13 GREENLAWN AVE - BUILDING INSPECTION \
1
The Commonwealth of Massachusetts
Board of Building Regulations and Standards I OR
7 m NWNR It'.AI.fl l
Massachusetts State Building Code, 780 CMR, 7 edition l S,:
W Building Permit Application To Construct, Repair, Renovate Or Demolish a R, iuwd 1,our ur
One- wo- smile Duelling
T is Secti n or Official Use Only
Building Permit in r: ate Applied: /
Signature:
Budding Comets er/ Inspect 1 n s Date
SECTION I: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers i
13�2a� L,4w.� /�}vP
I.la Is this an accepted street'? yes_ no Map Number Purcel Nuinlxr
1.3 "Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage ot)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
[1.6Water Supply: tM.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?lic❑ Pnvate❑ Check if es❑ Municipal ❑ On site disrxssal system ❑
SECTION 2: PROPERTY OWNERSHIP'
. Owne1 t�of Record: / /�
1, t R V'ZZ n 3 Ls(Z. ,n..o v �.,A c.✓A-. k !:' ,C
Name(Print) Address for Service:
G`r 'Z -7 uw S R �_
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
;Descol
onstruction❑ Existing Buildin Owner-Occupied epairs(s Iteration(s) ❑ Addition ❑
lition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Description of Proposed Work
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
(Labor or and Materials)
lding S 1. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/ own Application Fee
trical S ❑Total Project Costa(Item 6) x multiplier x
bing E 2. Other Fees: Ehanical (HVAC) S List:hanical (Fire Sssion) Total All Fees: S
Q Check No. Check Amount: Cash :\mount:l Project Cost: E 8 U �5 ❑ paid m Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ( 9 (-1 --? 6?�,— 5 _ I tA— I O
—T— License Number Enptration Date
Nan te of CSL- Holler r-� A ' Ltst CSL Type (see helow)
/ L 4/vi A f �T' o O b o V Y%Q T pe Descri lion
ji
AJdr•s>,s ^ L Unresinc(ed iu to 15.p00Ca Ft.(
-P �— J o
R Rrs(nc(ed 1&2 Family Dssellin
Si numr`c� .bt Niasonry Only
RC Residential Rocifing Coccnn
Telephonc W'S Residential Wntdot .utd SiJm ,
SF Residential Soli) Fuel Uwnin¢ .\i tl i Lill,e lu.i,illawn
D Residential Demohwm
5.2 Registered Home Improvement Contractor (HIC) p O 1 ,
LP � � b..oL� ��'r
HIC Company Name or HIC Registrant Name Registration Number
1 9f M qr v o4 bo�V MA --�—Z
AJ ss
`—` � � �^ Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 5 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pniv(de
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.
Si nature of Owner Date
SEC TION
�7^b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner o Authorized Agen hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print N 1 J
Signature of Owner o Auth ' Date
sd(Signed under the airn ru ) 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.R6 and 110.115, respec(isely.
2. When substantial work is planned. provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemendattics, decks or porch))
Gross living area(Sq. Ft.) Habitable nx>m count
Number of fireplaces Number of bedrooms j
Number of bathrooms Number of half/ba(hs j
"type of heating system Number of decks/ porches
Type of cowling system Enclosed Open j
3. 'Total Project Square Footage" may be substituted for "Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le¢ibly
Name (Business/Otganization/individmi): L-V Ct i'7 A i t :'G L•
Address: / 4 cf /11 g t ti s r
City/State/Zip:� A . .t/ l n C / 9 6 O Phone.#:
Are you an employer?Check the appropriate boa: Type of project(required):
La I am a employer with 4. ❑ I am a general contractor and I
� -. have hired the sub-contractors 6. ❑ New construction
employees(full and/or part-time).
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub ccntactors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. Buildingaddition
[No workers' comp. insurance comp. insmance.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 LE)Plumbing repairs or additions
myself. [No workers' comp. tight 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 appheant that checks box#1 nsust also fin out the section below showing their workers'compeamtion policy information.
t Homeowners who subrrut this affidavit indicating they are doing all work and then hire outside convectors must submit a new affidavit indicating such.
-SCont attars that check this box trust attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have ernploym,they must prmide 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. nn T-
Insurance Company Name: f T L Is u A L
Policy#or Self-ins. Lic.#: EtC 1 C Ck '-� 9 i J 1 Q C^^C)R Expiration Date: 0 9 - C 3 C 9
Job Site Address: 13 G fL--e oN ( 4 c.., ,, (A u-_-P City/State/Zip: SA LP Nr MA
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 S 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 thepains and penalties ofperjury that the information provided above is true and correct
Signature: �_� � ^—D Dater
Phone#: g 1 2, S
Official use only. Do not write In this area,to be completed by city or town official
City or Town: PermittLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
0713112008
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Edward F Sennett Insurance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
gency Inc DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
16 South Main Street
opsfield,MA 01983 COMPANIES AFFORDING COVERAGE
INSURED
Len Gibely Contracting Company Inc
8 Jenness Street COMPANY A A.I.M. Mutual Insurance Co
Beverly, MA 01915 LETTER
CQ
R
1.0
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICYEFFECEIVE POLICYEXPIRATION LIMITS
LTR DATE(MMMDIYY) DATE(MMIDDrM
GENERAL LIABILITY GENERAL AGGREGATE
PRODUCTS-COMPIOP AGO.
=COMMERCIAL GENERAL LIABILITY
PERSONAL k AO V.INJURY
=CLAIMS MADE=OCCUR
EACH OCCURRENCE
=OWNER'S k CONTRACTOR'S PROT.
FIRE DAMAGE(An)'onc sire)
MED.EXPENSE(A.,.e person)
AUTOMOBILE LIABILITY COMBINED SINGLE
LIMIT
ANY AUTO BODILY INJURY
ALL OWNED AUTOS (Per perms) S
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY
IPvnmAcnG
GARAGE LIABILIT
Y
PROPERTY DAMAGE
EXCESS LIABILITY EACH OCCURRENCE
UMBRELLA FORM AGGREGATE
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND STATUTORY LIMITS OTHER
EMPLOYERS LIABILITY X
E PROPRIETOR/ EL EACH ACCIDENT S 500,000
A AKNERSIEXECMIVE
FFIc1ERS ARE NCL =E%CL 6010979012008 08/03/2008 08/03/2009 EL DISEASE.-POLICY LIMIT S 500,000
EL DISEASE--EACH 500,000
EMPLOYEE
COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
NGELA SIROM HEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10WRITTEN NOTICE TO THE CERTIFICATE
OLDER NAMED TO THE LEFT.BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION
/O GIBELY R LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
149 MAIN ST
PEABODY,MA 01960 AUTHORIZED REPRESENTATIVE
ne,uO,Fen NEBS CUST61A"Prin Ong Servlre 1tO1ca9 W21 Nere...Ponrunwen.r✓M ea^59 +cow nea,.ecm
t
Page No. I Of 1 Pages
LENGIBELY CONTRACTING CO., INC- 18377 PROPOSAL
149 Main Street
PEABODY, MASSACHUSETTS 01960 All home Improvement contractors and subcontractors
engaged in home Improvement contracting, unless
(978)531-8234 specifically exempt from registration by Provisions of
FAX(978)531-9304 Chapter 142A of the general laws, must be registered
Submitted �_� with the Commonwealth of Massachusetts. Inquiries
To: _'-- t(-�Zjc+_--- about registration and status should be made to the
1 Director, Home Improvement Contract Registration,
One Ashburton Place, Room 1301, Boston, MA 02108
(617) 727-8598. Owners who secure their own
construction related permits or deal with unregistered
M A------ — contractors will be excluded from the Guaranty Fund
Provision of MGL C.142A.
Q REGISTRATION N0.
PHONE q� -a 8�5 I Imp MA. REG. 100811
i9
B NAMEMO. ICJ JOB LOCATION _
We�raby aubml cifm one aM stlmates far wo`c m padormed and matetleb tq be used. —
P-IcLcal��
�e
r
—ed
6
>�s
Gpi ructionI dye s
Of F
00
Se n o �— i
WORK eCHEDUIE
bout A will not begin the (rater. Or Me
Meng mateelay caused by the
cir Mid
docasll beyond eQgltraj.'gtofsgcpnbol!em wcunft s 0 ecolmplwledrin py rhino.Consect,,t win
OwMe ns Ran
acknowledges and agrees that the scheduiing those are approximate and Net augh delays ma Znet awitlaMe by the contrast of EgcypytleI'd as violations of NIa Aglo ro eet
WARRANTY �5411 Jowin coat lotion and shall comply v
The Canoranor war nis that Ne work furnishetl M1ereunder shell be Iree ham do'aCte 1n material and workmanship Mr a pee o d,employees or agents,is:11.6 Bred wit
the reeulrements of this Agreement.In the avant any`elect,s workmanship or materials,ie damage caused by the Canlretlos
one year after completion of any lob,including clean up,ma Contractor shag,at his own expense,MrNwith remedy,repeia corrco,replace,or cause to be remedieq repairs`,ar repbc
such ohmage at such tlefed in malarlals or workmanship.The beegotng warrentles shall survFre any Inspaetlan pre Or in connection with Ne egree6upon work.
We Propose hereby to furnish material and labor-complet in eccordpnce with above specifications,for the sum of:
p r } L, �- dollars($
Payment to be made as follows: 0 C4 1 j G �/,a
V❑ J
IS )ucoo pon signing Conhacf,G� 1p� {12"dVo' d -Name a5dom--rdWSrToesigWWc1�gm
A($ )upon completion of Sireet Address
T.($t)upon completion of Slate _shone
city/
shall be made foreerth upon ---- —'—
1 %($ )oomplagon of work under this contract. Pedetei iO N.
I
Notice: No agreement for home improvement contracting work shall require a down of Salesman
payment(advance deposit)of more than one-third of the total contract price or the - f�
total amount of let deposits or payments which the contractor must make,in advance, AWptlzed Spneture--
to order an`/or otherwise obtain delivery of special order materials and equipment. Now mbpmWaal may be vnmemwn try ua if rot eocapted wimin '
b
j '
Acceptance of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated.I undersV
that upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined site
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.
DO T SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
ram
SignatsignatureData /0 O signature
IV IMPORTANT INFORMATION ON BACK
Y
✓/t@ f00%1VAIOfrIlIA4�!/4 O�✓NRIddQ�BQb
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
uff Registration: 100811
Expiration: 6t23/2 6/23/2010 Trft 268971
.Type: Private Corporation
LEN GIBELY CONTRACTING CO.,INC.
Brian Dobbins
149 Main Street t�p y,aCLw`
Peabody, MA 01960 Administrator
-�,` Tie 106min6iswea/,GE ou�./�.aaaeai{atlafO '.
BOARD OF BUILDING REGULATKM
License: CONSTRUCTION SUPERVISOR
Number,.CS 094763
Birthdate:,05/14/1943
Expires.05/14/201Q Tr.no: 94763
Restricted: 00
TMOMAS R DOBBIN&
19 CEDAR HILL DRIVE'
I DANVERS. MA 01923 �'^'^' r
Commissioner