13 1-2 HERSEY ST - BUILDING INSPECTION N
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MAIL PERMITM L e„� G 1 b�-LY COtis
1 149 M A 1.,� S�
{�,aA I?CoK, Mfl D 19 &
i
No. 'd
APPLICATION FOR
PEPOWTO
LOQATION
PEFOAT GPANTM
ME;PECTOR OF
r
...•u.. r"wca 1 i vtr^KTMktHT 1
120.WASHINGTON VMMIT, 3R0 FLOOR
aALFM.MA 01970
TXL. (978)745-9595 ENT. a!O
FAX (976) 740-se"
`ISTAMAY J. UsOVICZ, Jlt.,
MAYOR ;
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MCR,a 40,334,I aclmowledp that as a caod1don
of Bw ding Permit IV .sII debris resulting froom the construction activity
governed by this BuildinS Permit shaft be disposed of in a pe<Oparly licensed soH waste
disposal fe aW, As defined by M(L c 711.SIMQA.
The debris will be disposed of at: _ T o �i Wig,i�i M �{
Location of Fsa
Signariae of Pemrii Applicant Dan
FULLY complete the followinS mfounahm
(PLEASE PRINT CLEARLY)
Name of Permit Applico t
J - 6.o1.V cr-� 7—
Firm Name, if any
Address. City& state
The above statute requim that debris fi+om the demolition,
h on, remo
vgbM rehab or other•
alteration of bluk3mg or swicttav be is s draposed propexly-lice Sed SOM&WW9
6lity as defined by MGL ca S I SOA, and the building permits or licamw are disposal
f
indicate the location of the fitcilitY•
The Conintompealth of Massachusetts
lu Department of Industrial Accidents
Office.of Investigations
600 Washington.Street
Boston,MA 02111low - .
tvtpi p.ntas s.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name(Business,Organization Individual): L .> i rr t ,r-i o L� l r' � 1
Address: 14 C1 -M 1 i t
City/State/Zip: jam— n q 1 ` n 6� t"') f1 Phone J `A
Are you an employer? Check the appropriate boa: Type of project(require[):
lI am a employer with iy— 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 7 ❑Remodeling
ship and have no employees These sub-contr ctots have S. ❑ Demolition
working for me in any capacity. AvorkcW comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME]Electrical repairs or addi c:s
3.❑ I am a honneowner doing all work right of exemption per MGL l LF] Plumbing repairs or addiiecns
myself. [No workers comp. c. 152. §1(1),and lye have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.] —
�ao applicant that checks box=I must also till out the section below showing their workers'compensation police indixnmtion.
t Homeowners who submit this allidavit indicating they are doing all wort:and then hire outside contractors must submit anew affidavit wdicaling such.
,Contracture that check this box must attached an additional sheet showing the name of the sub-contractors mid their workers'comp.policy information.
I tini ati iinplgper drat is providing markers'compensation insurmtce for my employees. Below is the polic),and job site
iirfarmution. (� �"
IusumuceCompam Name: , t -T M 1 "I ��+J Q l_
Police#or Self-ins.Lic. #: �i, (�. 4 C 9 7 %"d 1 D Expiration Date:
� `T,r
Job Site Address: L y ` P CL�e=o `��i City/State/Zip: `� gL.n t Y 1 A b i rl TO
Attach a copy of the workers' compensation policy declaration.page(showing the policy number and expiration date).
Failure to secure coverage as required under Sections 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 arh-ised that a copy of this statement stay be fom aided 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.
Sign><tture �iy C Date ! o -30-Ql
Piton#:
Ofjlciul use only. Do not write in this area,to be completed by city or tatty[ofliciul
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 1.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Pago No. I of 1 pages
_. —a LEN GIBELY CONTRACTING CO., INC.
149 Main Street
176a7�PROPOSAL
PEABODY, MASSACHUSETTS 01960
All home Improvement contraimprovement
and sung,, news
(978)531.8234 ectors
ngaged In home Improvement i contracting,Previsions
unless
epeclfleelly exempt from registration by Provisions of
ppp FAX(978)531-9304 Chapter 142A of the general laws,must be registered
Submittedter� _„ -1—� with the Commonwealth of Massachusetts. Inquiries
To:— -- about registration and Statue Should be made to the
t Director, Home Improvement Contract Registration,
1I�111r
4 h. �Z I'v� One Ashburton Place, Room 1301, Boston,MA 02108
(817) 727n related
Owners who secure their own
coned
tractors related permits or deal with ari my Fund
provision o will be excluded from the Guaranty Funtl
Provision of MGL G.142A.
PXO DFTE REOKIR.ON No.
T'S_zt, S�l'[y1/ q f ZZ�Q� MA.REG.100811 _
JOB NMArEMOo. 1 ZLs�' F juo=ATIONAA--
We hereby submit epedncabona 41ea1tlmele,tarwalk to be q Manned and meteb b rba sent: J
o� or-5
Of
f�'N
Construction relevant permits:
WORK SCHEDULE
Gonueclor pin r,ar DNer the maNtlaK before Me Plyd day hdit v nB Me signing of MIS Agreement,unbce apadlieE M1ereln writ p. on4eclor II begin Na xv,k an ar
about (tleto).earring delay caused by circumstances beyond contractors moral,Me woe will be completed by efe).TM1e Owner M1ereby
acknoMedgea end agrees Net Na ecnNuling come-maPnoxlmeNand Net such delays Nacre mica! able by lMcormatoratoll not be cor1±1 klkne of Nle Rpreamenl.
WARMN
Me rcontractorecommence
e 0 MIS Na Me woA Mevfamished Ice armat Mal be fromarro Item tlefecta In cur
eM cased W the Ica a padcd a blloxing M or alan and arse comply MN
Me ryoulremanb Glees 0any Job,
Neingmen up,
in connector
siaort his Sa a.ardemegerthalm Moody,
Crnar,cahkau eelws,am to bees oreWnb.btlbMRKd wINln
one your after co each
M PI any lob,ods or a Geer up.Ns no
shall,at he own expense,ym xec remedy refer,cm,act repuaft ore agre ed,m n massacre,repelretl,or reprecW.
such demegemauch detect In lNdsr�ele orwoMmawM1ID.TTe roregtlng warranties sell surNva any lnspecilon perbrmed�N cmnecllW wlN Me eyraeluyn work. '
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for th sum of:
dollars($ I.
Payment to bye� 'maado as follows:
%($71T� �+-\I been signing Convect Names CamenouOwpuled neoaeem
%(S—L)upon completion at _---.__—___. ___-_..__.—.._._—
BVaol addMe
%Is�lupon mmplagnoi an7suu
4mol be made forewlN upon
%I$ i IX mplindan al Nark used,one corltRa. Phone Foda211D NP
Nogco: No agreement for Name lmpoacment contracting work shall requlre a damn Name of seeemen � � `--
payment(advance dace elg of more Nan oneMlo of Na tool common
price or Ne
total amount of ell deposits or pay w"No Me conbeaor must make.In awence,
to order and/or omervelas obohn degaery of speatsl order materials end equipment, sae sip,.wn
hkhereramounte reefer tads.Tllw pCcoyy mryy eebarnm or ue u set e¢eaed name, dM
Acceptance of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated.I understand
that upon signing,this proposal becomes a binding contract. You are authorized to do the Work as specified. 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 after
the date of this transaction.Cancellation must be done In writing.
'D,Of NOT,SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. '
sgrewre /. �LV_(�— oem -'7�0 6 screares Dads
IMPORTANT INFORMATION ON BACK lb-
".., BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR }
� Numbe� 094763
S;rthdate-05M4119.43
Expues..0511412610- Tr. not 94763
ResdjGt6rh 0Oh
-
THOMAS R DOBBIN
19 CEDAR HILL DR11, , G-- i
DANVERS, MA 01923 (( :
Commisaionet. 1'�