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16 LEE ST - BUILDING INSPECTION (2)
c � a� v► E The Coin monwcalth of[Massachuaryset gp �T►pNAt SER Board of Building Regulations and Stai SAL OF Nlassachusetts State Building Code, 730 CMR q SALE v[ i g Aii spy 12 P Kvised Mar 201 Building Permit Application To Construct, Repair, Reno ate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only. ' Building Permit Number: ate Applied., fl.3Zonin Official(Print Name) . Da - SECTION I:SITE INFORMATION rty Address: L2 Assessors Map Br Parcel Numbers s an accepted street?yes_ nu Map Number Parcel Number Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard I, Acquired 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? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY'OWNERSHIPL 2.ywnert of Record: S.A >t ,/t722 o 1 9l o Name(Print) City,State,ZIP /fr o. o Sr a1- n, 47R5?y517g No,and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKs'(check all that apply) New Construction ❑ Existing Building` Owner•OccupiedCP� Repairs(s Alteration(s) ❑ 1 Addition Cl Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other Cl Specify: Brief Description of Proposed�Vork2: / IwJ....sa:rtt.,1 0. y'x.`-6y F � a s Tco,l>— .4'THd2rs.�J�-rr [�i.=nc 4_ 12L. S3 t, Z� SECTION 4: ESTENLkTED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only, Labor and Materials 1. Building $ >a q 5 os 1 L Building PermitFee-S Indicate how fee is determined: 2. Electrical S Standard..City/Town Application Fee ❑'Dotal Project Costs(Item 6)x multiplier x 3. Plumbing S 2. Other Fees:'S_ t. Mechanical (IIVAC) S List: i. Mechanical (Fire S SnP tressiun) — -- Total All Fees: S I'utul Project Cult S I 00 Check No —Chock Amount: cash \mount n --- 8 (3I'ud m Fnll ❑ Out;tmdin; Il dutcc Ihi I`— 3yi3i. .EcrION5: COYSTRUCrIONSERVICES 5.l Construction Supervisor C'iccuse'CSL . Cl tLA Q. License Number Expiration Date Name of CSL I loldcr `^� pill I List CSL'rype(see below) Z 3 2 L! i It "YpeWt Description No. and Street ^^ U DuilJin s u to 3i000 cu. tt.7 Y- / " ) A o t �(- IR &2 R—il DwellinCiry/ro%vn,State,ZIP Vl RC verinWS Sidin• SF uming Appliances I Insulation reie hone -F Email address I D Demolition 5.2 Registered Horne Improvement Contractor(HIC) b,.o L V• Co yam` FIIC Registration Number t� Expiration Date !I IC Company Noma or FI IC Ragistrnnt Name Email address City/Town,State,Z 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 ..........(3 No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO DE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 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. Print Owner's Name(Electronic Signature) Dnte SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, I 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 Owners o Audturited Mcu "Name(Electronic Signature) Date NOTES: \n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut r gistered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program can be found at www.mass.,,ov oca Information on the Construction Supervisor License can be found at%rww.mass.to�'dL 2. When substantial work is planned,provide the information below: Total flour area(sq. (t.) (including garage, finished bascnent/attics,decks or porch) fro'; living mea(y. 11.) _ Habitable room (aunt _ Number of tit eplaces_—_--_----- Number of bcdrooms NumL•crutbadtruums __ Nunaberofhalt'b;uhs ---------- — P%pe of Muting iystcin Number urdeck,'porches )pe areooling ivimna _----- _ _ _ Enclosed _ . pcn ---__-- 4 "I'n,il holoct Squ,iro PnnLt,c" in.ay I10 subitinned Gu Ploied Co[" The Conunonwealth of Massachusetts = - Department of Industrial Accidents . f1 Office of Investigations �r 600 Washington Street Boston, MA 02111 wwrv,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly NatTI (Busiuess/Organ zaciou/Individual): G e 6 o LY Cc,, —( tz A C 7'w A CO Address:_a 3 P, W r ,.i`C' e tL City/State/Zip: U 1 q oPhone #:—R'I 8 S ------ -------- Are you an employer? Check the appropriate box: Type of project(required): 1.2�1 am a employer with 4. ❑ I am a general contractor and I ❑ employees (full and/or part-time).' have hired the sub-contractors 6. New construction ❑ 1 lmi a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y9. ❑ Building addition (No workers' comp. insurance comp. insurauce.t ❑regUlfed.] 5. We are a corporation and its 10.❑ Electrical repairs Or Zldditious � i ❑ l ❑m a homeowner doing all work officers have exercised their l L❑ Plumbing repairs or tLU!10u1 myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs nswance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other__ comp. insurance required] '.ewy upplicmII flail checks box#1 must also fill out the section below showing their workers'compensation policy rnfurmatiun. t i!mncowners who submit this atlldavit indicating they are doing all work and then hue outside contractors must submit a new adidavit indicating suet. :Cnaaccurs that check this box must attached an additional sheet showing the name of the sub-comractors and state whether or not those entities Iwvc employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I urn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site injbrrruaion. Irsurince Company Name: H. _r1 . M el Tv A L =� L C o q p policy # or Sa1f--ins.. Lis#: A D ] 0 9 � ! - .2O 13 Expiration Date: 8 3 , D G ub Silt Address: 1 4e- .s� J<f- City/Sta1e/Zip:_S!9_ _SA_0 Cet,� Attach a copy of the workers' compensation policy declaration page(showing the.policy number and expiration duev). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal peualtics 6 t u iinc up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and so-: 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 Lnvestigations of the DIA for insurance coverage verification. I du hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sienarure: Date: , ..._. Phone Official use unly. Do nut write in this area, to be completed by city or town ofj'icial. r City or Town: PermittLfceuse# issuing Authority(circle one): I 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing luspectur �I 6. Other_ (i Cuntuet Person: Phoue#: AQORQR CERTIFICATE OF LIABILITY INSURANCE 02/06/2014 DATE(MWDDIYYYY) PRODUCER 978.887.4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennett Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 16 South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P. 0. Box 457 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Topsfield, MA 01983 _ INSURERS AFFORDING COVERAGE NAIC# �rsuNeo Len Gibely Contracting Co. , Lric• INSURERA: Catlin Specialty Insurance Co 23R Winter Street --- -----_--� --- wSURERe: Safety Indemnity _ 33618 Peabody, MA 01960 INSURER C: INSURER D' INSURER E: ;OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWI I HSTANDING 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. N: RAqDD'L ------- POLICY EFFECTIVE POLICY EXPIRATION --- .:fR INSR TYPE OF INSURANCE POLICY NUMBER DATEIMMIDDNYYYJ DATE MWDDIYYYY LIMITS GENERAL LIABILITY 3700302145 01/29/2014 01/29/2015 EACH OCCURRENCE $ 1,000,00C M-10 RENTED -j X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ ____1__Q_Q_,DDC _.. CLAIMS MADE aOCCUR MED EXP(Any one person) $ S_DOC A PERSONAL&ACV INJURY $ 1,000,000 GENERAL AGGREGATE $ 21000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ 2,000,000 7POLICV1-1 PRO- -- EDT LOC L AUTOMOBILE UABUJTY 6221693 COM O1 01/29/2014 O1/29/2015 COMBINED SINGLE LIMI I ANY AUTO (Ea aooidanl) -_ - $ r-"- _ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ �X SCHEDULED AUTOS (Per person) H X l HIRED AUTOS --- -- -- - —_.-_ "'- BODILY INJURY X $NON-OWNEDAUTOS (Per accident) PROPERTY DAMAGE $ (Per occidont) -- GARAGE LIABILITY ---� I - AUTO ONLY-EA ACCIOENi' Y ANY AUTO --- EA ACC $ OTHER THAN _ AUTO ONLY: AGG $ II�EXCESS I UMBRELLA LIARILITT EACH OCCURRENCE $ ] OCCUR f__J CLAIMS MADE AGGREGATE _ $ ICI j DEDUCTIBLE j RETENTION $ ON UTY IN --_�WORKERS ND EE IMEI M UER EXCLUDED? Y❑ EL._DIGS'.H ACCIDENT NMPLOYeC- $ ANY PROPRIETOWPARTNERIEXECUTIVE SPECIAL PROVISIONS Wlow EL DISEASE-POLICY LIMIT $ OTHER II DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIO145 ADDED BY ENDORSEMENT I SPECIAL PROVISIONS +'roof Of insurances. I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRIT I EN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO ODLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE _ Robert Sennott RPF — ACORD 25 (2009101) ©1988-2009 ACORD CORPORATION. All rights reserveu. The ACORD name and logo are registered marks of ACORD ac R® CERTIFICATE OF LIABILITY INSURANCE F DATEIMMrowrvrYI `..�� 07/26/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELYOR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject tD the terms and conditions of the policy,certain policies may require an endorsamant..A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 01634.001 c Edward F BannonInsurance to South Main Street Topsfield,MA 01983 ING COVERAGE _____ NAIC 6 --- A.LM.Mutual Insurance Company 33758 INSUREO -'— ---- Lon Olboly Contracting Company Inc INSURER R 23 Winter Street Rear ---- Peabody,MA 01380.6341 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 VMTH 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 POLICES.LIMITS SHOM MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPB OP INSURANCE POLICY NUMBER GENERALUASILITY EACH OCCURRENCE --.$_---- COMMERCIAL GENERAL UABIUM AM N Ems_'.$ ---- -- I U„wcel .1 CLAIMS•MAOE OCCUR MED EXP(Any eno PNso_I _ PERSONAL 8 AOV INJURY GENERAL AGGREGATE 1. ICY I n.00 PRODUCTS C CN OMPIOPAOG S L AGGREGATE UMIT APPLIES PER: AUTOMOBILE LIABIUTY BAED_&Ri'E-11M1 S 1Fa eccitleA ANY AUTO BODILY INJURY(Pot pmwn) {- -- �- ALL OV,N® SCHEDULED AUTOS AUT09 BODILY INJURY(Pal acddan0 1 HIRED AUTOS NON-0WNEO AUTOS Po,accident) UMBflELLA WB OCCUR EACH OCCURRENCE i EXCESS LIAR CWMIS MADE AGGREGATE 1 OED RETENTIONS _ f ----_--- NYaNpsp�psaxpRgp�i�Nv�nRp -YIN k -- A UFFICQiMER 1ER k%CLUpGpT�VTIVELN I NIA E.L EACH ACCIDENT _ i_5_00_000.OU �IlMundeotory In NH) - J VWt:•t00E010879-2013A 8/312013 813I2014 E.L.DISEASE•EA EMPLOYEE_s 5001000.UO Ot_ ?OPERATIONS E.L.DISEASE.POLICY LIMIT { 6001000.UU DESCNIPTION OF OPERATIONSI LOCATIONSI VEHICLES(AnecN ACORD 101,Addldonel Remarks SCMduN.It mom specNs m400ea) --- --..I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 9)1988.2010 ACORD CORPORATION,All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD __� N GIBELY CONTRACTING CO., INC. Page No. of / Pages PEABODY?MA SIACHUSETTS'01960 256351nterStreat PROPO'SA:L - Ailshome-Improvement.Contractors an d.aubeoldractors (978)631-8234 Fax(979)531-9304 engaged.In home Improvement contracting,unless www.lengibelyconlracting.com. specifically exempt,from.registration by,Provisions of ,. : Chapter 14SA of the:9eneraLlaws,MUM beaegietered Submine0 Vld� I with the Commonwealth,of,Massachusetts.lnqulrlea To: _ Cl I R } }_Q �tifLJ. A� about reelstrailon end'stet is should be made.to the Olrectoq Home orprovement`Contract Registration, �� (.p(u ,S..F One Ashliurton Pleee,Rbom 1301;Boston;MA 02108- W—'--� r;�-1 n (617.).727.869a:.Owners,who,secure their.own A.� O Il rrl ,v construathm,reletad permits'or.deal.with.unregistered , �- _ contrectore. dIVIle"cluded,fromtheyGuaranty,-fund Provislon Cf MGyl.c.142A:: y:�� - .ME - MlE .. xEaeleATlON NaiiTJS �"1"Oxxy rIl ^' A" "'}, I l �MAsaEo�}o9at1 `�t. ,,_._t....., T .- JOB I-000 t{ WO Mrepy ed$pX epaclllwllwe erld aXmabalwwoMy Dadamwd ad m0 dW Wbe ueaa" 1 F - . tv azrdau.o' �s�4��r�2�2M+ 0 L rslL ,(Qw%TnDIM[ �LOQ11tS Sux(� fPn� ��a t r t�kJcl i�'�i. r 4- r 1w n- /�/q� r� owl P1�rJl � Jf r - J rCC 1L 44 nL��a�OrOL, f Gh eGY 7d.L c; d- / ,.•' a �.C. % C�rvv pCl 1,rn/ r r-U�Mr✓t p (n0 V^t y-JQ�C nQrU S rl"�� ". Mrd const an ral ted lot Pao IA Z35330 WORK SCNEOULE OOnt b Xw xmM wade tlw meYnel9 Mlwe M NLtl Ew MIwYq tlp elpnln8 d Nb ADrednent apllW M1e M II bepl th wwk on a 1 ebom lame).BenlnO oeley caused by I memncea 0eyond CoMMdohaOMrol N k wlllbe mDlebd by v Idde).The Purer M1ereby WAFRANry MEpINaXW IM iXBOYII pE 10ae10 ylp(w]mBb BM tlW Oudl deters MMe 0nd9wddBN b/Mem11VB010r411011 r1d he ,BE b18Wn9 oI1M1b A8r9em0nt Tne CAnaeclw we MtlW Hie wvXb nlahedh rabM reM1ell Da Xea lrom Eefecbl Imlel�end'vbMnenMp biepedosd�kllorvba mpbtls end'M1ell cwnpty wlN tlw requlremenbd Mla AlpeemenL'In th Crept wry Edecl In cVM1 nenMlp or mebddc,wde p9 wuaed lvtlre ConlmtlOf.Xb cubmneetlwe, mplWaN eO Ma,le dlx0reted MMln on ym,eXer Wmaglbnd wry lap;NBIUOhe clean up•NB Gen4aclw MW,el M1b o0n expanN,bNMN remeQy,,epalr,[Ortep,replace,Br taws b he MmeENE reDelred,or MPleaea, eucM1 tlBmepe OrwM Colecl In mBfeXBbwwaMmBneM1IPTM1e brepdnO wBrtBnwaeM100 wrvDw aM lnWeetlon DedDrmeE In oanneclb INNe eeeed eWnwaM �' - " We PrOPOee her Ki furnish material and labor'-'complete In accordance w_Ith above specifications,for the sum of: fy..: - dollars Payment to be made as nool %( F ,. .'I B4NI•W x y. clN/sae—. CBTpk,L dVgM aMBr We CenVBOt V pM1yp F ,al N Move: No agreem.Mkr hams"n ment mmmoting work shall meulm a down N payment ladf a too deposit)of mord than one-tllird of the total aomred ppcs or total arrount of all deDOBXe or pao max,width the eontmClor most most,In adV ince. W aMe,and/or omwwbe obtain dalNery of terolal order materiels rent sewp oent:' wM1ltl,emr mm�u Ik •f t rr Npla lly D�Waay,rrrNMtlM' wH,N,auras mrjo Ea e., v Acceptance of Proposal I have"read both sidesol this document end accept the prices;epacrficafone send conditions statedA understand, 'that upon signing;thls pmposil 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 trensaction.et any time prior to midnight of the third business day after the date of this transaction;Cancellation must be.done In wrlting.T r t7"` a• PJD.NOT SIGN THIS CONTRACTSF.THERE AR NYB NK SPACES. ce.. N'LK'I JL' stone. o.t. 4k'61 �. IMPORTANT INFORMATION ON BACK PI Att vi.o yi.g! o pl! y y ... . .... uv: IN N, IZO it �_.t tt 4 k- I I 9�:111 it 77-7 7,1 gi;il T 9, 'El of Is ion MP lk -kit .. ........ ....... -------— et S I IV- Ipt litill I Omcc or C911114flur ti"R1 It"t hOMEIMPROVEMENiC TOR idul tisv only CONTRACTOR Wrore tho 0xPIr4jlO0 04 il000ll %. -11 to Tice of c Type: officc Of Consumer A OU Cut ratlof n Business Rquiation �;�txpl 1: 6/23/2014"'%1 P(ivale Owporatipi, 10 Park Plaza.$0110 51 i Boston.MA 16 BEN GIBELY CONTRACTING 3(iarl Dobbins tj '13 R WINTER ST. PEABOD Y. MA 0 1 goo. Not v I ....... w ut 1811aluro :7 4: kJ ri .,I it qIV.; I it IN it I t7-- it t V, IM It. it g. s. d i ..I.... it k% it % it tt �;t