41 OAKLAND - BUILDING INSPECTION J
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY SALEM
Massachusetts State Building Code, 780 CMR dMar
w Revised Mar 2011
\ Building Permit Application To Construct, Repair, Renovate Or Demolish a
w
V\ One or Two Family Dwelling
This Section Fof Official Use Only
Building Permit Number: Date A 'ed. V.
Building.Offlcial(Print Name) ^: :«Signat re -.- `r Date
SECTION
N 1: SITE INFORMATION
1.1 Prope rty ddr 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Providdd 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 OWNERSHIP'
2.1 Ow of Record: (J �
Name(Print) 1 , d City,State,ZIP
14 Z ouid cr ,
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION'OF PROPOSED WORK2(check all that apply) ,.
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of-Units— Other ❑ Specify:
Brief Description of Proposed Works:
SECTION* ESTIMATED CONSTRUCTION COSTS "
Item Estimated Costs: OfficiaLUse'Only
Labor and Materials - - -
1. Building $ 'I. Building Permit Fee $ sIndicate how fee is'deterininedi
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost}(Item 6)x multiplier x '
3. Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ List:-
5. Mechanical (Fire
Suppression) $ Total All Fees.$ .
Check No -Check Amount Cash Amount
6. Total Project Cost: $ �� ❑paid in Full El Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES s
5.1 Con action Supervisor License(C$ )�/� a
-60 G/(// (r' / License Number Expiration Date
Name of CSL Holder
/ 1 1 ' / List CSL Type(see below)
No. and St re t /� C/� V' ,- r r :Descnpnon
Li ( U Unrestricted(Bmldm s u to 35 000 cu ft)
Restricted 1&2 Family Dwelling
City/Town, State,ZIP
M Mason
RC Roofing Covering
WS Window and Siding
L SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered onle I provem n Contractor(HIC) e/
CHIC Registration Number ExpiratictrTrate
HIC Coyny,"Jig Regi r Name
No.and Street '` C)L// Email address
City/7own, State,ZIP 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 .......... ❑ No ........... ❑
SECTION,7a: OWNER AUTHORIZATION TO BE COMPIETED WHEN ,
OWNER'S AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT_ ;
I, 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) Date
SECTION 7b: OWNERr OR AUT$ORIZED 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.
I/ /z-I)J,2-
Print Owner's or Au orized Agent's Name- (Electronic Signature)`� ate
NOTES '
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.rnass. og v:oca Information on the Construction Supervisor License can be found at tivww.mass.eovr"dos
2. When substantial we is planned,provide the information below:
Total floor 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"may be substituted for"Total Project Cost"
V
CITY OF SAI..EINI, TNLkSSACHLSETTS
BUILDING DEPARTMENT
N 130 WASHNGTON STREET, 3' FLOOR
TEL (978) 745-9595
F&x.(978) 740-9846
KINtgFRT R.Y DRISCOLL
MAYOR- DR THosw ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/Bun.DNG CO\L\QSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL e
i 11, S 150A.
The debris will be transported by:
41 /, d 4
(name of hauler)
The debris will be disposed I of in :
(name off facility)
(address of facility)
signature of permit applicant
d�--lV/ 2,--�
date
•Icbrisal7dx:
Details Page 1 of 1
Licensee Details
Demographic Information
Full Name: BRIAN A LEBLANC
Gender:
Owner Name:
License Address Information
Address: 9 TIBBETTS AVE
Address 2:
City: DANVERS
State: MA
pcode: 01923
Country: United States
License Information
License No: CS-054882 License Type: Construction Supervisor
Profession: Building Licenses Date of Last Renewal:
Issue Date: 9/17/2011 Expiration Date: 9/17/2013
License Status: Active Today's Date: 8/14/2012
Secondary License:
Doing Business As:
Status Change:
Prerequisite Information
No Prerequisite Information
Discipline
Complaint Number: 2004-121-C
Complaint Status: 100
Date Complaint Received: 11/30/2004 12:00:00 AM
Date Complaint Entered:
Violation Code:
Violation Type: 2
Violation Description: Reprimand
Sanction: Reprimand
Sanction Start: 9/15/2005 12:00:00 AM
Sanction End:
Documentum
http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=243841& 8/14/2012
v
i CITY OF Sa1r . —,Nl, NLA SSACHUSETFS
Buimr,,G DEPARTMENT
Ira 120 WASHINGTON STREET, 3w FLOOR
e T)EL. (978) 745-9595
FAX(978)740-9846
KIN[gBRI EY DRISCOLL
T
MAYOR Ho.%Lxs ST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING COS611ISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A f llicant Information I Please Print Legibly
Name(BusineisOrganizatioNlndividual): Z
Address: W /� )
City/State/Zip: -fir l„ Phone If: L lJ d L
% you un employer?Chegk the appropriate box: 'type of project(required):
1. 1 am a employer with J 4. El am a general contractor and 1 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 t Z ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers' comp. insurance S. ❑ We are a corporation and its to.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL i I.❑ Plumbing repairs or additions
myself. [No workers'comp. C. 152, §1(4),and we have no 12,❑ Roof repairs
insurance required.]t employees.[No workers'
comp. insurance required.) 13.❑Other
'Any applicant cut chucks box sl most also rill out the section below showing their workui mmpensarion policy information.
I bnnmwndots who submit this affidavit indicating they am doing all work and then hire outside contractors most submit a new utf7davit indicating such.
:Comnwton that check this box must anachedan additional sheer showing die name of the sub<omndon and their worked'comp.policy information.
l um an employer that it providing workers'compturs�surance for my employees. Below is rite policy and job site
information.sunc
Insurance Company Name:
i
Policy 4 or Self-ins. Lie. 0: r Expiration Date:
VjJob Site Address: City/State/Zip: ���/C�
\ttacb a copy of the workers'compensation policy dectaratfon 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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and fine
of up to$250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of die DIA for insurance coverage verification.
l do hereby certify Larder the pains and pelt allies of perjury that the injarmurlon provided above is true and co rest.
Skmat tra• J /� Data:
Phone d, :5 / � (/
OJjic ial use only. Do not tvrite in this area,to be completed by city or town official
City or Town: _ Permit/[.lcenseft
Issuing Authority(circle one):
I. Board of Ilealih 2. Building Department 3.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ ,__.,____--- Phone B•
13ropoai
BBB F A.C. CASTLE CONSTRUCTION CO. INC.
MEMBER' Telephone (800) 505-LEAK(5325) • Fax (978) 777-7750
Brian LeBlanc, President
Please mail accepted proposal to the office located at:
9 Tibbetts Avenue • Danvers, MA 01923
Unrestricted Mass Builders License No.054882 Contractors Registration No. 166565
PROPOSAL TTE IXO V l n� r-t DATE 71 /
STREET JOB NAG /
L
CITY;STATE APO ZIP ODE , JOB LUCATI(Jiv
ARCHITECT DA E OF PLANS JOB PHONE
2)C 'r opoStp reby to turniishmaterInbor-com eteinacccda /fith speecificationns1lw` Vrhesumo
/ �
�
f Y �m /� � } e
dollars($ � 4
Payment to be as follows: , l ,
Y3 � �
i
NOTICE: All home improvement contractors and subcontractors engaged in home Authorized
improvement contracting unless specifically exempt from registration by Signature:
provisions of Chapter 142A of the General laws,must be registered with Agent
the Commonwealth of Massachusetts. Inquiries about registration and Note:This proposal may be
status should be made to the Director, Home Improvement Contract
Registration,One Ashburton Place,Room 1301,Boston,MA 02108. withdrawn by us if not accepted within days.
WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR:
A ROOF STRIP
We will cover the siding,bushes, and grass with Blue Tarps in order to protect the property during stripping.
We will strip up to 2 layers of roofing and remove all nails down to the bare wood.The ice and water shield will then be installed
at the bottom of all edges, under all step flashings, around all chimneys, skylights, and into all valleys.
We will install 15 pound underlayment onto all other areas of the roofdeck.The 8"aluminum dripedge will then be linstal d to all roof edges.
Any existing pipes will be covered with new m um rubbery fl es. edges)
Any
The roofing material to be used will b G
All the debris will be cleaned and dumped on a daily basis by us. Magnetic brooms will b use to extract all nails from your property.
We will protect your Property as best we can, however some foilage matting, breakage,or ring could occur.'vde ca-nn6i accept
responsibility for possessions inside of the house,or debris falling into attic areas. Customer should protect personal belongings.
EXTRA WORK IN WHICH A COST WILL BE ADDED TO ROVE PRICE.
Replace Rotted Roofboards ��e�6 Install Aluminum Gutters
' Relead Chimney(s) AAJ Install Aluminum Downspouts
Replace Facia Boards Install Skylight(s)
Install Ridgevent ( Rotted Roof To Wall Flashings
Install Roof Louvers Gutter Repairs _
NOTES: I
i p
I
J
Warranty mJ
be free of defec s o years;see manufacturer's warranty for exact warranty performance.
All labor rfofrcontract shall be of good quality and free from defects not inherent in the quality required or permitted for
a perio of J warranty excludes remedy for damage or defect caused by abuse, modification, improper or insufficient
mainte nce, iton,or normal wear and tear under normal usage. This warranty shall be limited to the work performed by
A.C. Ca ConInc. and limited to either repair or replacement by A.C. Castle Construction Co., Inc. at its'sole discretion
and election. ny and all claims are waived unless made in writing to A.C. Castle Construction Co., Inc. within 21 days after the
occurrence of the event giving rise to such claim.This warranty shall not extend beyond any limits imposed by applicable law.
Payment and Penalties- Upon substantial completion of all work under this contract, customer shall within 3 days make final and full
payment of the contract price. Any and all unpaid balances shall accrue with interest at 5% interest per month. You agree to pay all
court costs and collection expenses incurred by A.C. Castle Construction Co., Inc. in the collection of any amount you owe under this
contract, including without limitation reasonable attorney's fees. Please note: any illegal layers of roofing beyond a second layer will be
an extra cost of'35 cents per square foot.
Arbitration - Any controversy or claim arising out of or related to this contract, or the breach thereof, shall be settled by arbitration with
the American Arbitration Association or a mutually agreed upon third-party. Any judgment upon an award entered in arbitration may be
entered in any court having jurisdiction thereof. This section shall not apply to claims of A.C. Castle Construction Co., Inc. for collection
of past due accounts owed by the customer.
Attrptante of i3ropo5al -Signing this proposal means you have accepted all the terms led
Date of Acceptance Signature
d
Office of Consumer Affairs &Business Regulation - Mass.Gov Page 1 of 1
The Official Website of the Office of Consumer Affairs&Business Regulation (OCABR)
Consumer Affairs and Business Regulation
Home Consumer Home Improvement Contracting
Home Improvement Contractor Registration Lookup
You can search/filter the registration list by any of the criteria below.
Search by Registration Number 1166565 Search
Search by Registrant Name
Search by City �� Zip Code
Search Registrants
Click on the registration number to view complaint history. You can also view arbitration and Guaranty Fund
history.
The list is current as of Monday, August 13, 2012.
Search Results
REGISTRANT RESPONSIBLE REGISTRATION ADDRESS EXPIRATION STATUS
NAME INDIVIDUAL NUMBER DATE
A.C.CASTLE LEBLANC, BRIAN 166565 9 TIBBETTS AVE 06/09/2014 Current
CONSTRUCTION CO DANVERS, MA 01923
INC.
http://services.oca.state.ma.us/hic/licenseelist.aspx 8/14/2012