11 MARION RD - BUILDING INSPECTION J� The Commonwealth of Massachusetts
t Board of Building Regulations and Standards CITY
/ Massachusetts State Building Code, 780 CMR, 7m edition OF SALEM
Revised Jarraary
(� Building Permit Appli atio To Construct, Repair rnovate Or Demolish a 1. ?ooR
n - )r Two-Family elling
n Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/Ins for of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1 ! 4tZa,oti IRn
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Informatlon: 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 Require) 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 O
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin wner-Occupie j.epairs(s) ration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units- I Other ❑ Specify:
Brief Description of Proposed Work':
7
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMclal Use Only
Labor and Materials
I. Building $ I. Building Permit Fee: S Indicate how tee is determined:
2. Electrical S ❑Standard Cityrrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
d00 Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 6, S� 0 Paid in Full ❑Outstanding Balance Due:
r
A
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
-7 �06SA,I c License Number Expiration Date
Name of C'SI.• I(alder /-� {�— % / List C'SI-Type(see below)
1 4 Q r� 3T �R �Y F Description
Addre U Unrestricted(up to 35.000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Mason Only
�`;9, Szl �� �� RC Residential Roofing Covering
I'clephone WS Residential Window and Siding
SF Residential Solid Fuel Bumin A liance Installation
D Residential Demolition
5.2 R1egbtered H me Impr vem t Contractor(HIC) D 7
""' '1 bP Ora.r'-7' Registration Number
I IIC Com an Name or f IIC R utrant Name
Expiration Dale
Signature - Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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 ..........0 No...........13
SECTION 79:OWNER AUTHORIZATION TO BE 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, 6 o L V(2 en,� as Owner o Authorized—Agent,1hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
—T_ ( 3 0 b t trLf
Print Name
Signature of Owner o 6 oriud Agen Date
(Signed under the pains and penalties o u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe 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 Please Print Legibly
` �t c
Name (Business/organ;zation/tndividnat): L 2,.i t7"I .bn L� [ ^ i�A r'
Address: I Lk 9 N Ate SZM
City/State/Zip: q Phone #:9 9 9 5 3 l $ 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 LE3
construction
employees(full and/or part-time).` have hired the sub-contractors
listed on the attached sheet.
deling
2. I am a sole proprietor or partner- These sub-contractors have olitionship and have no employees employees and have workers'working for me in any capacity. ing addition
comp. insurance.t[No workers' comp. insurance trical repairs or additions
required.] 5. ❑ We are a corporation and its3.0 I am a homeowner doing all work officers have exercised their bing repairs or additionsmyself. [No workers' comp. right of exemption per MGL f repairs
nsurance requ red.]t c. 152, §I(4),and we have noer
employees. [No workers'
comp. insurance required.]
-Any applicant that checks box M 1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
tContractors that check 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 must provide thew workers'comp.policy number.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information. ,,//J�
Insurance Company Name: Iq = p1 5 �••-o —
Policy#or Self-ins.Lic.#: �, t0 1 () 9 r7 9 ® IIJ tD / Expiration Date: M 1 a
Job Site Address: M A tut A J �P City/State/Zip: ��L� �+ ✓ Ui �����
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required tinder 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:
�—'� �' p, r Date ( ✓�' ! O
Sign ature p
Phone#.
Official use only. Do not write in this area, to be completed by city or town ofiiciaL
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]InsPeltor
6. Other
Contact Person: Phone#:
aJ ISS1JT DATE 07/3111009
RODUCER
'dward F Sennett Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
Agency Inc DOES NOT AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
16 South Main Street POLICIES BELOW.
ops6elLL MA 01983 CONIPAINMS AFFORDING COVERAGE
usvRED —
en Glbely Contracting Company Inc
CO)@ANY A AI.M. Mutual Insurance Co
THIS IS TO CERI IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE➢JSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED.NOTWITHSTANDING ANY REQU➢1ENIENT•TERM OR CONDITION,OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
TO WHICH THIS CERTIFICATE MAY BE ISSUED OR NI.AY PERTADJ.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBIECT
TO ALL TI IE-TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY ]AVE BEEN REDUCED BY PAID CLAIMS.
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Page No.Hof y Pages
1� LEN GIBELY CONTRACTING CO., INC. .. - PROPOSAL
149 Main Sheet _ � ",
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
_ I Chapter 142A of the general laws, must be registered
mitt Subed with the Commonwealth of Massachusetts. Inquiries
O
TO: `/ t'1 G about registration and status should be made to the
/lam Director, Home Improvement Contract Registration,
v f Cif I 71 / One Ashburton Place, Room 1301, Boston, MA 02108
(617) 727-8598. Owners who secure their own
SG, /, - M q- 0(q 70 construction related permits or deal with unregistered
/ contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
PIPI NE 11aa / ppp aAiE rearnRATgN NO.
(� 4 I C MA.REG. 100811
10.liberal. +Oa LOCATION
.S. i.,
submit mp and estimates for work a be p mend e l and materiels Id be used'.
,oaFj n�PGgC€itleti/
ns(11U LA Pa[/�S ff� Q/�/lam �/C �l hoc (mac 40
I rea-
�'
37e —,elT;v c' it/
t L
Gonsnlction relarttl permits'. �—
elk
r,I I. /�''� J�
WOPNCSCILDtIIE
creada II nN be Ik of orda,the malnlials bolero In.Cl,ad 0•L wreathe far siynia, 1 Nis Alloemenk unless spoclhod beroin win Or will boyin Ina work on o,
J 1/y (a Ube.Baring dem,smade by sr umic a, °s aeyon0 Conlraooh corbel,in.wed wJl bo computed by 1 (b. no Owner hc,uoy
XOuui o Area c/l trot lno scnobuling 1,Ies a,o approximlllO Ann lM1al SucM1 dol•y5lnpl are nOlnwld.NIis W the so.Iso1.1 shall not bo eoneldee ns of mia'grammar".
WARRANTYs /qi
in°ccamd...wm,unts mul led wort haduthod ncmundar shall be ties Iron defects In malenal and workmanship lore modest MC/�.1611oAi a pT;un..a snail dena,wiu,
roqualarn tit also Agr°amed.In Ins avert a ny tlolal in workmanshipm'telmlals,or damage causud by Iha Cmlraclor,blssubcondaclO,e'.amp,.....or agem;Is discw.,u0 willnn
n°yanr.1he traditional OI a,ry lob,include,clean up.Ill.Conlraclor shall,at his own sspan forthwith lonedy,raga,,,c replace.or cause to be readable.,ep°i,ad,or replaced.
uel dal -allm di in ahf±a a wmk •nsbip.Tire Iommid, ur s bar svlw any inspected p°nm mOd in commission ,,,,a..,,..a mW n wmk.
We PrOPOSO hereby to furnish material and labor,n complete in accordance with above specifications,for the sum of:
dollars
Payment to be matle as follows:
----% IS upon signing Conbedl �es10ma d Ji4C / / rJ d' �/r'N•m IC°n acmJO R5A,
— :e(8 .)upon cemVletion of
street wa,..
)Cpon be me ifoof
City/el PM1°n°
IS_ f shall le made lack U h a on
completed of Welk under this CenVUC1. PF,°ne Fedoal
Nmice: No agreement tar hams ImV,ovammtl conllncling wort shell require a tlo
paymam lhdvenco tldpCsin.(mere Nan one third of the feel ablemcl price or is
Iolat amount of all deposit or farmer;what i lire collector must in advance, dda•d egnelu
to older Under,,ammwGasobmin dead,of special under motorists slid edi iph= fO
µlliOlsy9[9plpynLF).et Wl19L me? l nls pmWsai as,Oar awn W act her nccasse m ted ,n
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 NO SIGN THIS CONTRACT IF THERE ARE ANY
BLANK SPACES.
Si,eha. able /V Sg,aw,° �—^ • Oam
MPORTANT INFORMATION ON BACK Iif►
lIMPORTANT INFORMATION ON BACK illi
Massachusetts- Department of Public Safety
Board of Building Regulations and Standards
.Construction Supervisor License
License: CS 94763
Restricted to 00 ,
THOMAS R DOBBINS
19 CEDAR fti-DRIVE r
DANVERS, MA 01923 4r
Expiration: 5114/2012
.;,,r, ('unmri+sionrr' Tr#: 23757
•...•..✓/ee 1�narivnsa�u�irull/e o�✓�aaoac�uaeCld
Office of Consumer Affairs&Business Regulation
lugHOME IMPROVEMENT CONTRACTOR
Registretion h 100811 Type: '
Expiration O/Z3/2012 Private Corporatioi
LEN GIBELY CONTRAC�ftJq:CO`ZINC.
Brian Dobbins
149 Main Street
Peabody,MA 01960 'ice Undersecretary