125 MARLBOROUGH RD - BUILDING INSPECTION S
1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards I'OR
gd Massachusetts State Building Code, 780 CMR. 7"'edition NIUNI(f 1.11 )
v Building Permit Application To Construct, Repair, Renovate Or Demolish a Rrri.,rd./rurrr u c
( � One- of Tiro-Family Duelling 1. 2008 .
This Section For Official Use Only
Building Permit Num er: Date Applied: O
Signature:
Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
L( Property Address 1.2 Assessors Map & Parcel Numbers
JQS(�C2L1�a90Qe6 RI,
1.It Is this an accepted street'? yes no Mup Number Parcel i1'unibcr
1.3 Zoning Information: 1.4 Property Dimensions: —
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks (fa
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 Owner]of Record:
a r
J _S l ISc,N O gfLr -e j FMl'72 L j6o2 n H 1^
`D
Name(Print) Address for Service:
478 � tiy 9v
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Buildingl5(_ Owner-Occupie Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ ^Other ❑ Specily
Brief Description of Proposed Work2: _Tza n v
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
1 Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost' (Item 6) x multiplier x__1___ j
3. Plumbing $ 2. Other Fees: $ ILLS
4. Mechanical (HVAC) S List:
5. Mechanical (Fire
_Suppression) $ Total All Fees: $
0 0o Check No. Check Amount: Cash Amount:
6. 'total Project Cost: $ ;
Q — 0Paid in Full ❑ Outstanding Balance Duz:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ® 9 4 6-31 �j 7
License Number Expir;uion Dale
:'o �,, �.� Ire b t ��
Nano of CSL- Holder ,.I List CSL Typc(see below)
ICi4 /Z�Ar.v �'� �� lJ (7�o�MA T c Descrinion
Address U Unrestricted(u m iS.000 Cu. Ft.)
R Restricted I&' Family DDwelline
Signature '` ' t - M Masonr Only
�� Q S 1 , 3� RC Residential Roolin�Covenite
TelephoneAvS Residential AVindow un�i5�ehuP
SF Residential Solid Fuel I3umme .A,lli:mcc Inslallauwm
p 1esidential Demolition
5, A egistered [ionic Improvement Contractor(HIC) 1 C> C) is ) )
!" a r ✓ Cowl Registration Number
HIC Company Name or HIC Regtstra Name
, L Mar ,✓ Sr oqh ►� r~ Ifr b - `2- o
t 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'? ties .......... No ....... 0
SECTION 7a: OWNER AUTORIZATION TO BE CO
H MPLETED 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
Signature of Owner
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I L_.pA-.j Gc._F,_ LV ' ate+1 -, as Owner u Authorized ARen hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
beh:)Jt v
Print Name
Date
Signature of Owner Aut ized Agen
(Signed under the 2ains and penalties of er'u ) NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registgred 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 1 10.116 and 110.R5, respectively.
2 When substantial work is planned, provide the information below:
(including garage, finished base men dattics, decks or porch)
Total Floors area (Sq. Ft.)
Habitable room count
Gross living area FL) Number of bedrooms
Number of fireplacesces Number of half/baths
Number of bathrooms
' Number of decks/ porches
type of heating system
Open
Fnelosed, It
"type of cooling system t
v
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
UIV www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
_Applicant Information Please Print Legibly
Name(Business/orgmization/Individual): o i 4 k>.-,, l_V 0
Address: / i ! �i' /� t t ✓ S r
City/State/Zip:'Pp t� fl`j/I 0 l 9 G D Phone.#: 9 ` I J S 1 J 3 y
Are you an employer? Check the appropriate box: Type of project(required):
1.,Nr I am a employer with � `A- 4. ❑ I an, a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
sbip and have nu employees These sub ccntractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#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 must 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 subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. nn
Insurance Company Name: S . Co
Policy#or Self-ins. Lic.#: C 1 Ci q '-1 9 0 t Q C O R Expiration Date: 0 g - C)
Job Site Address: (ZS M A,_L L n r,z Ls 6-(. City/State/Zip: CD ` 5?L�
Attach 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 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$250.Op a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the painsand penalties of perjury that the information provided above is true and correct.
Signature Date
t
Phone#: 9 7 R _5 3 1
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
/ / J1 / LUUO LUY : LO Ylvl - OYJJ 4j UL / UL
IS.0
1_lEIi.a'CE 07/31/2008
RODUCER 'THLS CMMMIMERT;IC
ATE 1S ISSUED AS A MAI"l'ER OF INFORMATION ONLY AND
�F'dward'?Sennot-I'll
CONFERS RIGHTS UPON't'[-!ti CERTIFICATELEOLDER THIS CERTIFICATEGAgencync 70ES NOTMEND,EXTENDOR.ALER THE CUVFR.AGE AFFORDED BY THEPOLICIES BLOW.
�1e South Main Street
rGibely
1983 - - COMPANIES AFFORDP.�IG COVERAGE
racting Company Inc J COMPANYAA1.M. Mutual InsuranceCo
LETTER
91 S
THIS IS TO CERTIFY TIJ 4T THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
TO WITICH THIS CERI IFICA PE MAY BF ISSUED OR MAY PFRTA.ild,THE INSURANCE AFFORDED BY'FHE PO!1C:[E.�DESCRIBED HEREIN IS SUBIECT
LTO ALL THE T2RMS,EXCLUSIONS AND CONDITIONS OF SLCIi I OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUUHD AY PAID CLAIMS.
f0 POLICY EFFECTIVE POLICYEXPIRATION LIMITS
LIR TIRE OF INSURANCE POLICY NUMBER DAl'E(MM/DC/YYI DATE III MIDDITn
GENERAL LIABILITY GEIJEMLAGGReGAIE
JRODUCTSCOMP/OP AGi.
OCOMME4CIAL V'ENEFAL:.IABILITY P$ry$ONAL@ADV INJURY
I _
==CLAIMS MACE=OfNR rEACry OVCURRENCS
=OWNERS 4 CONTRACTOR'S TROT.
f:RE DAMAGE(Anyua<Mol
MEL E%PEN..^.E(Anln,l
-1
AUTOMOBILE I•NBILIT; '' C-MBINED SINOLF
LIMIT
pNT ALM, I B06ILY INJURY
ALL O'll I Al (P,,pnTT
r SCHEDULED AT-•.`.
I�HIRED AUTOS SO:FLY IIW`JGl'
N0H10 :D AUTO' I j lPv 7,FF ,
GpIJ.aE.:\dI:ITY
PRPPERTY DAMAGE
FYCEF LIABILITY
L'1CN OCCURREN:= —J
'UMBRELLA FORM AGGREGATE
_OTHER THAIJ UMBRELLA FOR 4LI
WORKERS COMPENSATION AND i �EL
TATO LIMB^.EhIPLOYERS LIABILITY
RE PROPRIETOLACHACCIDENT SOO,000
A ARd EhAII:ECUFIYC
FFICIERS ARE_ 6010979012008 , 08/03i2008 08/03/2009 IEDISEASE-POL!CYL:Mr1' 500,000
INCL �EX'-�
2LDISEASE-EA^_`. 500,000
. EMPLOYEE
COMMENTS,DE$CRIPT'•ON•iF OPERATIONS OR LOCATIONS.
I
it
C: ?
HO=ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EYPIItAT10N DATE
rNG'ELA $I RC1 N I r1 HEREOF,THE ISS U W G COMPANY WILT,FNDFAV UR I'O MAIL 10 WRITTEN NOTICE TO THE CER rMCAT
OLDER NAI ED'ED THE LEiT,BLIT}'AILVRE TO MAL SUCH NOTICE SHALL Ee0'OSE NO OBLIGATION
,C(O GIBE LI' IIILIABILITY OF ANY RIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES,
I I
49 MAIN ST
EABODY,MA 01960 14UIHORIZED REPRESENTATIVE
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Page No. of / Pages
LEN GIBELY CONTRACTING CO., INC. 1
149 Main Street fyo-'�jyto- 18273 ,PROPOSAL
PEABODY,MASSACHUSETTS 01960 It/ :.
All home Improvement contractors and subcontradtore
,`(978)531-8234 engaged In home Improvement contracting, unless
specifically exempt from'reglstratlon by Provisions bt
FAX(978)531-9304, "! Chapter 142A of the genial laws; must be registered
Submitted with the Commonwealth of Massachusetts:Inquiries
To: 115o, .6 t-1 a In about registration and status should be made to the
1 7 Director, Home Improvement Contract n, MA
u (.t One'Aahburton Place, Room 1301, Boston, MA 02108
... r
r Y l 11 construction
related
owners who secure their own
construction reletetl permits or deal with unregistered
/ contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
PIgNEE OQE ^� REGemagONNO. MA.REG. 100811
-
to 7yLi- 16q a 7/Z�1C'.t?
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JOB NMffJNO. - l r' r JOB LOCATION
5,4 M�
We ha M ait spedfinetlons erM estimates br work b be pedarmed arM materials to bs uaetl: -
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Construction related related permits:
-f t Apt, �s
MMBC EDULE
Con I e WOt,Or oNer Ina meMdels bebre ins NIN tl y Mllow gins signing d Nis Agreement unless specnetl hero
ln wri n ConuMcer II begin the wort,on or
{ about (date) Bertlnp tleleyceueatl by dreumstancoa beyontl ContredoYe control.Ne work will on
com0letetl by ate).The Owner hereby
m sail the ecM1adullnp tletes are apprwlmeM errd that auto dBbya that ere not ewideble Dy am mnbaclor aM1ell rwt be con I retl lationa d Nls Agraemenl.
WMRAMY,• .s -+K. , w.rl.. .. t.:i:
The Convector werrenm stet ale work NrnLNBtl hareuntler snail be Ime kom tlefetl8 In material end nmrkrnanMlp br a padotl of blowing completlon end shell comply wIN
ale rpquiremen4d Mb Apreemem.m Me avert airy dated in worlmarWllpwmatedBle,or damage cpusetl by Ne Convsdor,hiew n m,emphyaes or spans la dlup+ared within
one yam slier pomplatlM d a,ry IoC IrMud,p dean up•ins Convector aM1ell et his punt dgie .toMwlN remedy.repdr,tuned,replace or cause to ba remMletl,repelree,or replecep,
auto damage a each dated In malerlels brwot,mensM1lp.The bragdnp wMMmies anon curvive em/mapectlan pedormed In connection wmi me egraetl-upon wort,.
we Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
dollars($ )
Payment to be made as tpllows: ,a
%IS )Wen signing Contract a —`-.—
�,� ` Name otoonva_dmlpimignrso RbeSVani
%(5,,:�6.1.)upon completion of _
ahas Mtlreo
%($ )upon completion of
%($� ups—..
)shall be met.forewith upon
completion of work under ands contract. Phone
- Rrr¢-�
Notice: No agreement for home improvement contracting work shall require a down �lgeemmn Bdamen
payment(a no,deposit)of.more than onedhird of the towl contract price or the
total amount of all deposits or payments which the contractor must make,In advance,
to order and/or oarerMse obtalRdellyi of special order materials and equipment.
hid,Bgrl am-1101ja lgffim 1 ., .Note:This propel may be MNemwn by us n not accepiee within days.
Acceptance of.Proposal I have read both sides of this document and swept the prices,specifications and conditions stated.I understand
that upoq signing,It",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.
sigr,awre l 1�""snaJ m' J n_.., J Dale 7 2.1 sronewre
_ - IMPORTANT INFORMATION ON BACK BW
Board of Building Regulations and Standac.
R
ds ,
HOME IMPROVEMENT CONTRACTO
Registr�r�100811 - i
-�-••- p n 3/2010 Tr6 268971 i
• wte Corporation I
LEN GIBELY CONTRAC,. ! �CO;INC.
Brian Dobbins
149 Main Street
Peabody,MA 01960 Administrator ! '
d.
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ucense QONSTRUCTI,ON SUPERVISOR �r
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