336 JEFFERSON - BUILDING INSPECTION �f3-I q - I LICE) $ f2 CA�- -7 -7
Aa The Commonwealth of Massachusetts RECEIVED
� Board of Building Regulations and Stan 1 f� CITY OF
Massachusetts State Building Code, 78dLT Y11ETIONAL SERVICES SALFM
Revised tiler 2011
Building Permit Application To Construct, Repair, Reno Oj&eirJisJ6,a 31
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applie
Building Official(Print Name) Signature Date
E
CTION I:SITE INFORMATION
1.1 P•q er iY Adrl� 1.2 Assessors Map& Parcel Numbers
Is this an accepted street?y - Map Number farce!Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(l)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Rovided
1.6 Water Supply:(NI.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 ❑
SECTION2: PROPERTYOWNERSHIPt
2.1 vnefrrutRfnnMir
' tA
Noma(Prinu City,Snua ZII� y►�
No.and Street 'I'clephone J Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Numberoh'Units Other ❑ Specify:_
Brief Description of Proposed Work'': _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 7 I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑'total Project Cost' (Item 6)x multiplier_ x_
3. Plumbing S 2. Other Fees: $
4. Nlechanical (IIVAC) S List:
5. Mechanical (Fire
Suppression) S 'Total All Fees: S_
6. Total Pro
J Check No. _Check Amount:_ Cash Amount:
Paid _
ect Cost: S ❑ d in Full ❑Outstanding Balance Due:
`Jeff 0 .� CQ�N7lZ r�LTOI�
5 V J1 -711 %
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor " egse(CSL) 0 — / G I —
License Number F.-piration Date
Name of CS .01
Mar f� List CSI.,Type(see below)
No.and Stree .f Description
�� � v� U Unrestricted Buildin s u to 35,000 cu. It.
VVV r I V ir" Restricted 1&2 FamilyDwellin,
Citylfown.State,LIP - M Mason
ry
RC Roofin Covering
WS Window and Siding
ejfj SF Solid Fuel Burning Appliances
0 I 1 Institution
Telephone Finail address D Demolition
5.2 ReKiste�ed�Ilomeil�'p�I nlConlractor(HIC) S L
//f1VVVV l!ll�� LL vvDO
HIC Registration Number Expiration ate
1I1C Company ame q � IC icg stra t r
No.and: 't '^ /- „ 75 .�} ) , Fmuil address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(NI.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 Is/l� 14 VU 0W
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: OWNEW 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 in this apklication is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(H.lectronic 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[Ionic Improvement Contractor(HIC)Program), will nol 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.ntass.,ov/oca Information on the Construction Supervisor License can be found at www.niass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. It.) (including garage, finished basement/attics,decks or porch)
Cross living area(sq. 11.) Habitable room count
Number of fireplaces _ Number of bedrooms _
Number of bathrooms Number of half/baths
Type of heating system Number ol"decks/porches
Type of cooling system___ Enclosed
3. `Total Project Square Footage" may be substituted for`Total Project Cost"
i
zy� A.C. CASTLE CONSTRUCTION CO. INC.
MBM. a 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
I�1�� Unrestricted Mass Builders License No.054882 Contractors Registration No.166565 4
P \ A FO t0 1 ONE^ DATE / ,n
STREET T 10.1 NAME/ vJ
42 to
yCY
CITY,STATE�WaZJV 0O?E JOB LOCATION f'
ff�
DATE WORK IS SCHEDULED TO BEGIN V DATE WORK IS SCHEDULED TO BE COMPLETED J(�Tf�E`� -
'fie coP ¢h y0ship/te�ria W r-comple inacc dancewith if atlons rthe sumoll
dollars($
Payment to be as follows: Va 1 0 h/)n
NOTICE: All home improvement contractors and subcontractors engaged in home Authorize
improvement contracting unless specifically exempt from registered by Signature:
provisions of Chapter f Ma of the General Inquiries
must t r registered with Agent
the Commonwealth of to the Office
consumer
about registration and
ss 9
status should be made to the Oaks of Consumer 0211 and Business Note:This proposal may be
Regulation.Ten Perk Plaza,salts fiDO,Boston,MA 0211fi. 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 she fleshings under all roll flashing,around all chimneys skylights,and into all valleys,in heated areas only.
We will install 15 pound underlayment onto all other areas of the roofdec . e 8"aluminum dripedge will then be installed to all roof edges.
Any existing pipes will be covered with n w mi 1p-rubber flan a J�/' _ ,- / —
The roofing material to be used will beny�P j-' /Y1'XI(�1J_ Or/ ti(/ rj')'
We wily cfaencu4alhgutters'und'doamspo0ls:Ail'the debris will be cleaned'ano'dumped'by'us•on n daily'basis:Magnetic broomswilPbe'usadlo—
extract all nails from your property.We will protect your property as best we can,however Some foliage matting,breakage,or morning 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
SE DDED 0 THE ABYV RRIIC
Replace Rotted Roofboards � 6"r - i Mall Aluminum Gutters
Relead Chimneys) Install Aluminum Downspouts
Replace Facia Boards Install Skylight(s)
Install Ridgevent/4� _(� (S Rotted Roof To Wall Fleshings PO(ry G(/
Install Roof Louvers Cawn� Gutter Repairs
NOTES: O
6
i
i
Warra manufacture to b ree of defects for a s,see manufacturer's warranty for exact warranty performance.
All la art r d ands is ntract shall be of good quality and free from defects not inherent in the quality required or permitted for
a per
d of years/ s warranty,excludes remedy for damage or defect caused by abuse,modification,improper or insufficient
metric nance,Improp eratian,or normal wear and tear under normal usage.This warranty shall be limited to the work performed by
A.C. Ella C lion Co.,Inc.and limited to either repair or replacement by A.C.Castle Construction Co.,Inc.at its'sole discretion
and also Ion. Any 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.
It is our obligation to obtain any and all necessary related permits.PLEASE NOTE:owners who secure their own construction-related -
permits shall be excluded from access to the Guarantee Fund.
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 awe 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 awgird 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
ofpast due accounts owed by the customer.
The homeowner's three day cancellation rights under MOIL c 93 s 48;MGL c 140D s 10 or MGLc 255D-s 14 as may be applicable.
.acceptance of Al3ro 1ooal-Signing this p sal means ou have accepted all the terms as statedand us as acting agent for permitting.
Date of Acceptant Signature 8 —
CITY OF SAL M, NL1SSACHUSETI-S
/ Y
BUILDING DEPdRT>lE.\T
120 WASHLNGTON STREET, 3`as FLOOR
TEL (978) 745-9595
F.te(978) 7.10-98.16
KIMBERLF_Y DRISCOLL
y,-StkYOR THoM 1.S ST.PIFRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\CMSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t flicant Information Ptcase Print Le ibl
V;II 1C(Ilusiness Org.vfiratium'I dividua )'
Address: p
City/State/Zip: v Q� Phone It: 7 0 Y 0
: r you un employer?Check the appropriate box: F
project(required):
I� 1 am a employer with 1- 4• 1 am a general contractor and 1
employees(full and/or part-time).' have hired the sub-contractors w construction
( 2.❑ I mda sole proprietor or partner- listed on the attached sheet. t modelingship and have nu employees These sub-contractors have molition
working for me in any capacity. workers'comp. insurance. ilding additionINo workers' comp. insurance 5. C] We are a corporation cold itsrequired.) officers have exercised their ctrical repairs or additions
).❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or udditions
myself. (,No workers'comp. c. 152, §I(4),and we have no 12.Q Roof repairs
insurance required.) t employees. (No workers' 13.❑ Other
curtp. insurance required,)
•nnv uppl oant that check,bux/1 must a6-NI out the seniun bctuwahowing their worked cumpen flon policy is,a, iun.
'I L+meowncrs who,uhmit this alndavit indicating Ihey am doing all work and then hire outride runtmctrxa mml suhmit a new amdavit indicating such.
:Commclvn(hut check Ihit box must atuchur an addoiurwl.hut showing nu nunc of the,ubeon:nrfurs and the It workcrt'comp.puIicy infurmatian.
I unt an employer that is providing w�er�ntpe(isadon insurance for my employees. Uelow Is rbe policy and jvb.sile
infarnuation' _!�f((/11
Insurance Company Name: I—— /
Policy It or Sclf-ias. Lic. th /�Y`� Expiration Date: / I
lub Site Address: . ( b �I Y 1 ► (��[S (11''1 City/State/Zip:�u
Attach a copy or the tsurlecn'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in thu form of u STOP WORI(ORDER and a line
of up to S_M.00 a day against file violator. Ile advised that a copy Of this statement may be f-unvardcd to the Office of
hn rstig,uiuns it [Ile DIA for insurance coverage verificatiun.
/do hereby certify under the pains mad Pena/lies of perjury that the infuralation/provided above is trueand t•orre•t
si-vi'llu c; lid:
Phone i� 7 & 6 I L
Official use rutty. Du not write in this area, to be cuurplelad by city ur town offleful
City orTown: Permitfl.kcnsc4__ _
lesuiag Authurily (circle uric): -- ---- _-- - -- I
I. Board of licalth 2. nudilinq I)epartutcot I. Cityatmn C'ierk .1. Electrical tnspecfr 5. Plumbing Inspector
G. Other
(:noted l4rasn: - Phone 't:
CITYOFS,UE,%f, J%L-1S&; CFjUSETTS
11) :".. 4' BCILLDLNG DEP.IR-MENT
h , 120 V/-%SHLYGTON STREET, jw FLOOR
aL. (973) 745-9595
KIAMM-EY DIUSCOLL FLY(978) 7-10-994,3
L"L{Yo;2
I'-tascU ST.PMvts
D[UC 0R OF PhoLIC PROPERTY/aEADLYG Co-w(ISSIONEZ
Construction Debris Disposal Atl7davit
(required fur all demolition mid renovation work)
In accordance with the sixth edition of the State Building Coda, 730 QWR
Debris, and die provisions of tb(GL c 40, S 54; section l I I.5
Building Permit N is issued with the condition that the debris resulting from
this
S ISOA.work shall be disposed of in a prope
I
l It, licensed waste disposal facility as defined by NfGL c
The dchris will be transported by.
(n�mu ut haul¢r) .
Che dchns%will be disposed ot*in ;
,Bpf4Or Al
(n. m of t:mihty)
sign�rurc ut'p<rmit a{,pfie,nu