBB Or a9enle,beu[merad wa`b
one year enar WmpbLbn 01 any pE,Ir,clWlnp clean Op,Ina Canlreciw eMn,el nb un operas,bNMih remedy,repair,cOnecl,replace,ar ceuaB b pe rem6elae,rBpelree,ar'.'lobed.
wcn Oamape or eucM1 select In meleNN o/wppnen¢hip.Tpe MepoNp werrentlw eMll aurvlveaM N¢pgYw pprlarmae lncmaxtpn wllM1 Ne eBreBduPon work
We PYOPOae hereby to lurniah.materialantl labor complete in accordance with above specifications,fo[Ihe sum ol:
Payment to be made as lot 1A{a /�J\�-��\T�— tlollars
Romove ell lab trash,
� Gap�jj�gq V V All Buerleeson ed-a Imm manutadure[
%(S pnm cored; Atld Permit cost if needed e Pull permit.
%I4�L upon ebmplepon of greemenl or home Improvement conirading work shall require e
NOIiCe: N00
gown payment laevence eeposid of more Ihen aneNlN 01 the bbl Wnlmd
%4:.bob wmdepon of priceOr Neblel amount of ell d.Poai r paments whidr the contractormust
make.In rannowe,to order and/or amise Oblaln delivery.f special order
.y wral be matle brew) upon maledela d aquipme t i
completion cl wOAu wthi¢ronlmd. I
N.w:rma p,op.ul merb.wl"do-Oruaen"noteeewery db.,
wa prams
Acceptance Of Proposal I have read both sides of this document an cept the press,specificailons and conditions stated. untleistand j that upon signing,this proposal became$a binding contract.You are authodzetl to do the work as specified. Payment will be made a$outlined above. f`
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 done In writing. k
SDO N0/T SIGN THIS CONTRACT IF-THERE ARE ANY BLANK SPACES. - !F
/ F
51nalwn pa'e� senwum om.
IMPORTANT INFORMATION ON BACK 10--
_.._......._..................
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
(11n I ru r lit,l tiu perN isur
License: CS-094763
THOMAS IL DOByINS,p-�...
19 Cedar Hill Dr1* t W _
Danvers MA 01923 t� -
Expiration
Commissioner 05114/2016
Consumer
Affairs
& Bus e�s Regulation
License or registration valid for individul use only
„� DI'nce of Consumer Affairs& Business Regulation g � y
=9Ulpiration:
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
olstratlon: 100811 Type: Office of Consumer Affairs and Business Regulation
�x 6/23/2016 Private Corporation 10 Park Pines-Sulte 5170
..;.;,;, Boston,MA 02116
LEN GIBELY CONTRACTING CO., INC.
Bnan Dobbins '
23 R WINTER ST.
PEABODY, MA 01960 ___..... _________._.._... _____._._._...____
Undersecretary Not valid wit ul signature
r
C