16 LEE ST - BUILDING INSPECTION S .
� Y .
The Commonwealth of Massachusetts
r r Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR, 7"'edition MIiNII'IP:ALI'I'1'
LJSI
Building Permit Application To Construct. Repair. Renovate Or Demolish it Revised✓ nonr_r
One-or Tiro-Funidv Dn eging US
This Section For Official Use Only
Building Permit Nu ber: Date Applied:
Signature: 4 -j 3p= Oi
in i Commissioner/ Inspi or of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property .Address: 1.2 Assessors Map & Parcel Numbers j
/ 6L . � $T
l.la Is this an accepted street? yes_ no Map iN'umber Parcel iN'umher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) 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 Cl
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
iK
Name(Print) Address
9ter Service: C� (y _r, 7_
Signature Telephone 7 '_ /�
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Buildin+s 7L. Owner-Occupied gP4- Repairs(s)-.G� Alteration(s) ❑ Addition ❑
Demolition ❑ 1Accessory Bldg. ❑ INumber of Units Other ❑ Specify:
Brief Description of Proposed Work': .e t.1 i I- •�`T r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 9, Q 'N t—no L Building Permit Fee: $ Indicate how fee is determined:
o. Electrical $ c.� ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees:
4. Mechanical (HVAC) $ List: '/✓� � y
5. Mechanical (Fire
Sim ression) $ Total All Fees:
�,.1 � � � Check No. Check Amount: Cash :\nwunC
b. Total Project Cost: $ s•J
❑ Puid in Full ❑ Outstanding Balance Due:
r
. r
SECTION 5: CONSTRUCTION SERVICES
• Y
5,I Licensed Construction Supervisor (CSL) 0Ci L 3
�,� o ✓ S,. License Number Expiration Date
Name of CSL- HuMldcr �� List CSL Type (see below)
4 1 1 "✓ T e Description
>ddresy _ U Unrestricted up to 35,000 Cu.
R Restricted 1&2 Family Dts'clhng
Signature M Masonr Only
(4 '1 1R S 3 1 RC Residential Roofing Covers ne
Telephone WS Residential window and Sidim�
SF Residential Solid I'uCI Bonne A>>li;mce Inst.dlnuun
p Residential Dcmohoon
5,2 Registered If me me In v3e�ment Contractor (IIIC) Q
.L.Oa� Cr( �,p-�'f s z.. t Registration Number
HIC Company Name or HIC gistr tt Name ,/ �A q, r
%;, Y-LI P)rr Y d'I oQ Q t 'tH I 4 -
Ad 9 �g � -� � �__�Z� Expiration 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 .......i. No _......... 0
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: OWNEW OR AUTHORIZED AGENT DECLARATION
it CLIA,+-T , as Owner o Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
'T � e b•:r�.s
Print Name,���Signature of Owner or u n Date
A gent")
(Signed under the Cams and penalties of era ) NOTES:
An Owner who obtains a building permit to n do his/her own work, or an owner who hires a unregistered contractor
L
(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 l IO.R6 and I IO.RS, respectively.
2 When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenUatties, 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
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
u,p www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Leeibly
Name (Business/Organizador✓Individual): L e* ✓ Cr , h /� 1_V 1 Ow ST
Address: 1 L-1 4 M A I m
I�,
City/State/Zip:?e A Jo 7V� t lA 6 1 9 Lh Phone #: 9 7 $ S 3 ( S oZ3
Are you an employer? Check the appropriate box: Type of project(required):
ram'[ am a employer with 1 )4 4. ❑ I am a general contractor and I
Y� —l—Z g 6. New construction
jemployees (full and/or part-time)." have hired the sub-contractors
'_.❑ I am a sole proprietor or partner- listed on the attached sheet. i 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' cgmp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ElWe are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 atn a homeowner doing all work right of exemption per MGL I LF❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] I
13.❑ Other _
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
' i lomeowners 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.
I ann an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. h q
Insurance Company Name: ATM 1_I ^u� y A L. w S C C) _
Policy T or Self-ins. Liic. #`: &O I O Q 1r7 C1 O 7. 0 0 7 r� p Expiration Date:
L
Job Site Address: �4 �._..o,2 S'T� City/State/Zip:EA I_. A 9 - v
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
I:inure 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 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.
I du hereby certify under thepains and penalties ofperjury that the information provided above is true and correct.
Si to ur Date -3 0
r
Phone r:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk,4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
4 fi q+ 0 a
j sy xG11i ''A
':RODL'CfiR
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Edll-:.rl F S.nnon Insurance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
DOES NOT.AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
ib 'sol::Ih Main sGret
Too.l;.i:i. I:\ Iilas; COMPANIES AFFORDING COVERAGE
Is��l<Isn
Lcn Gibeh Contmcine Company hw
COMPANY A A.I.M.Mutual Insurance Co
LETTER
COVERAGE-
P 11, A trT+t..' .. I .
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD 1\1)IC:NTED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WISH RESPECT
-I'()I"111C II THIS CERTIFIC':\TE MAYBE ISSLED OR:MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TI I LL THE TERMS. EXC'L US IOU AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN IT 01'IIA R:UCE FDIIC1'NUMBER POLICI'EFFEMVE POLICY EXPIRATION LINHIS
II�RI DATE IMStUOYI'I DATEIMMIDDOL
f a v R V 1 f.vw fl GENERAL AGGREGATE
_ 1'RQDUC6{0\IP.OP AGG.
I Li2]FY+.L Ll al LIT\
PERSONAL R AD\'"INIURI1. MADE
EACII OCCtItP.ENCE i
MIRE DAMAGE Um:m Iirel
'AEU.EXPENSE A..'eN
4 IOIIIII;t1.1,1,1 IIT11 111 ,
111T NFD SINGLE
L HIIT
"COILI I'll K)
U
_ UVU10 IVI N\
PRnl'FRTI'DAb1AGE
I I U11 LI IN LAC1i OCCURRENCE
AGGREGATE
�=I'aII11lELL.n IORM
llTOH R TITAN UMIIRUL\FORM
.Il'U RF ERS CO NI PENSAT10N AN'D STATUTORY LIMITS )THER
E\IPLON ERR LIABILITI'
EL EACH ACCIDENT 500,000
60I U9 79012007 08/03/2007 08/03/2008 EL DISEASE--POLICY LIMIT 500,000
EL DISEASE—EACH 500 000
ENIPLOYFF.
COUAIE\"IS DE:SCRIP'FIO\OFOPERA'I-10\SORI.OGATIONS:
CERTIhICATg:}lO1r40;M1jbQ
HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
HEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL JkW RITTEN NOTICE TO THE CERTIFICATE
OLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION
Evidence of Insurance
IR LIABILITY OF ANY MD UPON THE COMPANY.ITS AGENTS OR REPRESENTATIVES.
-" >UTHORIZED REPRESENTATIVE
. WA
Board of Building Regulations and Standards ,
HOME IMPROVEMENT CONTRACTOR
Regist tsry 100811
E - ---- 3/2010 Tr# 268971
{ to Corporation
LEN GIBELY CO „ _ ! �;INC.
Brian Dobbins
149 Main.Street
Peabody, MA 01960 Administrator
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' '„ ✓�! 704�JIOR[LCIv.HR o��dOQ�/l1eQa�i' ..
)s BOARD OF BUILDING RkGJLATIONS d
{' j,IFen§e.STRUCPN SUPERVISOR '
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Numbe �r 0947Q3
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n '94763
TN1AS Rt 946 gY ,
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Page No. • Pages
LEN GIBELY CONTRACTING CO., INC. PROPOSAL
149 Main Street 18106
PEABODY, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
(978)531-8234 engaged In home Improvement contracting, unless
FAX(978)531-9304 specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered
Submitted S - )/ with the Commonwealth of Massachusetts. Inquiries
70: Qlpl /_4u�e r'1.C�.j_. _ __ __._._ - about registration and status should be made to the
// Director, Home Improvement Contract Registration,
One Ashburton Place, Room 1301, Boston, MA 02108
(617) 727-8598. Owners who secure'thelr own
construction related permits or deal with unregistered
contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
PHONE \ PATg REGISTRATION NO.
MA.REG, 100811
9 NAM`2No. =/ JOB LOCATION
> sAHE
We hereby submit subc,hcadons and estimates for work to be perforated a materials to be used:
ta9d__Jl
r1
-
__co.[nar5_o�'_�-��2�y_�-r we_��n �d�9���e✓l ou w�.1S�cpC1_�44d�- /---_.zxlZ- �I _LtlPa+ G tt_ Ccf��2 cPacts tAtJ, ZC
'ts_-ft /
CJaaI �2j��
IKp IlirN�OVQf /-
[f�_ (C (-ClYY4/5-,rISLfIG�IfJ, cn./t�li0l_CQ lr ��inl-l�I�_Ota_n�� (Q / p. /T/
IXAI-'OS ---
>M�f �-(22 a
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\,-(J�nrt-IsIL�fa -�+�— �- � r.j'te_n_i.oue�_�o raAL o+c, �(r
l`-t- — o11ta_1w�_WGr�rs _ rc� �2µ lt _S.2�O0
— — —
WORK SCHEDULE
Contract r will no In the work or order the materials before the third day fancying me signing of this Agreement,unless specified herein w' Contr ctor will begin the work on or
about (dates.Barring delay caused by circumstances beyond Donhector'a control,the work will be completed by a (tlete).Tne Owner hereby
azknowlo gas antl agreaz that the achlitluling tlates are approximate and That such delays that are not avoidable by me contractor shell not be ronshal vk letlpns al this Agreement.
WARRANTY C�/y��'�)))��'(
The Contractor warrants that the work furnished hereunder shall be free from delecle in malarial and workmanship for a periotl of�following completion and shill comply with
the rec ulromental of this Agreement In the event Any defect In workmanship or materials,or damage caused by the contra dop his so Contradom,employe65 or egenR,la hma.of..,red within
ne your aher completion of any job,ixludlnI clean up,the Contractor shall,at his own expense,fonhwia remedy,repelq wrred,replace,or cause to ba ramedleq repaired,m replaced.
such damage or such tleleq in materials or workmanship.The foregoing wanantles shall survive any Inspection performed In connection with the eBreed-upon work.
We Propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
Payment to be�make as follows:
dollars
%is )/`-'( )open signing Contrail: ____ _ ____
Name MConaed /Daslpretetl NeBlsaent
%is 0. )upon completion of Q
Spear Address
%($ )upon completion Oi
Ciy/Smu pndne
(s )shall ut made to rk,under
upon
aomplBgOn of Wpr1{Ilnder this CanIRCt. plpry -- FOMnIIG Np.
Notice: No agreement for home Improvement contracting work shall require a down Name of Salesman
payment(advance deposit)of more than one-third of the total contract price or the
total amount of all deposits or payments which the contractor must make,in advance,
to order and/or olDemise obtain delivery of speclal order materials and equipment, ,Bnewre
Whichever emount's greeter Note:This empaYl may ae withdawn by us N riot accepted Main royal
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.
0 NOT SIGN THIS CONTRACT IF THERE ARE ANY B NK SPACES.
S.'-Iure ome�tLY some. oam 41`f d
IMPORTANT INFORMATION ON BACK
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