118 HIGHLAND AVE - BUILDING INSPECTION The Conunomaealth of Massachusetts
r Bomd of Building Regulations and Standards I OIZ
'Y "' Ml'NI('ll'.\I.I'll
� '� ,� Massachusetts State Building ('ode. 7S0 ('MR, 7 edition I ltil[
1 Building Permit Application To C'onstr ICt. Repair. Renovate Or Demolish a Hrris,d Jointw,
tcu-Fumit', Dtrrlling
This Se'tiun Fur Official Use Only
fBuilding Permit Number: Date Applied: Ito, 2�- O C7
we: l0 3� �d---
&iilJing Conunis. oncr/ 1 - e uildings Date
SECTION 1: SITE INFORMATION _
I.1 Pro er[Y Address: 1.2 Assessors Map & Parcel Numbers
I.la Is this uu accepted street? Yes_ no Map Number Parcel Numner
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use � I of Area(sq i:7_ ._ Frontage l til
LS Building Setbacks (ft)
Front Yard Side Yards Rear Yard
! Raluired Provided Required Provided Required P1i-,
I
rI- Water Supply: (M G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'.' Municipal ❑ On site Jis osul s sten: ❑
Public ❑ Private❑ Check it yes❑ P P y
SECTION2: PROPERTY OWNERSHIP'
0 trt of Record: --
Name(Prino Address for Service:
re
C1 Z R -7 -11 Q
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKz(check all [hat apply)
N,ew Construction ❑ Esis[ing Buildin Owner-Occupied Repairs(s Alterthon(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: —
Brief Description of Proposed Work": Hau fro I?t�7�
I
SECTION 4: ESTIMATED CONSTRUCTION COSTS —�
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa (Item 6) x multiplier x
i
1. Plumbing $ a. Other Fees: .$
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Total All Fees: S
Suppression) -
Check No. Cheek Amount: Cash :\mount: _
6. Total Project Cost: $ 4 5 0 0 Paid in Full 0 Outstanding Balance Due:_ ___
SECTION 5: CONSTRUCTION SERVICES c
5.1 Licensed Construction Supervisor (CSL) O 9 41 te`3 S—1 Ll—10
k.
�olnht,u• C License Number lixpn;wun Uma
Name of CS I_- Ifolder
A r �- 1"J.p 11 �rak Lis( CSL Type Isce below)
1dd ss �" T c Descn Ilion
l l:nrestncled (tip to 35.(H)l1 Cu. Pl.i
�—J R Reslnclad I&2 F mile Dwelling
Signature M Masonry Only
53a as- �� RC Residential Rooline Coserme
Telephone \1'S Reudenti l Wmuow : Id SlLding
I
SF iL�il Solid Fuel Bmlmlg \ >>li:mcr 1111l,l dll1111
D Re.idenual Dentuluwn
5.2 R:�;red Ilorne Improvement Contractor(HIC) + I --
L. ,p�.� !n r �/ COv�
HIC Cunip;my Name or HIC Rcgatrant N� nc Regisuauon Number
I t 14 MA z �r bn—ke
Address 6-Z�— 1(�--
9z 13�c Expiration Date
I gnatul _ 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 (o pnrcide
this affidavit will result in the denial of the Issuance of the building permit. -
Signed :'affidavit Attached? Yes ........_ O No __...... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES NOR BUILDING PERMIT
as Owner of the subject property hereby
authorize - to act on my behalf, in all mailers
relative to work authorized by this building permit.app!ication.
I
SiEnmure of Owner Date__
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
...---, as Owner or( uthorized Ag_n hereby dec late
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
T^
Print Name q�f �O_-2— _.O,g
Signature of Owner o"A�uth—o—rr eu A enr Date -
ISi ned under the ains an pcnalties ofperjury)
NOTES:
L An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(nut 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
Construcoon Supervisor Licensing (CSL)can be found in 780 C'MR Regulations I l0.R6 Lind I IQ.R5, respectively.
2. When substantial work is planned, provide the information below:
Total flours area (Sq. Ft.) (including.garage, finished base ment/att ics, decks of porch)
Gross living area (Sq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of half1baths
fvpe of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Toed Project Square Footage" may be substituted for "Total Project Cost"
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wrvw.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name(Busmess/OrgmizekonnMividml); LY
Address:_ / L4 q /11` g r ti s r
City/State/Zip:�c� ra �. ...4< l�7 C / 9 6 O Phone#: Cl q `: S.3 1 s 3 `i
Are you an employer?Check the appropriate box: Type of project(required):
1.� I am a employer with y 4. ElI am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).` have hired the sub contractors
2.❑ _I am a_scle proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These s-.:b ccmraetors have g. ❑ Demolition -
working for me in any capacity. employees and have workers' 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 their11.El 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' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 most 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 hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contrectms and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers:cbngt.policy number.
I am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 17 1 ] 1 v T c 4 L
Policy#or Self-ins. Lic.#: Et Q I C Ct '-1 7 O 1 C O Expiration Date: 0 9 - U 3- C 9
Job Site Address: 1 t F In L d-,.5 ✓.1 Lr-t City/State/Zip: _S.41 o✓'a-r M n ZD tj -7(7
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 i ip.sonment,as well as civil penalties it 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 penaltiei ofperrFury that the information provided above is true and correct
Signature �11G�—��s_t Date;
Phone#:
Official use only. Do not write In this area, to be completed by city or town offrciaL
City or Town: Permit(License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Tovv%Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
t „ ri, ISSUE DATE 07/3U2008
, .
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
dward F Sennott Insurance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
Agency 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
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 POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MMIDDM) DATE(MMIDDNY)
GENERAL LIABILITY GENERAL AGGREGATE
PRODUCTS-COMP/OP AGO.
=COMMERCIAL GENERAL LIABILITY
PERSONAL k AD V.INJURY
=CLAIMS MADE=OCCUR
EACH OCCURRENCE
=OWNER'S k CONTRACTOR'S PROT.
FIRE DAMAGE(An)we
MED.EXPENSE(Anyone persm)
AUTOMOBILE LIABILITY COMBINED SINGLE
LIMB T
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (PL prowl
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY
GARAGELIABILITY IN,o &.H
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 ARNERSEXECUITVE
FFICIERS ARE. 6010979012008 08/03/2008 08/03/2009 EL DISEASE--POLICY LIMIT S 500,000
INCL =EXCL
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 SIRONI HEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL QWRITTEN 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 Au rHORIZED REPRESENTATIVE
IT
Page No. �_of / Pages
YCONTRACTINGCO., INC. 1 �5 PROPOSAL
149 Main Street
Y, 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
with the Commonwealth of Massachusetts. Inquiries
.. --C�GpDM/Cns --- - -- - -- about registration and status should be made to the
Director, Home Improvement Contract Registration,
��I/ ��d One Ashburton Place, Room 1301, Boston, MA 02108
l (617) 727-8598. Owners who secure their own
M i� - O l 97Q_. _ __ construction related permits or deal with unregistered
,(,,,1 - - - - contractors will be extludatl from the Guaranty Fund
/ ProvisionGATE �} REGISTRATION NO, MA.REG. 100811
,d O J< /��� JOB LOCATION
Wen by subm t spec f/[�dons and estimates for work to be pedormetl and materials to be dead: - - - --
_ _. ------
/"-
- A /
Jd
__ (I t / GEC t l✓c�T'ri b°'✓�i-L.[-r VC eS
,.•.O� `.� J /`'�L c.,� _.f'Jwl dG_✓:� ,S�I 1 .� �.—S - n i .__.—.
(,j) P) alC7C
Constr
> oNs -
I uction related permits
1 - —
I WORK SCHEDULE IID A e t unless specified heron wrl a.. Vacl(date).T� O hereby
jContra will t ba New k d the le h 1 IM1e third day following the '9 9 O YYY///
1 about�—(data) 0amng delay caused by Clcumsldnce5 beyebtl CO I odors ont ID oM will De completetl UyI adds.,
acknow tlgos and ag,evs Tha1100 sche0ullnB dales are aDWoxlmato and That such delays that ale not avpida010 Dy Pa conwcfor shall not De cote bred completion and shais ll wiN
WARRANTY
wetl by Ne GontmcmA hiz subconvotlors,employees or aAantz.Is tli Wovero0 wiNm
The Gonlrador warrants Thal Iha work lurnisbed hereunder shall be Iree Irom tl¢leca In materiel and workmanshp lo!a period of g
the requirements of this Agreement.to dw event any delem,n workmanship or malerbls,or da ege„ca
one Yaar atlor completion OI any job,indutling Been up,the Oontractm shall,al his own expense.PoPotNwitD ran dey, rnei4 totted,replica.Or cause lobe romodled.reDaire4 or,eplac
such damage or such defect In malwials m workmanship.The Iwegoing warmness spell survive any Inspection perlwmad In conn¢dion w11D IM1e agreetl ul%,n vrork.
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: )
q �o dollars($
Payment Id be made as follows. �� f; oa
ne S uppe algning Contract Name M Can, la designated Re/g/i/$i
e„($_641_)upon completkm of Street Address
)upon completion of ' sees.
ferore P
N shall be made th upon F tle anp Nv.
Pny,m• / Gt,� o'er-C�.
P 16 )completion of ve oi Up this centred. ✓NSA`'
It n
1ti pay e', No agreement for home re than one contracting work shall acquire a down Name of Salesma L J
payment amount
at all
barbells
of more is one-third of me total contend price or the h
to
order ant of alldepositsorpadelive Which meal ordd oaten melee.in advance,euipmet. M,lhiseignawre
to order and/or otherwise obtain delivery of special order materiels and equipment. dal
A h Il��t tag Note:T is p,opoa may he wi b2wnb uaHrotdttepleO whin
o-.
ill Acceptance of Proposal I have read bath sides of this document and accept the prices,specifications and conditions stated. understan
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
B,1 the date of this transaction. Cancellation must be done in writing.
DO-NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
l • ' \. 10�2�-D� lgw,a DrI¢
/ cars sna
Sigvaw, IMPORTANT INFORMATION ON BACK 10
.-
7k ClcL o�✓ka�aaQL..eelQ
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 0081
lug Expirati 6
on: /23/2010 Trill 268971
.Type: Private Corporation
LEN GIBELY CONTRACTING CO.,;INC.
Brian Dobbins
149 Main Street
Peabody, MA 01960 Administrator
.N
r.: Tire i00m�N6It[(�B¢UM1 �`�
BOARD OF BUILDING REGULATKW
License: CONSTRUCTION SUPERVISOR
Number..CS 094763
Birthdate:'05l1411943
:- Expires:05/14/2010 Tr.no: 94763
Restricted: 00
THOMAS R DOBBINS -
19 CEDAR HILL DRIVE /
DANVERS. MA 01923 r
commisaloner