14 LEE ST - BUILDING INSPECTION (2) 7�7C) cK q -7�
T'he Commonwealth of Massachusetts INSPECTION L SE� S
� Board of Building Regulations and Standards SALEM
qlt,� Massachusetts State Building Code, 780 CMR 2015 APR - WeV,2190/1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
N This Section For Official Use Only
Date A liid:
I Building Permit Number: pp .
y /YJ
Building OlTicud(Print Name). Signature Date`
SECTION 1:SITE INFORMATION
1.1 Pr opedty�Qress: 1.2 Assessors Map&Parcel Numbers
t��F 5—t--
t_ I.I a Is this an accepted street9 yes_ no Map Number Parcel Number
l 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 Requited Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION2: PROPERTY OWNERSHIP,`
2.1ner of Record:
tvt3.v 0 A n t MA
NN me(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building vner-Occupied Repairs(s) Alteration(s) Cl 1 Addition ❑
Demolition 131 Accessory Bldg.❑ 1Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and blaterials
I Building S 00 V O I. Building Permit Fee:S Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee
' ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 1!sother Fees: S
d.Mechanical (tIVAC) S List:
5. Mechanical (Fire S
Su ression) fatal All Fees:S
e>a Check No._Check Amount: Cash Amount:.
6. Total Project Cost: Sq 5 d Q - ❑Paid in Full ❑Outstanding Balance Due:
�F>tt_ti^p � ` ty lt5
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supetisor License(CSL) 4n�,3 �_
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
1N\cOry_S'� Type Description
No.and Street
U Unrestricted(Buildings tip to 35,000 cu. IlJ
rA, R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
53k 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
1-- C;-LE>4. y CM-es — HIC Registration Number Expiration Dote
f IIC Company Name or HIC Registrant Nmyyee�.�
�� �✓ r I '".c>1 S•ems Ind fl h,��
Email address
I A !2WYn State ZIP Tele hone
CTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)),
Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
avit will result in the denial of the Issuance of the building permit.
gffidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION,TO HE COMPLETED WHEN.
OWN ERIS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or bonze Lei ante(Electronic Signature) Dane
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 Line have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
%vww mass.cov'oca Information on the Construction Supervisor License can be found at%y .mass.,ov:'dys .
2. When substantial work is planned,provide the information below:
'total floor area(sq. d.) ~ (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room court
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halffbalhs
Type of heating system Number of decks/porches
Type orcooling system Enclose) Open_
.i. "I'mal Project Square Footage"may be substinacd fitr"Total Project Cost"
The CommottveRa/th ofMusspchusetfs
Department oflndus=Mal eeidenis
Office oflnvestigahons.
I Congress'Streefi Suite 100
Boston,MA 02114-2017
www mass gov/dig
Workers'.Compensation Insurance Affidavit:Builders/Co
Applicant Information ntractors/Electricians/Plumbers
Please Ptmt i Palbly
Name(Business%OrgaWzation/Individual): L. e, G, b,ie u ...1 n A c T: I ✓ C
Address:City/state/Zip': Phone#r °('l $
Are you an employer?Check the a 3 $a 3
PPropriateboz.
1.U9 I am a employer with / &Z 4. ❑ I am a general contractor and I e of Project(requiredj:'
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.
Remodeling
ship end have no employees These-subs-contractors have
working for me in any capacity; employees and have workers' g' ❑Demolition
1N0 workers' comp.insurance comp insurance.: 9• ❑Building addition
required.) 5. ❑ We are a colporation and its '1l).❑Electrical repairs'or additions
3.❑ I am a homeowner doing all work officers Have'exercised tti'eir 11. Plumbing
myself. [No workers'.comp. right of exemption per MGL g repairs or additions
insurance required,] t. a Ik,§lj4),and we have no 12.❑Roo€repairs
employees. [No workers'" 13.0 Other
comp insurance required.]
My applicant that checks box#1 must also fill out the section below showin$their workers'compensation policy informauion.
t Homeowners wlin submit this effidevit`indica' th - -outside sntractors_
:Contractors that check this box must attached ana they
heed showing r��me of the sub-coonhactois'eod state submil a now afflOvii or not those aunties have: .
employees. H the spb-contractors have employees,they mutt provide their workers comp_policy number. _
lam an employer that is providing workers'compensadon Insurance for my employees. Below is the policy and Job ske
information
Insurance Company Name:: v 7'V q 4- j r � �z
,v c iZ A c.
Policy#or Self-ins. Lic. #. "UWC ..1 D D- 6 O I n 4'7 4 tgaExpir Da
te:ate:
, 8—,-
Job Site Address:_[ L4 L e S� City/State/ZrP. S�Q[ MA
Attach a copy of the workers' co
mpeusatio.a policy declaration page(86wmg the policy number and expiration date).
Failure to secure coverage as.rRuired under Section 25A of MGL c 152 can lead to the imposition of criminal penalties ofa
fine up to$1,500.00 and/or one-year imprisonment as well,as,.civiI 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.coveragc:verification,:_ ,
I do hereby eerdfy under the pours and enplues.o
� ^ p
p f perjury Thal the information roruled above
.is true and correct
Sienature t p�"M �� i9 �. Date 7 !>
Phone#:
Offlcial use oWy. Do not write in this area,to be completed by city or town official.
City or Town: Permlt/License#
Issuing Authority(circle one):I.
Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
LEN GIBELY CONTRACTING CO., INC. Page No. _.Lof PagesPROPOSAL
• 23R Winter Street 26514
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
(978)531-8234 Fax(978)531.9304 engaged In home Improvement contracting, unless
www.lengibelycontracting.com specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered
Submined D��I l ,'-w with the Commonwealth of Massachusetts. Inquiries
about registration and status should be made to the Director, Home Improvement Contract Registration,
One Ashburton Place, Room 1301, Boston, MA 02108
(617) 727.6598. Owners who secure their own
SA `E M r/ construction related permits or deal with unregistered
- — /— ---- Q'9 ----- contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
PHONE U PATE REGISTRATION NO.
it `'� /� ��' MA.REG. 100811
JOB NAMEMO JOB LOCATION
505- S�-3 - /;t-89 SAS i4S A i V vte
We hereby submit specifications and estimates for work to be performed and materials to be used:
ovte 2 �S__ 0 CXcF
��T ,t-1 SiLQLe_ 14,1;rJo%(� iNS�'A/l
—T •b W�ff2 Sl7 e 4 _ w�2
_ 0 �o�Fl� .3 ,
I:- --_--
°dt If E �a eeZ C/cwN ANd <<f By----
F4 �hg� Ixs�alAl 60 a// e���r�
SNj�// S AA(dow —5-0;I
---- ----- ----- ,Soo. oa
WORKS / [1�
Contra jot begl he w�ILol/tle�meteriala before the IM1iN day following the signing of This Agreement,unless specited herein wdtl II begin the work on or
about (dare).Barring delay caused by circumstances beyond Contractor's control,the work will be completed by rate).The Owner hereby
acknowledges and or as that the scheduling dates are approximate and that such delays that are not avoidable by me contractor shall not be cons dared az A stems of this Agreement.
Hidden mt or conditions not Seen at One at weapon that are required to Be repaired In order to complete thus condo win be mnplsted at$ per hear HOUR).
WARRANTY
The Contractor warrants that the work furnished hereunder shall be tree from defects in malarial and workmanship for a period of flowing completion antl shall comply with
the revolts ants of this Agreement,In the event any defect In workmanship or meteriala,or damage mused by the Contact,his subce actors,emplOyeBs or agents,is discovered within
one year after completion Of any lob,including clean up,the Contractor shell,at his own expense,f0lNWllh remedy,repair,cotreM,replace,or cause Be be remedied repaired.or replaced
such damage or such defect In materials or workmanship.The foregoing warrenlles 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:
Payment to be made as follows:
dollars($ q-SD O' Od )
Remove all job trash.
All guarantees on all products from manufacturer.
is )upon signing ContraD�t�11r� Add permit cost if needed-we pull permit.
($ )upon completion of ofice: No greement for ho a improvement contacting work shall require a
wn pay nt led in dep it)Of more than one-third of the total contract
($ )upon completion of or a or t otal a oun of all eppsits or payments which the contractor must
in ,in an to o or A d/or otherwise obtain delivery of special order
_,($ )shall be made knowlth upon me fall eq pme I.
completion of work under this contract
Note:This propose may be wimdrawn by us it not accepted within days.
A d d Wr
Acceptance of Proposal I have read both sides of this document and a cep ill,specifications and conditions stated.I understand
that upon signing,this proposal becomes a binding contract.You are authorized to o th o pacified. Payment will be made as outlined above.
You,the Buyer,may cancel this transaction at anytime pri r to I 1 ght of the third business day after the
date of this transatUbirt Cancellation must be done in writ ng.
D O NTHIS CONTRACT IFTHE E A ANY BLANK SPACES.
sig�a oar-- ' � Bgaewre oat.
IMPORTANT INFORMATION ON BACK Di
.__. ......_.....
......_-.-----_.___
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
C ofWruction Supercisor _
License: CS-094763
THOMAS R DOBJJIN
y
Expiration
Commissioner 05/14/2016
_ � V/ee tpm�uncareeoeal�4�C�/V�aa9aclerdeC/d -_
ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
`^ Office of Consumer Affairs and Business RegulationW- )
-
.... . , Registration '0'p$j TYPe 10 Park Plaza-Suite 5170
IF Expu ,pn 23/201I Supplement Card Boston,MA 02116
LEN GIBELY CONij�f ._:eIN _C ;;;`INC.
THOMAS DOBBINS.�� _ _j
23 R WINTER ST ' �+:
PEABODY, MA 01960 Undersecretary Not valid without signature