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1 HAYES RD - BUILDING INSPECTION L jt' The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards Massachusetts Massachusetts State Building Code, 780 CMR, T"edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a � One. or Ttco-Family Dwelling This S ion For Official Use Only Budding Permit Number: Date Applied: Signature: l7 Building Cammtsswner/Inspects o(Bwidings Dam SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map dt Parcel Numbers 1-IaYrs CLp Ma Number Parcel Number I.la Is this an accepted street''yes_ no D 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Arca(sq It) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rev Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.a0,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ - � Check if es❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) Address for Service: Signature Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction O Existing Building- Owner-Occupied= Repairs(s)tA Alteration(s) ❑ Addition ❑ Demolition O Accessory Bldg.13 NumberofUnits _ Other ❑ Specify: Brief Description of Proposed Work': ruo s N11]t SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Of lclal Use Only Itcrn Labor and Materials I. Building f I. Bung Permit Fee: f Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical f ❑Total Project Cost'(Item 6)x multiplier x J. Plumbing f 2. Other Fees: f � d. Mechanical (HVAC) f List: S Mechanical (Fire S Total All Fees: f Suppression) Pa Check No. _Check Amount: Cash Amount:_ 6. Total Project Cost: f �t — ❑ paid in Full ❑Outstanding Balance Dur r ) SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 01 y ?6�& C` i 4_ / �`7 , 'ibr�' b b v, License Number EsJ � pirauon Date N,gme of CS/L/) 1 w ! rr., ry-�1 LCSL T • •4-s4 - -� r 1 eiT.` YPr 1>cr brluw) Addr s Type Description U Unrestricted(up to 35,000 Cu. Ft.) R Restricted Ik2 Family Dwelhn Signature ((�� .M Mascinry Only RC Residential RoofinX Covering Telephone IS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Reg stored Route Improvemeol Contractor(HIC) g L.o,✓ La v b.a Lim C',�✓-h / � o � � I HIC Companyy�'Name or HIC Rr�istranI Names Registration Number l g s 5Z'1"�Gt Expiration Dale Signature —J Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.S 2SC(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 7s: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:O7 WNEW OR AUTHORIZED AGENT DECLARATION I. L +', Gni b a i--v- C_l- B.,T as Owner or uthonze Aden ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. / DP- Print Name Signature of Owner orKuthorize gen Date Si tried under the sins and nasties of r ury 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 g&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 11016 and 110.R5,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(Sq. Ft.) Habitable room count Number of fireplaces .Number of bedrooms Number of bathrooms Number of halfbaths Type of heating system Number of decks/porches Ts pe of cooling system Enclosed Open 3. "Total Project Square Footage"may he substituted for"Total Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p Ivww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organizationttnaividna]): L 2 n/ Address: I Lk 9 tl 91,Z1 ST City/State/Zip: LC r, V' q Phone#: 9 9 15 1 $ x 3 Are you an employer? Check the appropriate boa: Type of project(required): 4. I am a general contractor and I I. I am a employer with 6. ❑New construction employees(full and/or part-time)." have hired the subcontractors listed on the attached sheet. 7. ❑Remodeling 2. I am a sole proprietor or partner- These sub-contractors have 1. Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. ❑Building addition [No workers' comp.insurance comp• a corporation required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' 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 him outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they most provide thein workers comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Be ow is the policy and job site information. ,//�� M Insurance Company Name: l"} T M tj t XU AI. 3:7445 C n Policy#or Self-ins.Lic.#: .[ D`9 7 D �� ©0 q Expiration Date: [ 0 Job Site Address:1 �✓ t -� City/State/Zip: !�_lLo, eez, i` 4 «�U 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. Simature �nJJ �r-� Date, 2 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#: ISSUJEDATE 07/311_009 RODUCER 'd\vaid F Sermon lasulance TMS CERTIFICATE B ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE AEencv lnc DOES NOT AMEVD,E\TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 16 South Main Street opAfitl[L MA 0I9S3 CONIPA,�S AFFORDING COVERAGE NsuRED — ----- an Gibely Contracting Company Inc cWffANY A A.I.M. Mutual Insurance Co THIS IS TO CERTff1'7H.AT 7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 455UED i0 Tlff INSURED NAMED ABOVE F00.THE POIJCY PERIOD WHICH THIS ERED.NFICATE AY BE IIS ANY OR LAY PE NT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO LL TI THIS CERTIFICATE MAYBE ISSUED OR CLAY PERTAIN,THE BNISURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBIECT 70 ALL TIM TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY 11 AVE BEEN REDUCED BY PAID CLAIMS. CO LIX n9[Of gRRAHCE FOLICYL[FTCTI\'[ FOLICA'ELWPATION IOLIW NUNB[R L'ArEIMBLODIn, DAT[OANIDIVTYI LIMBI LLNLfiAL LIA9ILI[Y GLJILFAL ACOA LATC OCO—N IHLCRI GLI LYaL W.b1Ui1 iP.OVVLISIUNFPI ALG Q IJGLi1M:(A:.C(OIXNR F(ILYHAL t AVV IIOVRI' L]cx'utAs L rnarnAnO.rs aeG?. R12 Dw✓JL[IA.:. enI 11.1uruMUtlILE LLWILIi\' IICt•[ASCII:[I:np..w-:1 COMp111ED iIRCL[ LIMB .LLL G'MILf AY?Ri ti•[•ILI'IMIVRI' 1 • [CNLGULiD AViOf On in,wl wPsvums it YaLcvv:DAVix WDILVIIIJUF.T :uecRT i I no[vn'Duu� — aCL(Y LUBILIi I' GCP.OCCV!l!NC! '.rI,ICF1LLl MFA AGOELUTL CLiEF.ntAV UMpItLLA IOPA XVORJXL CONUENSATION AVy AT CUBITS STATE THOI EaILPLOMU LIARILITI' xC 7P.VVPI[Tn'n/ Nu I 'a Air.¢>•;µ[un'V[ EL EACH ACCIDENT 5(1(1,(I(1D C7� 601097901'_OU9 06/03;1009 OSl03/1010 ma LV Ga EL DISEASE-POLIO\LL,uR 1 500,000 EL OLOYEE.-EAL�N U USE EE 500,000 mIc1JETy4 \ 7%7VMOMZED °D=iOF rl¢ABOVEDESCRIBEDPOLICEESSECANCELLED BEFORETBEL DLArIISSUING COATAVY'IVI L ENDEAVOR TO AIM,10%NTT'TW NOTICE TO THE CERrmcATEED TO THE LEFT,BUR EI TO LLUL SUCH NOTICE SEAIL DPOSENOOBUOATIDN OF.WS'RDTD UPON TRIECONIBAM•,RS AGENTS OR PITWENTAMI 0 WHOM IT NIAY CONCERN REPRESENTATIVE 6169 Pape No. I Ll x PROPOSAL � � !.EN GIBELY CONTRACTING CO., INC. 1 zQ 526 •� 149 Main Street yfactors PEABODY,MASSACHUSETTS 01960 All home Improvement contractors and eubcontunless enga,ad is home Improvement contracting, n by Provisions Of specifically 142A of Phe from laWs'omust be registers strall (978)531-8234 Chep FAX(978)531-9304 with the Commonwealth of status should berm Ie to the ration an at .ubmined / n� �(�/I Ot/[L(�— ------ about r72718596. Ow Bots 1301 Bwith n,r. A02108 To:Jr— �/1 Director,Home Imp 2 One Ashburton rovedi Pso W� --P -.'_ ._. -- - o as (617) ( S q construction related perm rl Q 1170.-- - - contractors will be excluded from the Guaranty Funtl --cu-VO — Provlsion of MGL c.142A. orae REGOTRWmN No. MA.REG.100811 aNONE Z-1-/0 1 � 1 7 / JOB LOCFTION dOrmetl antl malatlals to go' q'Icl .antl estL ales lOr work lO depa - wenere/Ms'ubmitspayJlia'1-n I S��P Q���-jp�'t_ C �-T— C? -- - b is 'Y'rMI_. - — ` IAy; r JL.pIGhC_ - - -- Consvuclion Lr� �-� 7 O m I finA9 n P fen - '" g' is iN O9 n9w H SGHEOOLEhandl L h%. k II l pl t d by L II not n me work en meet n, mater...end b Me day till g signing m f hall f 0 e a 4 ComraLlO Itlelel.Bening delay causaa b'Plrcbmatanc be tl C l l l Itl d by .>. //// f ll g p n M M1 tl py wIN eb°m 11 ripmrap ins fs is duw+aretlwthe' cktwwlaages ansa es NauhescnetlmmgdoneemeaPp'wi ale ens met naelay int me cnmmcmr.tianKontractPn,a plv)es nr aa^ ly or ragacaa. WARHANrY to be mmedied rape r Tne GonVacWrwarm^L9lM1alfne wenkmnu^e]hereunder shall be tree Vwn tlefed5'"malar al e"a actino peMrmetl In connecson with lM1e ngreetlup0^wo'k Ore requlremenU of mle Agreement In aro went any tlelect In woM1mensM1lp or malerals,or damage roused by se,loMwI1M1 rematlY.repaiG rurrect mP ace."r wase one year anar wmpleu-n-I any loo mduon,nein op,fbe rnmranor alae.mail surveme any nsP for the sum of: soca eamege or sato defect m"`.lotl+ls or wcrMmanamp Tne romgomg wanan dollars($---�) We PfOpOSe hereby to furnish material and labor-complete in cortlan wish ab vp specificahons, iPayment to be me./tle1 as followsfT I{ 5G0 I upon signing Cony Name of Lonvecio mealBna a 7 :: WJl upo(Eupwmpleli0n of eiy'Srere ,duo rvo. snaa be made mrewlm upon ionone completion of work under lois contmm. ��,�..,B.gy asman - prove (%.ball n,"im sown / - Nolice No ag'eemanl fm twine Im ment c-ntrac.ing w- paYm-nl ladvanw tleP-sill of more lhan t5 which M1ec onVano mucod, make,pina anb.. axed 5gnaae a adv% ,da,arisen,Of all deposit.OrpByrrta^ atonement, Ie:this Ploweal may ba wlmdrewn by ua 11 n" URPted wiNin m order an 11,Whimsies-blain delivery of special order materials Bntl equipmen. rvo meant a alar Acceptance of Proposal have read both sides of this document and accept the prices,specifications and contlitions stated.I understand that upon signing,thls.prop a becomes a binding contract. You are authorized to do the work as Spa after Payment will be made as outlined above. - You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day atter the data of this transacfile .Cancellation must be done In writing. I DO NOT SIGN THIS CONTRAC IF THERE ARE ANY BLANK SPACES. - Date 2� 4 rare sgnav,e sewwe�'d�� IMPORTANT INFORMATION 014 BACK I BOARD OF BUILDING REGULATIONS r License: CONSTRUCTION SUPERVISOR 3 Number: CS 094763 Birthdate: 05/14/1943 - Expires:05/14/2010 Tr.no: 94763 Restricted: 00 THOMAS R DOBBINS III 19 CEDAR HILL DRIVE G-� DANVERS, MA 01923 Commissioner p� Board of Building Regulations and Standards - HOME IMPROVEMENT CONTRACTOR ReBistratitIfu\ 100811 Explratlon: 6/23/2010 Trp 268971 TV* Private Corporation LEN GIBELY CONTRACTING CO..'INC. Brian Dobbins - 149 Main Street V Peabody,MA 01960 Administrator