0022 COLUMBUS AVENUE - BPA 13-453 The Commonwealth of Massachusetts CITY OF
t� e Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Bui(ding Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
# This'Section`For OfficraLU'se'Only
Building Permit-Number
Building Official(PnntNarile) ,r ,°_''Signature
-'>SECTION 1 SITE INFORMATION �; ` ' >'" '
1.1 Property Ad¢ress: /V" I I /� 1.2 Assessors Map& Parcel Numbers
1.1a 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 ft) Frontage(ft)
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? Municipal ❑ On site disposal system ❑
Check if yes❑
'rS.v
"; SECTION 2'i PROPERTX OWNERSEIIP' ; ;{
2.1 ll
il f��OwnertofReF rRP l lc-f rYUc ) Uf 1 " to/V �S�c N fGl
Name(Print) // -- City, State,ZIP
No. and Street Telephone Email Address
SECTION 3i DESCRIPTION OF PROPOSED WORK (check all than pply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
,SECTION 4': ESTIMATED_CONSTRUCTION COSTS , z _ .n
Estimated Costs: Official iTse Otily
Item Labor and Materials
1. Building $
1 Buildmg Petmit Fee $ . Indicate how fee is detennmed:
❑ Stand'ard Citygown Application Fee-
2. Electrical $ ❑Total?Proaect Cgst (Item 6):x multiplier x
3. Plumbing $ 2 Ottyer bees $^
4. Mechanical (HVAC) $ List ---
5. Mechanical (Fire $ Total All Fees
Suppression) - '
' 1 Check No Check Amount Cash Amount
6. Total Project Cost: $ �V �� ❑ Paid in Full+ ❑ Outstanding Balance D'ue
SECTION 5: CONSTRUCTION SERVICES "
14
5.1 C ,"etionSu�rervisor License 1 L
License Number Expirati/on Date
Name of CS�er))) I
List CSL Type(see below)
No. and Stre/ey-,, �J / T :I ', Descript(on
Z / 1.�d) ��/1 / U Unrestricted(Buildings u to 35,000 cu. ft.)
City/Town, Sate,/�ZIIP, /� V� Restricted I&2 Family Dwelling
M Masonry
RC Roofing Covering
// WS Window and Siding
/ l SF Solid Fuel Burning Appliances
VI Insulation
I eiepnone Email address D Demolition r
5.2 Re gi ed H e Impro�ment for(HIC)
�� FIICC Registration Number `J ExpuaationlDate
HIC Company ty me o eo' tram dme
No. and Stre e Email address
% li (2s G U U1, U)
City/Town, 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 COMPLETED.WHEN
OWNER'S AGENT OR'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 Owners Name(Electronic Signature) Date
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 i application is true ayd acc t ithe best of m knowled e g.
u d andin
l-��i )G�2 y Print /�-
Owner's or Authorized Agent's Name( ctromc Signature) Date
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.mass.gov/oc Information on the Construction Supervisor License can be found at www.mass.uovldns
2. When substantial work 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"
i%r t CITY OF SaU.F-.LVI, NWSACHUSETTS
BUILDING DEPARTNW-NiT
a, 120 WASHINGTON STREET, 3'n FLOOR
bF TEL (978) 745-9595
FAX(978) 740-9846
Kn BERi FEY DRISCOLL
MAYORTHORiAS ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BCIIDL*IG C0\12MISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r rlicant Information !! Please Print Legibly
Nance(Busincsa0rganizano du 1)'
Address: TK7 � J l
City/Stat&Zip: �C i'1 br�l Phone
,l,ayeyou an employer?Che the appropriate box: 'type of project(required):
1.Is'l l ant a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. [1 Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. - 9• ❑ Building addition
(No workers comp.insurance 5. ❑ We are a corporation and its
required,) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL I I.❑Plumbing repairs or additions
myself. [No workers' cump. C. 152, q 1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. LNo workers' 13.❑Other
camp. insurance required.)
-Any appiicam du[chtxks box AI must also fill saw the uctien blow showing their workers'compensation policy infurmatiom
♦I Lwneuwnen who submit this affidavit indicating they are doing all work and then hire"iside contractors must submit a new amdavit indicating such
:Comraeton that check this box must attached an addidoml sheet showing the name of the sub-conuadors and their workers'comp.put icy information.
I am an employer that is providing workers'eampensurdaR insurance for my employees. Below Is thepoll y and jab sire
Inrrnaei C/
Insusu Company Company?lame:
Policy #or Self-ins.Lie. 0: �j )^ Expiration Date: ,
Job Site Address: f CityiState/Zip:
,\reach 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 S1,500.00 and/or one-year imprisonr=4 as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify corder the putts and penalties of prrjury th armurlon provided above is true and c'orreeL
Skiriaturc: Dater
Phonc d:
Ojjiciul use only. Do not write in this area,to be completed by city of town aff7cial
Cityor,rown: __- Permit/I.Icense#__
Issuinr Authority(circle one):
1. gourd of Health 2.Building Department .l.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other ,— --------
Contact Person:
Phone ti:
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
> Registration: 166565
j-7i Type: Corporation
��—'��`�1 • ( !rl Expiration: 6192014 Tr# 228167
iF A.C. CASTLE CONSTRUCTION CO HdC x - 1 s1
BRIAN LEBLANC
9 TIBBETTS AVE
"y ,, _ /1
DANVERS, MA 01923 � r,-i,�
Update Address and return card.Mark reason for change.
J✓ � Address E] Renewal [] Employment E) Lost Card
'PS.CA1 0 5OM-04/04-0101216
License or registration valid for individul use only
Otnce of Coasamer AQaas&B sraess Regalauoa
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration T 166565 Type-_ Office of Consumer Affairs and Business Regulation
Expiration 6f9/2014 Corporation 10 Park Plaza-Suite 5170
.Boston,MA 02116
A .CASTLE CO„N$TRUCTION COINC. -
BRIAN LEBLANG
9 TIBBETTS AVE
DANVERS,MA
Undersecretary Not valid without signature
Nlassachuutts- Department of Public Safct)
1 Board of Building Regulations and Standards -
j��JJ Construction Supervisor License
License: CS 54882
BRIAN A L EBLANC
9 TIBBETTS AVE
DANVERS, MA01923
Expiration: 9/17/2013
('nuuuiauimcl. Tr#: 1288
11-002644746 ;mac
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1b19buctipn Sa[aty mad Hea96
Brian LeBlanc
4norl0u
Ralph Ramal.#2=
- (imh«neme-vrtrd«type) (OouraeeM date)
J
J
Vropofsal
B o` 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
PROPOS ,IJ13p<L TTE � ^ Cl
O ` PHONE DA�� l�
STREET J u� If JOB NAME /
I /,1- rnC
CITY, ST �� O� JOB LOCATIQND_ CO j' m
ARCHITECT DATE OF PLANS �� `VJOB PHONE
We �;rOp05e a to furnish material and la r-complete in accordance with specifications below for the sum of:
dollars
Pay nt o be as follows:
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
the Commonwealth of Massachusetts. Inquiries about registration and gent
status should be made to the Director, Home Improvement Contract Note:This proposal may be
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 grasses with Blue Tarps in order to protect the property during stripping.
We will strip up to 2 layers of roofing and remove all nails, screws and staples down to the bare wood.The ice and water shield will then be
installed at the bottom of all edges, under all step flashings, under all roll flashing,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 installed to all roof edges.
Any existing pipes will be covered with n w mn rubber fla / /�/ p�
The roofing material to be used will bE ��i I,J �M 6 r6 it 3 r/ 1 9_
All the debris will be cleaned and dumped by us on a daily basis. Magnetic brooms will be use o xtract all nails from your property.
We will protect your property as best we can, however some foilage matting,breakage,or marring could occur. We cannot 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 ADDr TO TIE ABOVE PRICE.
Replace Rotted Roof ds r O Install Aluminum Gutters
Relead Chimney(s) Install Aluminum Downspouts
Replace Facia Boards Install Skylight(s)
Install Ridgevent Rotted Roof To Wall Flashings
Install Roof Louvers Gutter Repairs
NOTES:
Warrant
yyy cturer o free of detects or P y see manufacturer's warranty for exact warranty performance.
All lab under is co tract shall be of good quality and free from defects not inherent in the quality required or permitted for
a p od of year . his arranty excludes remedy for damage or defect caused by abuse, modification, improper or insufficient
mat [enance, improper dpera' n,or normal wear and tear under normal usage.This warranty shall be limited to the work performed by
A.C. astle Construction Inc. and limited to either repair or replacement by A.C. Castle Construction Co., Inc. at its'sole discretion
and ele An 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.
3tteptante of firopo5al -Signin this proposal means you have accepted all the terms as to
Date of Acceptance �f �Z Signature --