2 HOLLY ST - BUILDING INSPECTION (3) The Commonwealth of Massachuscils
(' �I Board of Building Regulations and Standards Town of
f YtY Vlassachusens State Building Code, 780 CMR. T"edition BudJtw
J0 Building Permit Application To Construct. Repair. Renovate Or Demolish a
One-or Tuo-F mils'Duelling
This Sect n FoR Official Use Onlyl
Building Permit Number' `att A lied:>
Signature: IJAIVO ' ('� 7 /�
Building Commissioner/Inspector of Buildingf I Dats
SECTION 1: IN RINATION
.I Prtsfr Address: 1. Assessors Map& Parcel Numbers
"7 HLLV
1.1 a Is this an accepted street'!yes no Mito Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions.
Zoning District Proposed Use Lot Area(sq R) Frontage(n)
1.3 Building Setbacks(it)
Front Yud Side Yards Rear Yard
Requued Provided Requited Provided Required Provided
1.6 Wafer Supply:(M.G.L c.40..14) 1.1 Flood Zone Information: 1.3 Sewage Disposal System:
Public O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check if O s
SECTION 2: PROPERTY OWNERSHIP'
2.1 O i7'of Record: 1 �o l L ST
R N/✓/L
Name(Prim) Address for Service:
9 -7g -79 0 � 30
signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Existing BuildingdiF- Owner-Occupied epairs(s).XL I Alteration(s) O Addition O
Demolition O Accessory Bldg. O Number of Units_ Other O Specify:
Brief Description of Proposed Work': J2 L-A c Le.i w
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials !
I. Building S I. Budding Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
I Electrical g O Total Project Cost'(Item 6)x multiplier x
Plumbing S 2. Other Fees: S U
4. Mechanical (HVAC) f List:
t Mechanical (Fire f Total All Fees: I.
Su rest on
O O pp Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S i 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL) Cl TI y,ta3 -- 04 - L0
'' . 'T— T)o 6 b C.tif b,cn.e Numbr Espnation Date
.NOW tift CSL IIQIJer Lin CSL Type Ixrc below)
• -`i s A� J T s.�A j97
Type Description
AJJres
a o U Unrestricted I up to (M Cu, Ft.
R Restncted 1&2 Family
Dwelling
Siyrumre M Masonry Only
RC Residential Rooting Covenn
Telephone w'S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement ontractor(HIC) , R 1
Liv Grb�Lf ��-vr^
HIC Compan Name or HIC Re ustr t Name Registration Numb rk
T T 9 �-i ram TPOg 6Z3D L -z 3 to
A
Expiration Date
SigNNrc Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. c. 152.1 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.......... O No...........0 -
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L 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
I SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, L !.✓ Cr(.�- L-0 L-V r— ,as Owner o Authorized Agent ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Prim Name
Signature of Owner or Authoriz gees Date
(Signed under the pains andpens ties o perjury)
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 @A 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 790 CMR Regulations 110 R6 and 110 R5. respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage. finished basement/anics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
,Number of fireplaces Vumberof bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/porches
T�peof cooling syslem Enclosad Open
1 'Total Protect 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 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
i -
Name (Business/Organi7atioo/Individua]): L Q n/ Gt IJo LV Ce,,u—Iied C 1 tiv! n i
Address: I L( 9 H At..� SZL
City/State/Zip: Phone#: 9 9 5 3 l $ a 3
Are you an employer?Check the appropriate box: Type of project(required):
rr��rr��tt 4. ❑ I am a general contractor and I
1.�l I am a employer with f L-�' 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
Listed on the attached sheet. 7. ❑Remodeling
2.El am a sole proprietor partner-
ship and have no employees
These sub-contractors haveyees 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9.
❑Building addition
[No workers' comp.insurance comp. insurance.:
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 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]: c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
Other—
comp. insurance required.]
'My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors most submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide 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.Insurance Company Name: ►/�^ } t+T'U AL r415 Cr)
—
Policy#or Self-ins.Lic.
D#: [ 9 D D q Expiration Date: 0-3
L j a
Job Site Address: -A C2 L,��( P` City/State/Zip: AL, +, MA \Cl_l'p
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 iss true and correct.
Signature �G
Phone#: 5
FEdonly. Do not write in this area, to be completed by city or town official
n: Permit/Licensehority(circle one):Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
rson: Phone#:
" N ISSIB D.4TL 07131POO9`
' RODUCER
'd\vard F SennoR Insurance TIM CERTIFICATE IS ISSUED AS A MATTER OF NFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
Agcncv Inc DOES NOT AMEND.EVEND OR ALTER THE COVERAGE AFFORDED BY THE
16 South Main Street POLICIES BELOW
upsfickL MA 01933 CONIPAINIES AFFORDING COVERAGE
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•n 01bely Contractmw Company Inc
coMPANy A AI.M. Mutual Insurance Co
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THIS IS IN I ATED THAT THE POLICIS OF Y REQUICE LISTED BELOW HAVE BEEN ISSUED TO THE INSURID NAMED ABOVE FOR THE POLICY
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PERIOD INDICATED.NOTWICNSTAWPIG ANY REQUDiEMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
TO WHICH THIS CERTIFICATE MAY BE ISSUED OR NLAY PERTAIN,THE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL THE TERMS,EXCLUSIONS. COW ITIONS OF Sl1CH POLICIES.LLM S SHOIVN MAY]l.4VE➢EEN REDUCED DY PAID CLAIMS.
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HOIRD AN'Y OF TH ABOVE DESCRnED POUCEES BECANal'm BEFORE THE L-OMATION DATE
F.THE ISSLIDIO CUPIPANY ll ENDEAVOR TO MAD,ID A777TENNOTICE TO THE carmCATE
OLDER NAIAD TO THE LETS BLn'MORE TO ELUL SUCH NOnCE SMALL NGIOSE NO OBUOATION
A LLA807TY OFANY F.LNO LNPON THE CO\IPANY,ITS AGENTS OR RDRESENTArRI
TO WHOP4 IT 'MAY CONCERN _
11rRNORIZED REPRESENTATIVE
6169
- / of
LEN GIBELY CONTRACTING CO., INC. Page No. Pages
r / PROPOSAL
149 Main Street /
PEABODY, MASSACHUSETTS 01960
All home improvement contractors and subcontractors
(978)531-8234 engaged in home improvement contracting, unless
FAX(978) 5 1-9304 specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered
TO.
Submitted / with the Commonwealth of Massachusetts. Inquiries
To C_I Q Q. P. _-_ /J� about registration and status should be made to the
y / //� �� Director, Home Improvement Contract Registration,
I One Ashburton Place, Room 1301, Boston, MA 02108
(' (617) 727-8598. owners who secure their own
J Cr f� C t F'70 construction related permits or deal with unregistered
/ / contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
PRONE DATE REGISTRATION NO.
97,9) 7Ld-�," MA.REG. 100811
IOB NgME/N .
JOB LOCATION _
S fM�
varietal Submit specifications and estimates forceuk to be performed and materials to armed
(�`A ` PNe \\ °�2l/'^a,f• W_ cI2rLS/
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Construction related
6 f
lL Pr7 0 ic, %,e,
WORK SCHEDULE - j
aonlmct n In to Ny or order a-
balore N¢ did following the signing of Ibis Agreement,unl¢ss specilietl Herein wnf}T Vaetp�will begin the work on o bout_ (dp661e).Baiting delay Caused by cimumslancas bey0ntl Conbador's control,the work will be completed byn[- ate).Tho Ownar Hereby acNnowl¢tl9 ',deaths 1 scheduling dales are approximole andihal such delays that are not avoidable by the c.oraclor�n�.. pSo ,tlereda "ions of No Agreement.
WARRANTY
✓c Y
The Contractor warrants that the work furnished hereunder shall be free from defects in material and workmanship for a period of following completion and shall comply wild 1
the requirements of this Agreement.In the Men,an,deted in workmanship or malerlals,or damage caused by the Contractor,his subcona ace"be employees or agents,is discovered within ne year alter completion of any job,including clean up,I,.Cornractor shall,el his awn expense,forthwith remedy,repair,correct,replace,or cause to be remedied,repaired,or replaced
such damage or such detect In materials or workmanship.The foregoing wartanlies shall survive any inspection performed In connection with the agreed-upon work.
We Propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum Of:
i
($
Payment
m to be a dollars
as follows. ). )
%(S'Z/ooq upon signing Contract: ��//'�l'/�(�
Name of Con�vr/Olanclaled Fe l or
upon completion of
i sire.,Address
%IS )upon completion of /
co'c na Phone
eo I$ )shall be made lorewith upon
completion of work under this contract. Phone led...110 He. tt1
Notice: No agreement for home improvement contracting work shall require a down ales-man
payment(advance deposit)of more than one-third of the total contract price or the i
total amount of all deposits or payments which the contractor must make,in ativance, - 1
,a order and/or otherwise obtain delivery of special order materials and equipment, orized signame
whrup t q,4E, Nol�Tma wwpsm may rid wkherawn Wcan rim accepim wnhm ?oar.. i
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. I
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 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
slamwie �(yJ Opt Sim/r y1 �, Data cli 0 i
Signature Had
IMPORTANT INFORMATION ON BACK I111111-
i��- .`- [✓/te V/Ogt/It6RIlH!UG�� Ow G�Q:U(LGtUJfL�
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
`- Number: CS 094763
Blrthdats: 0 5/1 411 9 4 3
m
- EXPires:0 6/1 412 01 0 Tr.no: 94763
Restricted: 00
THOMAS R DOBBINS
19 CEDAR HILL DRIVE
DANVERS, MA 01923
Commissioner
71.
Board of Building Regulations and Standards -
HOME IMPROVEMENTCONTRACTOR
Registraticrl:, 100811
Expiration:,,6/23/2010 h# 268971
i, 'Typti: Private Corporation
LEN GIBELY CONTRACTING CO'
Brian Dobbins
149 Main Street
Peabody, MA 01960 - -------
Administrator