333 JEFFERSON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
l Board of Building Regulations and Stench ds I UR
r ,�, Mt'NIC'IP.\H I
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Massachusetts State Building Code. 780 NIR, 7 edition t IS
Building Permit Application To Construct, Repair. Renovate Or Denntlish a Rci tale/.hmuou,
One- or Tiro-Fam uz-
ily Dllin,e
This Section For Official Use Only —
Building Permit Num er: Date Applied: 0 0 V
I
Signature: -
sd IsCntr of BuildigBuildinE nunisionenpC ns Date
SECTION 1: SITE INFORMATION
1.1 Properh Address: 1.2 Assessors Map & Parcel Numbers
—S�!��i 2 C a� ✓_J_.`Ifs ._—_.-
l.la Is this an accepted street? yes no \lap Nwnber Pa]CCI Numhei
----- -- - ---------._".._.i
1.3 Zoning Information: IA Vrorerty Dimensions: -- ——"
�Zom—ing—Dntricl Proposed Use Lot Arra Isy 11U Frumuge Ittl
1.5 Building Setbacks(ft)
Front Yard Side Yards Rew Yard
Rryuired Provided Required Provided Required PI"Ub'IdC-al
r---
� 1.6 \Valor Supply: (M.G.L c. 40. §Sd) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone. Municipal ❑ On site disposal system 01
IFt--ublie ❑ Private❑ Check if yes❑ p p _
I SECTION 2: PROPERTY OWNERSHIP'
2.1 Own rt of Record:
�I c Ka1J 333 S
Name (Print) Address for Service:
9_-1 R -7 �4 o Q5
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Buildin Owner-Occupie(i; Repairswci :\lteration(s) ❑ Addition ❑
Demolition ❑ Accessory 3idg. ❑ Number of Units._ Other ❑ Specily: _
Bref Description ur Proposed Rrcrk' _ _t.{'._.:: "t2@_F__.�_C_fSd. ------
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only --t
(Labor and Materials)
I. Building $ I. Building Permit Fee: $ Indicate how fee is Jetetmined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa (Item 6) x multiplier x
3. Plumbing $ ?.
Other Fees: $
4. Mechanical (HVAC) $ List: / �✓ ' ���
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Chick Amount Cash :\nano'': _ �
b. Total Project Cost: $ r 5 a 0 Paid in Full 0 Outstanding Balance
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 0 Ct``, l-,,Z �I '-k—L O
-C)ohlr-, 1",_& License Number I:Xli ration Dale
Nano of CSL- Holder
y /J.IU �T T.o /-d�nO� /'1� List CSLf)pc(see below)
T e Uesrri nlion
\ddrcas
C Unrestric)rJ lu d, 35.U00 Cu. PI.i I
R Restricted 1..2 Fanuh' Dnselhne _
Signature M :Masonry Only
91 1 C L1 2
3y RC Residential Roulin`C'os rune
'felephune \\'S Residcnlial \vinduw .and Sedum _—
SF Rcoidantiul Solid feel Burtnn� .\i;lrmcc In.LJldn,�u
D ILesidcnn:d Uvnudwun
5.2 Registered llonte Improvement C+mtractor(IIIU)
L_P �rcboC 1� O O
-T 1j— -
HIC Company Name or HIC Reesnan,,..LL,,N, a ne Registration Number
l 4 9 M a t. 57-- i�v a lx�o V M a 8 1 5 GO
0--
y rp;raiun Dine
Signature Telephone ( j
SECTION (i WORJKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. e. 152. § 25C(6)) j
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to Pron'•:de
I ; '.`.a affidavit will result in line denial of the Issuanc,;of r;:e P b;r'ding ermit-
_
----------
Signed Affidavit Auached? Yes .......... 0 ........... ❑ ----
rSEC T1ON 7a: OWNER AUTHORIZATION TO SE .-OhiFk :-JED WHEN - —
OWiNEWS AGENT OR coNTRACTOR APPLIES FOR SU[LDING PF.RNIIT
I
suthorize_--_------ __—.--- _to act on my hehal 1. in all
relative, to stork c_?thoriae:l by this building permi: spphcation. j
I
Sienat arc.o- Ov r.
SF.C"I1(_.,N 7b: OWNF,R' OR A','1'IIORIZIsD AGEV t DECL.ARATiON
as Owner orCk—L, w Jiereby declare ;
at the statements and information on the Gxegoing application are true and accurate. to the best of my knowledge uud j
behalf.
T' ---
Print Name
Signature of Owner o uthoric gen Date
(Signed under the pains and penalties of perjury) _ ..
-- NOTES:
1. An Owner who obtains a building permit to do his/her own work or an owner who hires an unreListered contractor
(nut registered in the Home Improvement Contractor(HIC) Program), will not hate 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 I IO.R6 and 110.RS, respectively.
' When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basetnent/attics. decks or porch)
Gross living area (Sq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt/baths
Tvpe of heating system Number tit decks/ porches
'Type of cooling system Enclosed Open ---.---,-
3. "Tom) 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 Leeibly
Name (Business/Orgmization/indiwdual):�o Qi i �a L1l
11 .
Address: l t-F c M 1 t s r
City/State/Zip:'PP A :..,4 ;lA C / 9 G 0 Phone.#:
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with tt 4. Q I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).` have hired the sub-contractors
2.❑ I am a s--1e pr^prietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-ccntmctors have g. Ej Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers'comp. insurance comp. instuance.t
required.] 5. We are a corporation and its ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LCI 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 13.❑ Other
employees. [No workers'
comp. insurance required.]
•arty applicant that checks box qt rtwst also fill out the section below showing their workers'compensation polity information.
t Homeowners who subrrdt this affidavit indicating they are doing all work and then him outside tomtittors must subnrit a new affidavit indicating such.
.=Contractors that check this box must attached an additional sheet showing the name of the subKontiactors end state whether or not those entities have
employees. if the sub-contactors have employees,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
Insurance Company Name: I ° A L s ��
Policy#or Self-ins.Lic.#: Et C 1 Q C! 1 C C)R n/ CJ
� Expiration Date: - '3 C-
Job Site Address: -3 3 P 7— F�-1 J t c" o�., i' L-t- City/State/Zip: M 6�A t1\ 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 imprisonment,as well as ci-wzl 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 ceertifyunder thee pains and penalties of perjury that the information provided above is true and correct
Signature:A �. c>-e - o Date: / D — S'
Phone#• -I 3
Ofrcial 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 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ISSUE DATE 0713112008
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Edward 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 POLICYEFFECrIVE POLICYE%PIRATION LIMITS
LTR DATE(MMIDDKY) DATE(MMIDDNY)
GENERAL LIABILITY GENERAL AGGREGATE S
PRODUCTS-COMPIOP AGO S
=COMMERCIAL GENERAL LIABILITY
PERSONAL R ADV.INJURY
_=CLAIMS MADE=OCCUR
EACH OCCURRENCE
=OWNER'S d:CONTRACTOR'S PROT.
FIRE DAMAGE(Anyono lire)
FED.EXPENSE(An)w persw)
AUTOMOBILE LIABILITY COMBINED SINGLE
LIMIT
ANY AUTO
BODILY INJURY
ALL OWNED AUTOS (PCf person)
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY
GARAGE LIABILITY (Per azcidenQ
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 500,000
A PARNERSEXECUnVE
FFICIERs ARE: 6010979012008 08/03/2008 08/03/2009 EL DISEASE--POLICY LIMIT S 500,000
NCL =E%CL
EL DISEASE--EACH 500,000
EMPLOYEE
COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS:
Rurd"A�V
n_
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
NGELA SIRONI HEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL IB WRITTEN NOTICE TO THE CERTIFICATE
OLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION
/O G I BELY R LIABILITY OF ANY KIND UPON THE COMPANY.ITS AGENTS OR REPRESENTATIVES.
149 MAIN ST
PEABODY,MA 01960 AUTHORIZED REPRESENTATIVE
(�� wn'la iz: 'lk ,'S,w YA, Via'
LEN GIBELY CONTRACTING CO,,: INC r �N�w"4'"� y s �p�g�'
` ) _
" 149 Matp StfEet'ri+..� i c e Ya"•� �) t x rut
PEABQDYMASSACHUSEf7S0196n + _? x�' `ar'! ��+ 5 r�+d f�"SP-`f^�` . OVAL u.. .
' ')' ',e �" < u ` uc v 'tiL* AI(.h4!P@ Im�rgvament CeLlVaelora @nd aubco(Itractors
(978) -k engaged In homalmprovamant cot)tracting anises
FAX(978)631�9304^t;;JyCw$t, >y rG; �y s ltlo, (hr•. AmPt trgl�l�Fygletr�e n..bysRroYlslone.ot
Submitted C /� r r x;r„G 2rs' 'tf 2 G Ptalg7�77A ofigre gen8ral'lawa must be:registered
70:_.�� �C--_d:COCY O h ?- ' a^ t`:" ! y wlttl(1{�CoTmpnwealth of Massachusetts:;Inquiries
about istiatlon,and statue should be mad6;to the
+r)- C(rag{or Home,Improvement"Contract pegistration" `
xrr �$. .f ^„ ��%� y ) • 000 Aybburton;Place Room,:1007 Boaton, MA'02108 1
aMt (Bt7)""=,727 88887;Qwnera,who'I secure'their r:own .
_ S e� {M W r+4.`5}-�.��.F a4r �i•., " Jla Wna4'YCUotl:rolated.Permhs'tOr:deal:withunreglstared
' xa,, t"—y '•+ ;31 to wnVaetors will be elccludedcfrom the.queran Fund Provislon of MGL o.102A. ry
F FS c
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s /Q /• /!A � ' + Ir � %` ay r a A REGr 1Q0813 r
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1'Ja hurooy su nil spauooallons arW ashin.14,, [rgrk to pe pelpmpg yy mptgl(pb,ipyp !
Pam..
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Or
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Conslruc4on related permits a * �� - � 3.r eI. e g. 4 ..+
e'1E 'sh+ s°.h "I }?..K'rYA,uS ✓< r'm. ',yS"ft,1'mx
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� ,/1�/�I Gi C/'C i�_._, hi I "Y '>�,)f ham,t ry ,✓�' ,}.;� � S! .1''�"'4Tr)ra ,r,� `+fp t J. '
/� - ,w>•r+gs�}A:e S'..c.ty +:b{I '„ +.rx hl"Z 1+•Isaki( k^'( wt y'xJ4'-rCF � 1
' or„c eneou�a t e M+ll,y,+ rat t .s. a S `r..a'Y'}rr^. .wr r � eg+,• ., „%k ;..
Com ''7i7o II(of EG, �111e worts o IXda W nlaW Wa 0atore Na vied daY AVlewoe tly�m11+a a lit `.iaYnrlpeslllad Iw,Mn > n
aoo LeL oSa (oats) eamM�w pWOad M aroameams traobr rll n Its Huth m
Exey
acnr,c J alrpes list die edledalna data sala4f+bePlPIN�M (Ea41 'fhn eWMr Mr
f amb
Tns CO II now ants lM1al Ne woik saaaled 110raiMa,sMO Minio plan byq. 7y.�UFp4f1+'Ex nd�lt.
rhpf J pm Is oI IM1U AB Oament.In lbe eves allYfbWpN wo+MIBIgNp at104YIsiR'oCdaO�pa ar !j((,�bNOwala WnplBaorl end
bdbo0vared M a11e0 comply wlNM
one Sex anarmmplollan aany pb,old y,yd n _ Nlbrtnba(0M,M1ayWera ulna roan W.tM ComredIX Ilfron g9WIK',MRtlllb OppM0.TRrIKaIXf�WotoM anl0. N y l sucl '-mega or oucM1 deloclNnfeladaa IXworlmgnal�.'rbg bnaolgwananuea map aIXM'a'aoYnlpaFJbn arepla�,
(aagalsabaarolela OyeabialtllYVh." trx 2:' %J`t ��
VJe Propose Hereby to lurn(sn ms eriej n I o "
�Tt 4,�b 0•xco Ito 2, peolfl do Ior he PaYmsnt to be made as lollow9
k � N
I I P)lrn3'd 11ikA -
v (s )upon elanlng Conyacl '2 yJ, , '1C4+ u°s`: •r+`+"rSA+ a�
%' 'w`'T"GMt3 M'.l.kt•.^^ H .4w T.. .,, ._ -+R Ja'7Y(.
—_o14 )upon wmgatbnd
J'irr wJ'aSfRte� .ht
_>. ($
ponWlotbn of a A ' ' 4 ,t:
Notice. No agreement Whom bbIp �ItIp1I Y t l` y,:
gwstkaheY!s@!t4$,tPlp ant ll po a mom
tat amount of all deposits
N¢n pr�Pdldlt0ppY at�e yt -
N !ia order and/or olhpnvsa obtaina iayaef ,
lYhiFC4VLampiluUr sy _, T�• l .,:� J� }•* .;
Acceptance of Prgposa�(f,avey�rea�l,bo�y��td�,a •-"' ,I� '
(hat upon slgmng,this proposal bscortl g � '�- ans'pnAlw�, 3_ ur�� Srk '`
the date of this transactl0q"°Cahlcallation;rtlustbe One I, w �!� �M��,�'��da�J� a �} '
.:k. yap.DO NOT�SIG (g' O � F1t f 4aa
s 'fit r •r k�A, ,�SPAC S ;gg -rat ,- tSt,.rr
s�enn:,,u � 1., t• r .� ,� T
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Board of Building Regulations and Standards
HOME IMPROVEMENT 100 CONTRACTOR
Registration: 10081111
Expiration: 6123/2010 Trp 268971
Type: Private Corporation
LEN GIBELY CONTRACTING CO.,INC.
Brian Dobbins
149 Main Street
Peabody, MA 01960 Administrator
"' TXC UJ6fIL1XdX[(�eQlfla O�✓�g06fI0Alaga�f6
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number, CS 094763
Birthdate.-05/14/1943 „
j - Expires; 05/14/2010 Tr.no: 94763
i
Restricted: 00
THOMAS R DOBBINS -
19 CEDAR HILL DRIVE
DANVERS, MA 01923
commise