12 LEE ST - BUILDING INSPECTION ° w
1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR, 71' edition MUNICII'ALI'll'
r-•''� list:
Building Permit Application To Construct. Repair, Renovate Or Demolish it Rei isrd./unmur
One-or Tire-Family Du elling /. _llnb'
This Section For Official Use Only
Building Permit Numbe Date Applied:
Signature: air/6y
Building .omntissioned Inspector of Buildings Date
SECTION l: SITE INFORMATION
1.1 Pro per .ty Address: 1.2 Assessors Map & Parcel Numbers
6 L� S-T--
l.la Is this an accepted street'? yes_ no :Map Numher Parccl Numhcr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq (t) Frontage(it)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private ❑ Zone: _ Outside Flood Zone'?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1,..Qwneitt of Record•
�ttio s �K� vL ,�► � _ 1C, L.1 � �
Name(Print) Address for Service:
47 � �� � 1 -77 .7
Signature telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s-§B—r Alteration(sj ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Workz: T d
d-- �� T� 2 C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S - L Building Permit Fee: $ Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Costa (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su ression) 'S Total All Fees: S
6. "1o[al Project Cost /
7 6 p O� Check No. Check Amount: Cash :\mount:
$ � ❑ pa{d in Full 0 Outstanding B:d:ux'e Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) Q I y /0
b License Number Expiration Date
Name of CSL- Holder List CSL'rype(see below)
q �. M n I, S—r ?,A b.00 Type DeSeri 1tiun
4ddr sS ���� U Unrestricted(u�)00 Cu. Ft-1
1�11 d R Restricted I�C'_ Famil Dwelling
Signature `^ yl masonry On]
A� � S '� \ X Z� � RC Residential Rooting Coverm
Telephone \VS Residential \Vinduw ania Sidm,a
SF Residenti:d Solid Fucl liunung A>>liancc liuwlluuun
- p Residential Demolition
5.2 Registered 1 nine Improvement Contractor (HIC)
L. Registration Number
HIC Company Name or HIcJ Re strum N,ruuf>� 3—
Address CZ 9—�r1 S 2' lZ Z3Ui Expiration Date
Telephone
�—t
Signature
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152. § 25C(6))
ation. Failure to provide
Workers Compensation Insurance affidavit must be completed and submitted with this applic
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... ❑ No ........'.. 11
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
I. to act on my behalf. in all matters
authorize
relative to work authorized by this building permit application.
Date
Si nature of Owner
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agen hereby declare
1, L_
that the statements and information on the foregoing application are[rue and accurate, to the best of my knowledge an
behalf.
1�- �k-b 1,01>4
Print Name 1� �--- o Z
r 4uthortzed Agent
Date
Signature of Owner o
(Signed under the pains and penalties of egurv) NOTES:
1. 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 not 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 780 CMR Regulations I I0.R6 and 110.R5, respectively.
Total floors area(Sq. Ft.)
2 When substantial work is planned, provide the information below:
(including garage, finished basemendattics, decks or porch)
Habitable room count
Gross living area(Sq. Ft.) Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms
Number of decks/ porches
Type of heating system Enclosed —Open
Type of cooling system
�
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 1. Please Print Le2ibly
Name (Business/organization/Individual):e , fj L-Y C-bw ST
Address: 1 Lt 4 M A Ia ST
City/State/Zip:R' 4 be .�Vt MA 6 1 9 LA Phone #:
Are von an employer? Check the appropriate box: Type of project(required):
j 1.911 am a employer with�14 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
E_ I am a sole proprietor or partner-
listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' cgmp. insurance. g. ❑ Building addition
(No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL l l.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
AnP applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
' i lonreowners 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 their workers'comp.policy information.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
injottnarion. A-
!rsmance Company Name: A Y M 1_I t r—V' 4/ A N c c O
Policy # or Self-ins. Lic. #://� 1 9 g V Q Q �f Expiration Date:._Q nQ,g
Job S /-
-Site Address:_ �o ,�_ o S T City/State/Zip:_ YL.on-, ,/�)s] 0\9-1 O
Artach 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 a 152 can lead to the imposition of criminal penalties of a
ring up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Uf up to S250.00 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.
' /du hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
sw uu� �: �
fY� �1 Date S—Z 2 erJ
'hone r: U S 2-
Official use only. Do not write in this area, to be completed by city or town official.
Cite or Town: Permit/License#
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk. 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone th
Page No.'Z of Z Pages
LEN.GIBELY CONTRACTING CO., INC. 18107 PROPOSAL
149 Main Street
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subeontractods
(978)531-8234 engaged In home Improvement contracting, unless
specions of
FAX(978)531-9304 Chapter 14lly exempt from registration laws,
m st be registered
i
Submitted - Chapter Coo of the general laws,
To: DQI/IIS KQU/ends with the Commonwealth of Massachusetts, Is to the
about registration Home
I and status should t made to the
16 L t /, Director,Home Improvement Contract n, MA
e' r One Ashburton Place, Room 1301, Boston, MA Down
S0.ley" /r,l'/ 01M (ons) 527-8598, Owners who secure their own
construction related permits or deal with unregistered
/ contractorsProvision o will be excluded from the Guaranty Fund
' Provision of MGL C.162A.
P IONE WTE REOeTMer"NO
��46)�y5-/��� u�Z3A8 MA.REG. 100811
JOB Nouri JOa LOCATION
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II 1 B n Ina k o tM1 et Ceb IM1 Ito O Ny 1 II g N y g 1 Aq 1 Na pad I d 1 - � II Leg n k on or
0 ut (E 11.9 g delay d by 1 1 0 y d G a trot In rk N be composed t d oy I,.In.O hereby
:Anew edges and egrops In.ma YnWuring dates areaWroi meter shad NAt Such delays that are not asvtlotle By Ne cortnicor MNl me be eenchareesv rean.olthe Agr6emenl.
andum T,the Chi w Chi ewr Ina work lu ndred nareuMer shall too Beer Iran palpate In materiel am workmanship Be a Pi di following companion eM shall campy MM
u han r...his ar Nis Agra newas In In.eront any doled In workmen.hlp or materiels,or dam'.caused by Ne Contremor.his subcontractors,empo ere or agents.is rliscwered within
to yea,also,co nchnion at pny jpb,including clean up,me cataract era at res own..panse IOnnwith comedy,repair,Wrr.cl,reperas or W us be removad'rppairpp,a replaced.
cn d:tern,w such correct In matariob or wakmansnip.The convert w s sell auri any Inspection parameters In cM,KKlbn%wr tna egroolupon work,
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
EL6u-T i F,v- dollars(g 7f ii 1.
Yuynwnl I 11mZ�ade as follows:
—,.lS n`� rvpan algnmg Co....
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alCmpac NCeslgro-Ropiar
°a is V3 "becone"Blmof z C� ,I.rme
_xla ba` ,upon completledof �� spew Au
Oly/els.a fna.
`•IS_-�—, al)be made last upon
completion of wont mm an.cancer Plan '-i
Notice No agreement for home improvement contracting woda amen require a down MSWwwr
payment(advance depos0 of more than odr iN of No total donirocl Drive or Ins
"al amount of all debases or payments which me contractor me maka.inadvance, alhr¢v� MSiprwlw_
to bid.,and/or otnervpse obtain delivery of special order materials add equipment,
WlgtllO ttLgl glfj, nuts:IM1ie pgaW ma/bgllMrewn py ua rl rq,eccePlep wnbn dory.
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.
IMPORTANT INFORMATION ON BACKMew
"hl?ut�(clt THIS C'ERTIFIC:\T[ U ISSUED AS A NI:\TTER OF INFORMATION ONLY AND
'i:c.lani F ��nnnB Inalran.r CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
DOES NOT.AMEND.ENTEND OR ALTER THE COVERAGE.AFFORDED BY THE
�'� i�Ir POLICIES DELO\\'.
L\ III CO\-iPANIES AFFORDING COVERAGE
n Gi•.rll CCon+cicling CompMl�In:
COMPANY A A.I.M. Mutual Insurance Co
LETTER
a �
" PCOVERAGES " �3 .f A+; , L£a pT, ._
TI IIS IS TO C! RTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
Pia,101)IN DILATE D.NOT\VITHSTAN DIN G ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTR ACTOR OTHER DOCUMENT WITH RESPECT
O A HilC Ii THIS CERTIFICATE"MA1 BE ISSUED OR MAY PERTAIN.THE INSURANCE.AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TI 1, THp TERMS. ENC LLSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN N'I.A)'HAVE BEEN REDUCED BY PAID CLAIMS.
tlx.: I11'L OF I�pt R\?('[ PULICI'?I VtlER 1.OLICI'EFFECTIVE POLICI'EXPIRATION LIMITS
LIATEIfN1UDYl'I DATE I MMIDD'NN)
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LI 4 I IL LIIBILl11
I'ROULl T1.l[O11Y OP AG(i.
_ ','ll_ .IaI I:�h1+.1.1.1•.LI LI:\ PERSONAL.I"AU\ INILIRI'
�_j'.L:.I'.I:':e.Dt�••.J.is EAUII p(i L RRI, il,
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Pl'.II113hLLA RIRiU AGBRE(IATE
I I I:R TI IAN UMBRELLA fl1RM
LIYIRFERSCONIPEN'SATION AND TATUTORY LIMITS THER
F V III O0 FRS LIABILITY'
ELE\CIIACCIDENT 500,000
+1010979012007 08/03/2007 08/03i2008 EL DISEASE--roucv unur 500.
I'I I_ 11-.'_L ELDI:EASE--F.ACII 500,000
E NIPI FE
C{Ill till"N S UI:SCHII'EIONOFOI'E R.\F ION,1 Olt LOGAFION'S:
-39
C[Itl'1 FICATE il01 DFH Id;.n: 5 �f. 7\UTHORIZED
,. +iNY OFI BE ABOVE DESCRIBED POI ICII S BE CANCELLED BEFORE THE EXPIRATION DATE
THE ISSUING COMPANY WILL ENDEAVOR TO MAIL aWRITTEN NOTICETOTHE CERTIFICATE
AMED TO THE LEFT.BUT FAILURE TO MAIL SUCI I NOTICE SHALL IMPOSE NO OBLIGATION
ITY OF ANY RIND UPON THECONIPAN1.ITS AUENTS OR REPRESENTATIVES.
Evidence of Insurance
ZED REPRESENTATIVE
............
Board of Building Regulations and Standards
' HOME IMPROVEMENT CONTRACTOR
Registration: 100811
Ex pi ration: 6/23/2008
Type: Private Corporation
LEN GIBELY CONTRACTING CO:, INC.
Leonard Gibely
149 Main Street
Peabody, MA 01960 Deputy Administrator
.... . _ .._.. _. p_... . . . .. ..__..__..............
..:,..
''r �ife TOorxinomuea/d� o�./�aaoacs✓ruselD
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Numbex,� 094763
Blrtlldg It614/4943
1 0 14/^�010 Tr. no: 94763
THOMAS R DOBBINS� ,
19 CEDAR HILL DRIy/ G—
DANVERS, MA 01923
Commissioner