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2 LANGDON ST - BUILDING INSPECTION
The Commonwealth of Massachusetts y� Board of Building Regulations and Standards CITY y '�D Massachusetts State Building Code, 780 CMR, T°edition OF SALEM Revised January \ Building Permit Application To Construct, Repair, Renovate Or Demolish a i. 2008 One-or 71vo-Family Dwelling This Section For Official Use Only ^ Building Permit Number: Date Applied: �\ Signature: �—)q//a Building Commissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted street'!yes_ no Map Number Parcel Number 1.3 Zoning information:- 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided i 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public❑ Private❑ Check ifyes0 Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Ownert of Record: r /1.✓ �D L- ,:q f_ tJ aaP S 1 Name(Print) Address for Service: - ':� `7.3 - -7 Signature Telephone \ SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Buildin Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify: Brief Description of Proposed Work': 5—t CL, to fz�.e Tr4- —F— pl� SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S 1. Building Permit Fee:S Indicate how fee is determined: �. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: S 4. Mechanical (FIVAC) S List: 5. Mechanical (Fire S Su ression Total All Fees: S O� Check No. Check Amount: Cash Amount: 6.Total Project Cost: S � q, �'� — 0 Paid in Full 11 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES r r 5.1 Licensed Construction Supervisor(CSL) n © Y-7 S 1 14 _ l p 'D O b b License Number Expiration Date Name of CSL- I lulder �-7 List CSL Type(see below) j t-4 `t n�-) , fi t`Ca cr ba�� r Description Ad J sr�s _ D llnrestricteJ u to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling Sig�na3ture M Mason Only RC Residential Routing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered {j�-o�me Improvement Contractor(HIC) 7 o C) �.OnJ (� �A•-�� HIC Cumpanxx Name or HIC Re i>��trant Name Registration Number AJ ress ^ It gS 3 t4�?1 -r p J Ex iration Date Signature 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 to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , 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 /;�E�CTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION Lr I L -c b r, L-r -I- ,as Owner or uthorized Agenh ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. _1_' Print Name Signature of Owner o Authonzed Agent Date Si ned under the ainsandpenaltiesol7peduryl 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 no have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and 110.115, 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 half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total 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 Legibly Name(Business/Organization/Individual): L O N Address: I Lk 9 t-1 At 10 S<- City/State/Zip: q Phone #: 9 9 8 5 3 1 8 a 3 Are you an employer? Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1 X I am a employer with L1__ 6. New construction employees(full and/or part-time).* have hired the subcontractors listed on the attached sheet. 7. ❑ Remodeling 2.0 I am a sole proprietor or partner- These sub-contractors have ship and have no employees 8. Demolition working for me in any capacity. employees and have workers' 9 Building addition O workers' com insurance comp• insurance,S p 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] 3.0 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 12.0 Roof repairs insurance required.]t c. 152, and have no employeees.es. [[No workers' 13.0 Other comp. insurance required.] *Any applicant that ebecks box Nl 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 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-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must 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. ,//�� /�, coInsurance Company Name: l^} M 11 I X V A L �it z S Policy#or Self-ins.Lic.#: I 092 ��j� tf Q Expiration Dated 0 4i � ti �T- City/State/Zip: l/ M t 1 O Job Site Address: L Q a3 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains and penalties ofperjury that the information provided above is true and correct. Slenature � G Date I Phone#- 04 -7 -R 22 t R 7- a 1J- FBoard only. Do not write in this area, to be completed by city or town o�ciaL n: Permit/License# hority(circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector rson: Phone#: 1F3ti 3�� A,, 1 •>�'.p".•, ,1. ISSVZD.41'P 07/31/7009 RODUCEK THIS CERTIFICATE IS ISSUED AS A WTTER OF INFORMATION ONLY AND dward F Sennett ITutuance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE ggency Inc DOES NOT AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. lu South Main Street Dpsfielfl a'I.A 01983 COMPANIES AFFORDING COVERAGE NSURED — — �n GllT ly Contracting Company Inc CmIPANYAAI,M. Mutual Insurance Co VA THIS IS TO CEATffI'7H.4T THE POWCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE lNSIIRFD NAMID AHOVE FOR THE POLICY TO INDICATED.NOTWIITISTANDAlO ANY REQU'DtEMENT,TERM OR CONDITION OF ANY'CONTR4CT OA OTF�R DOCUMENT WITH RESPECT TO WHICH TERM CERTFICATE MAY BE ISSUED OR\L4Y'PERTAPI.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBIECT 70 ALL TIIF TEAMS,E%CLUSIOFL5.4ND CONDITIONS OF SUCH POWC03S. LUIITS SHOWN MAY!'1.4 VE BFETd REDUCED BY PAID CLAIMS. CO Tll[Di IPR'RANR POLI(Y[fiECT11•[ POLIO.O4IPATIDN LIF IgLILY NUMBER t`AT[LNWODInI DAT[IMNIDgfYI LIMB( c[N[FAL LIABILIn' GDICR.LL AGBFCUT[ iR0VL L7S LV YACI ACC Ol IHH!'�.t"..1 L GfNLYAL llAblflll II-�� ➢Ei."hLCAUY IIUVRY Q u C W 4:MAC[QI:CNF [ALIT LLY U'iALKf G W1Cp'J 3 CO:?eAR03'[iFGT ll Pl DAMAGC Uw:+,il:l AUiuIIUtlILE L4WILIiY — -- COMDIIICD'INC.LC I IIMR � „IIy Al11L` .LLLGWIS 4U•(C :OLIL1"IIU VV.I' - I g:YCLf LEL AU iOf Iin rllml I'' I "OF CMII[D AUTO$ ecwu•uunec i Pwivn eANAa �CLEY LIABILITY uce aal!Anr1 '.,He:.uu ra.H AecacuTc I�CTYCF.T`Vrll VNBISL'1.FORM �-I��,� {�. . SVORISRF COMPENSATION AND TAT LLIfTTS STATE TBER EIIPLO%E LL MirY' Fu IIC iP.JiRIfTI:+I A �AEN[igp3eun'e[ EL EACH ACCIDE VT SO(I,QQ(/ I LKL ♦ti 6010979011-009 OS/0i 0 EL DISEASE-POLICI'LDIIT 3009 OSiO3/301 �—J LY 500,000 EL MEASE-EACH 500,000 I I F.FII LTL'7c:1TEl{Q- 1 T. HOULD ANY OF 715E.YBOVE DESCRLBED POUCRS BE C,LNCEI I BEFORE THE LTPP.FTLON DATE F.TI[E ISSLRNO COMPANY WILL ENDEAVOR TO MLAIL 10 A?rnN NOTICE TO THE CERTTPICArE OLDER NAMED TO THE LETS BUT FAILURE TO ALUL SUCH NOTICE SBALL PPOSE NO OBLIGATION A LIABILITY OF,UW)LIXD UPON THE COMPANY,rrS,1OENTS OR P.FPRFSENTArn U O WHOM IT MAY CONCERN / '17HORIZED REPRESENTATIVE 6169 iwrnumq 1.,as"or"ia'Dringn,1-111 reRsa" ' NE45.mv.vemrwarq. xoxw w.a neuean Of I Pages Page No.� y- -��` /LEN GIBELY CONTRACTING CO., INC. C PROPOSAL 149 Main Street 2 1 3 5 5 PEABODY, 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 law-,'must be registered Subinitletl •/�/ with the Commonwealth of Massachusetts. Inquiries TO:_ e�r�--r->e-q_D./-) about registration and status should be made to the / Director, Home Improvement Contract Registration, One Ashburton Piece,Room 1In Boston,MA 0210a L (J" -------- ----- (617) 727-8598. Owners who secure their own Sa/ 0 r construction related permits or deal with unregistered L(/yi contractors will be excluded from the Guaranty Fund Provision of MGL C.142A. a ONe pPTe Q R...preAnole No. MA.REG.100811 O JOB LOCATION �- Italians and estiopsts(tlr work to be parlor eM as are to useB. v > 9q'r1�1(�`ys cpecil 41 �7Z_ ,00 /��-- faltel, R - Old fir_ f_ _ 4 . -M - _ - Construc�toan elat°°��ermiLa WORK e EOVLE m unlass apecl'oan a 'I�r�rill, M1e k n or C I ^1 k p Na mBt I Cab m lM1rE a Y bllb rq a Oa9 1 0 Y nar,lal me work wl11 0e cam l i d br v W 'M1�%O M1 holes, (a 1).a me data, d 4 t M^ �Pt yY1 Y 0�ra}n M a, aural Ne aanedulme",as are politenest and uxi sWn aelxya lCei ere mlewklable who cenveel0, the C�SbO�s /'T✓ a dlowin m u d soar cons",wdM1 ma rN^vecfor warRms Ilranne woA mr^iYra]nereOrMer an9II he line win deb«ts Io malenal ana w^Mine^she"tar 9"art an s "a on a^ omne,y�aer slier^ lop W.nv cU ircwdirq clean u0 Oonlxto�seep rat M1m rpwvo save se�brlMMer m1a0y�epai[Imr_t,r '..`or ca'use"to em�9ea1 epahaa�ue�evlacoa. sure aamaQa or cuCM1 Mt«t I^malerlals or walkma^snlD.ma breaomg warremias snail sarvNO any ma"«IeM perklr^ad N^^nnecti0n wins ma aereabup0^work. We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: ) dollars($ Payment t4 be m e es lopows: 'I. is )upon signing Carteret; Nama or com2tlorme:pnme0 nngiseam ` K $ )eon compeeYon of etrear naarev v($ 1`hall be ad.happ antsuw phone i$ I chap la mesa ark in a a. th R^0« i1 omp,apon of work under the mnvacl. No iKv No agreement for tame Improvement contracting work shall require e a win eseP payment ledverca tleposi0 0l more Nan one-IM1irC of the total wnimcl price me see late,a,nounl of ell deposits or DeYmanb wmcM1 the caniradar must make,In pme e. A n law, erMlor our amiss obtain tlelivery of 6peeiel oNer meletles and qa, 1' ob.Is prcWaee may 0ev n or Keel.1 ecmpme whin aeys' e`L nl a greater. 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 madras 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. DO NOT SIGN THIS CONTRACT IF THERE AREA ANY BLANK SPACES. sia^awre one sivnawe "IMPORTANT IN RMATION ON BACK ry - 92. (9d/IL/Il6/N!M'llL�� O�.:GLAAN(C�NWP"CId z, BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR ii � - Number: CS 094763 Birthdate: 05/14/1943 Expires: 05/14/2010 Tr. no: 94763 Restricted: 00 THOMAS R DOBBINS 19 CEDAR HILL DRIVE DANVERS, MA 01923 Commisaloner I U✓4e �o>nxmdrr+eal!/� o�✓llaaaarle«eelG Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration\ 100811 ExpiraUon;._ 2010 Tr# 268971 :Type: Private Corporation LEN GIBELY CONTRACTINGCO.,'iNC. Brian Dobbins 149 Main Street . Peabody, MA 01960 ----- Administrator i