18 LARCHMONT RD - BUILDING INSPECTION (2) The Connttonwealth of Massachusetts FUR
Board of Building Regulations and Standards \II'NI('ll'AI J I 1
M:1SSaCl1tlSl'tIS State Building Code. 780 C NlR. 7"' edition l,Slf
Building Permit Application To Construct. Repair. Renot'ate Or Demolisha RcrurJ lolnwr� I
(\ / One- or Tit a-f uwnil. Dn elllqg
This Se ion Fo Official Use Only — --
Building Permit Number: D to Applied: LJ
Signature: - 7/� ----------
Building Commissioner/ Inspector of iilJing Dote ------�
SECTIO I: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
`jg l .p/L c h or 9b
I —
l a L; this an accepted street? Numher Parcel Numberreet? yes_ no_
L3 Zoning Information: 1.4 Property Dimensions:
"Zoning District Proposed Use Lot Area(sy If) Frontage I It)
1.5 Building Setbacks (ft) ----{
Front Yard Side Yards Rear Yard _,---i
! ReyuireJ Provided Requited Provided Required
1.6 Water Supply: (M.G.L c.40. §54) IT Zone Information: 1.8 Sewage Disposal System:
Zone: _,_ Outside Flood Zone'! Municipal ❑ On Site disposal system
Public❑ Private❑ Check if yes❑ --_
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
_ p f�
_ Liy O D .�n ..-- -�-0.5—_n i°�1aL7 0.✓�Kam_—.—_---.
-;,me iPrinD Address ror Service:
_ q R 7
in¢uaturc — — Telephone
F SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
NewConstrucuon ❑ Existing-Buildin wner-Occupi epairs(s Alteration(;) ❑ r\dJil,��n ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:_ _---
�Bncf Description of Proposed Work-':_ Sir- IZ P ROV a s— Q-o RnOF
- J
SECTION 4: ESTIMATED CONSTRUCTION COSTS
— Estimated Costs: Official Use Only
Item (Labor and Materials) ---
I. Building $ I. Building Permit Fee: $ Indicate how fee is delerru led: �I
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression)
A Check No. Check Amount: Cash :\nnuuu:_ __ i
b. Total Project Cost: $ 11� 17� ❑ Paid m Full ❑ Outstanding Bal:mce
Aga
Sa 6 i
a � �
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) y� 6 r
1 )Obbf�rJ S License Number 6spiralwn Date .
Name of CSL- I IoWer '
•)i � rn•Q.. ('.�__ .baDv Lisl CSL.T}fx(scc below)
�d ss `t Type Descri oon -
1- C UnresuieleJ)u u115.1Hit Col. [--I.)
R Restricted 1&7 Faind Dwelling -.
Sign sure M Nlasonn'Only '
�� s 3 Q a3 RC Residential Roofiiig Cusenng
Telephone WS Residential Windoko;utd Sidra
SF Residential Solid Fuel Burning \ t th:mce liulull.unui
D Re,idenli:d Denndnum
5.2 Registered jlgme Impr •ern,ent Contractor(HIC)
�. ..O.v (rr 6 o L C.bts� in 1p . --
HIC Rtmpml Name ur HIC Rc�atrant N nc Regisvation Nuinhei
�V � t� Q�6�flY 4-23 /0
Add
��y,_��- 9 / 53 1 S � Expiration Dote
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 .......... O 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.
I
I
_ I
Signature of Owner Date _
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
_o .^--' Ca>� �- ,as Owner o Authorized Agen ereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
-{—' ate--
Print Name
Signature of Owner o Authorize ent- - Dalc
(Si ned under the pains an nalties of-perjury)
NOTES:
1. 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. l42A. 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 base mendattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of halt/baths
type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted tier "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 (Businessiorganiaation/Individual): r✓ G, J,7a e, i t� P 1 tiylr
Address: I Lk Ci
City/State/Zip: Phone#: C1 9 9 S 3 k 8 a 3
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).# have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner- These sub-contractors have g. ❑ Demolition
ship and have no employees employees and have workers'
an capacity. 9. ❑Building addition
working for me m y p tY comp insurance?
(No workers' comp. insurance 10.❑Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ I required.]
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.]t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
-Any applicant that checks box H 1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then him outside contractors must submit a new affidavit indicating such.
$Contractors that cbeck 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: ►�}
Policy#or Self-ins.Lic.#: ' (01 () 9 ? !7 j c� O t� q Expiration Dater d
Job Site Address: 19 ( ,a 2 6, an rN Z i Rr, City/State/Zip: S4 L P M t1 0 k 4-70
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 is true and correct
Signature �
Phone#:
FOfficialuseonly. Do not write in this area, to be completed by city or town offtciaLn: Permit/Licensehority(circle one):
Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspectorrson: Phone#:
I 1 r ISSliG DATE 0713112009
RODUCER
'divard F Sennott Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INTORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
Agency Inc DOES NOT AME1D,E\"LEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
to Snulh Main Street
opsfid(L. M.A 01933 COMPANIES AFFORDING COVERAGE
NSVRED
en Glbely Contracting Company Inc
COMPANY A AI.M.Mutual Insurance Co
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE L1STlD BELOW HAVE BEEN ISSUED 70 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 CERTMCATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TIM TERMS,EXCLUSIONS. CONDITIONS OF SUCH POLICIES. LMIITS SHOWN MAY AVEI1 BEEN REDUCED BY PAID CLAIMS.
co
L(x ME INLPRANCF 1'OL10'NUM ER FOLIM'IMCTIVE PDLIn CLTIPA(I0N
LATE WWDUnI D.iII IIA NIDMr11 LWITE
GENEfi LMUM" OEIICFAL ALOF EGAT[
EO'L'I!fAIA IL`!C'I.:L GLIILY.AL yAtll Llil FE0000Sxm.F PALL.
u�CLJIA'++MnC[OCC R'F FEE 41I 1-0 AUY,IIIIURP
LJL W IIEF.':1 CD!li!ARO�S PFFiT U,CG UCCUU..EIICL
II -� PIFS D,LNACL IA W:I:Ii::l
n Vi O>IU91LE LIAbILIiL'
LIMIT
IM !INOLL
IIM.D I
'
nLL cwYI>y AV?LL. W-L-ILY IrUV F,Y
I 9:4EG1'l.L AU70S (ia pn:ul
HIPSC AVTOS
II 1101,OVIIED Awns 50011.1'1 UOF.Y
I�OAFAOE LIAPILrrT I%n cnenl
]eoFtFn DUAAa
pCOS LUBILIi I' fACM.000V!1aIC_
i VAIPRLLLi FJiH AGGFLGA
OTTEF.P.v,U UNDPSL' FW.
WORhTRS CON. ENSATLON AND
LIULO17"RS LlA Mrl' .AT LDniS STATE 10TEUt
IIE]RO]FUELCJ Au
,� ARUEF_.c:TCunV[ EL EACH ACCIDENT 50(I,Qpll +�!nlna:::CL
lua c:C:a 6010979012009 0S/03/2009 OS103/2010 LV EL DISEASE-
PGLIC\'LULrI
i00 000
i I '
EL DLSEASE-EACH -
___.__
tl
I
I
IGlTET1.:. .u, �ntL"-� . ;ua•�. .. L _ ,!s..;`,
HOEHD ANY OF THE ABOVE DESCRIBED POUCEES BECAVCELLEO BEFORE THE EaMATION DATE
F THE ISSUING COA@A.`Ll'W"LLL ENDEAVOR TO MALL IO WPUTTENNOTICE TO THE CERnFIGTE
OLDER NAMED TO THE LEFT,OUT FALLURE TO KUL Sl"NOTICE SHAD.D11POSE NO OBLIGATION
R LLABIITY OF ANY AND UPON TILE CO\(PAN-,RS AGENTS OR RFPRESENTATTVES.
0 WHOM IT MAY CONCERN
llEI'FIORIlED REPRLSENT:\TINE
6169
Page No. of / Pages
149 Main Street LENGIBELYCONTRA CO., INC. 2�914 PROPOSAL
PEABODY, MASSACHUSETTS 01960
/. All home Improvement contractors and subcontractors
(978)531.8234 engaged In home Improvement contracting, unless
(978)531-9304, specifically exempt from registration by Provisions of
Chapter 142A of the general laws,must be registered
Submitted /'' with the Commonwealth of Massachusetts..Inqui ries "
To: ({� / 'I_ (,J Ufl L1� about registration and status should be made to the
Dlrector, Home Improvement Contract Registration,
One Ashburton Place, Room 1301, Beaton,MA 02108
(617) 727=9598. Ownerswho secure their own
construction related permits or deal with unregistered
/ contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
PNONE pj samemanoN xa MA.REG.100811
(47lEdoo, S66 7�zz�d4
JOB NAMENO. JOB I OCgTIIXi
webJ auemll epetlficationo ark ea0metea br woM1 a be perlormetl arW meloriab to ee uaeC:
_LS d o 11�C£GPI E 1
/"001J _}- �W'O
---1 —�c�
�-
� •a �C:Cf tea Ni b g� �i' o�Iy a�//ParxJ s rda/.cl/r
—fir ,o A --
--sue ?� /9// /del 1514
f sC���1r
'cp a nL IhdC T J .r.7 f /�I - /
Sir
F/ �Pnc� �v /L2_c7i�7Yiir ._/-/2801.�
it
WOPK SCHE LE ,
C tom II t begl the ork or order the m dame s Oebre No eard day MbMng the signing of this Tr,morn M anises epedllep herein C nlm w II Eegln Na work oI or
aodrorus�ldal¢I.Barring delay cauaetl by dreumetances beyonE Cantnctore control,the wo,k will Ee cpmpleleo by - t O^y.Tha Owner heresy
Base are 1 WeacM1atlullnp tlatee ors approximate eM that path deleye Netare Wtevddade Ey the Con4ealonhell nptG nen red ev al Nb Ap,aamenl.
wrZAAAW
with
er rshemeThe an.or Ib thattthe L In Ne ewnrk adteo,eunder usual to wlarMmanshlhim rom dianoteriels or dams in dBendwordd enthepcontracpr.ol Idl poowaoa or agents,is dand acwot emU within
e hat In.n iry pormlect and
dame Fry nb sudvnVeOon,eml agents,
ne year alter r such boat any a Includlna dean in tM1e Contractor w all,at Ms own r—ded a brNwlN remedy,repel[cored roplace,ar ease to he rem aiietl,repaired,or replaced.
audl damage or such tlelecl in materula or workmanship The breadng warmnYee shell survlrs any lnapeclbn performed In mnnecYon wI1111M1e agmebupon work.
We Propose hereby to furnish ma7eriat a d lab -p�plet i^accor nce ith bow pecifications,far the sum of:
/IOJ I 71 71 p_
Payment to be metle as follows: 37X0 OS
% - 1�I upon&aping Geared: /Y ]1 P,�. lJ-- luema — rlo�ap8rem aepbven> __� �__ —
%ts\h/LI )upon mrmanorof
mead
ClryleM1le pryone
,bI )cl be made domain upon oa ////
platoon W work underthk eanirect P �p tD�a.'��
Ccn b
Notice: (advance d M br home re than one-wrd o ftheirig weaPat shall dd a down
payment unt ofllw aalfts)of more then one-third u 0f the dtel must
make pike ne Ifle
tool amount of all tlepoal, or payments wolfs the al order
make,In e edvenw,
to order end/or oNerwda obtain delivery of apedel ortlar materials and equipment
Wh'cM1everemfunte teeter Nota:TNe propaul may GVAadrmm b)ue ll rwlewptaf xiNln Eryp.
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.
////��// DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK,SPACES.
sbnmar/&Z� C4-4 cam` 4P oda Z ( Sommer. Dal.i
IMPORTANT INFORMATION ON BACK filles-
� �1��14i' F S} ti: ✓!LC UJOJlLIlt6lN!/F'¢�r/p 6� C�.�L,uac{tuoe!!s
BOARD OF BUILDING REGULATIONS
'spl License: CONSTRUCTION SUPERVISOR
I - Number:CS 094763
Birthdate: 05/14/1943
Expires:05/14/2010 Tr.no: 94763 _
Reatricte�: 00
THOMAS R DOBBINS
19 CEDAR HILL DRIVE C.�
- DANVERS, MA 01923
commissioner
_�
�-\ Boardf Bulld�l g� l�o 9
HOME IMPROVEMENT CONTRACTOR
Reg lstrallwt\,100811
'ELcpLrat�on �3/2010 Tr# 268971
i �1 ,Types Pnyiata Corporation
�4.
. LEN GIBELY CONTRACTING.P�O`.$IINC.
Brian Dobbins
149 Main Street
Peabody,MA 01960 -'-
Administre[or