5,7 FLINT ST - BUILDING INSPECTION 1
The Commonwealth of Massachusetts INSPEC7SEWaSBoard of Duilding Regulations and Standards� � Massachusetts State Building Code, 780 CMR lotit
Building Permit Application To Construct, Repair, Renovate Or DRINK
One-or Two-Family Divelling
This Section For Official Use Only '
Building Permit Number: Date Applied
z- l-
I Building 01ficial(Pont Name). Signature Date
SECTION I:SITE INFORtIVlAT10N
1.1 Property Address: 1.2 Assessors Nlap&Parcel Numbers
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 'Lotting Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(11)
1.5 BuildingSetbacks(it)
Front Yard Side Yards Rear Yud
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§SJ) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ outside Flood Zone? Municipal 0 On site disposal system
Public❑ Private O Check if es0
SECTION2: PROPERTYOWNERSHWP
2.1 Owner of Record: ^
throe(Print) City,State,ZIP
5 )�i'A) Gi
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Existing Building 0 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) O Addition 0
Demolition O 1 Accessory Bldg.❑ 1 Number of Units_ I Other 0 Specify:
Brief Description of Proposed Work^ < - r ......J_ j\A S 14 1141 Paz-,
f J tx2 r�
MSEC�TIONMATED CONSTRUCTION COSTS
Itcm OfOciai Use Only
I. Building I. Building Permit Fee:S indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing �,Qther Fees: S
d. Mccll, i..1 (FIV;\ List:
i. Mechanical (Fire $ Total All Fees:S
Su ressiun)
Check No. Check Amount; Cash Amount:
6.Total Project Cost: S Q; 709, ❑Paid in Full ❑Outstanding Bahmce Due:
i � 7D COVLTr,1\C�
- " I SECTION 5: CONSTRUCTION SERVICES
5.1 CoustructionSupervisoeL'icense(CSL) CSSL "/6081N /a " t/ -/Jr
Isc License Number Expiration Date
Name of CSL tlulder List CSL'rype(see below) R�.
271 Type Description
No.and Street ..
U Unrestricted(Buildings tip to 35,000 cu. Il.
Sc,t p , IVA 61 1 70 R Restricted I&2 F:unil Dwellin
Cityffown,State,ZIP ht I Mason
RC I Roofing Covering
WS Window and Siding
'SgK:�nW d I/PUt'?.a/1.NE a' SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address U Demolition
5.2 Registered Home Improvement Contractor(HIC) /f, l l 2 5
�1 �. ��`c(nwn !// • =/�L HIC Registration Number Expiration Date
IIIC Company Nam r FlIC Registrant Name
No.and Street •mail address
Strlen•N AA& 0147d Q7�—"71/1 '75
Citvfrown.State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I5L 9 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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN'
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nane(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 in this nppli/caSion is true and accurate to the best of my knowledge and understanding.
hlt/ /1) —
Print Owner's or Authorized Agent's Name(Electronic Signature) Dnle
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 nol have access to the arbitration
program or guaranty fund under I.G.L.c. I42A. Other important information on the HIC Program can be found at
www m rss euv'oea Information on the Construction Supervisor License can be round at jyjy. mass.eov:!dns _
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3. `Total Project Square Footage"may be substituted for"Total Project Cost"
QTY OF SALEM, MASSACHLSEM
a
BUILDING DEPARTMENT
120 WASMNGTONSTREET,3" FLooR
TEL. (978) 745-9595
F
KIMBERLEY DRIS�LL FAX(978)740-9846
MAYOR THomA.S ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING 00N IISSIONER
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
Tr3 1< , C c
(name f hauler)
The debris will be disposed of in:
Sg K,- ir f i�i Zn/c
(name of facility)
O I- S al r.M o,CY7 0
(address of facility)
Signature of applicant
/a-
Date
1 Massachusetts - Department of Public Safety.
Board of Building Regulations and Standards
Construction Supenisor Specialh
License: CSSL-100819
SCOTT M KEDNE}r
24 BRADFORD ST _.
SALEM MA 01970 _
w
�� � Expiration
Commissioner 12/04/2015
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration:. 151123
Type: Private Corporation
Expiration: 5/17/2016 Tr# 254750
J.B. KIDNEY & CO INC.
SCOTT KIDNEY f
in
41 OSBORNE STREET
SALEM, MA 01970 ti -
i. ,4- i Update Address and return card.Mark reason for change.
-' - Address ❑ Renewal 7 Employment Lost Card
SCA 1 Co 20M-06/11
VRe �Pcmvmr�ea�a�VOLa,6oacLiudeUd .
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
gtstrat1,n: 151123 Type: Office of Consumer Affairs and BusMess Regulation
xpiration: 511.7%2016. Private Corporation 10 Park Plaza-Suite 5170
a - Boston,MA 02116
J.B. KIDNEY&CO INC.
SCOTTKIDNEY 41 -
41 OSBSBORNE STREET
SALEM, MA 01970 Undersecretary Not va id without signature
D
Q-I-Y OF SALEM, l/'WSACHL:SETTS
BUILDING DFPARTNff—NT
3 ) )� 120 WASHCVGTON STREET, 3"FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI.NIBERLEYDRJSCOLL THO6IASST.PIE an
`,11AAYOR
DIRECTOR OF PUBLIC PROPERTY/B(:QDItiG CO\MiSS[ONER
Workers' Compensation Insurance AlTidavit: builders/Contractors/Electricians/Plumbers
Applicant Information 1 Please Print Leeibly
Name -
Address:!1/ O S6vs f fag a E
City/State/Zip: Sci onnF AA& ®/ca-70 Phone #: 97f-- 71jU-,? �5
Are you an employer."Check the appropriate box: Type of project(required):
I. i am a employer withSg Knij 3• ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time). have hired the subcamractora
2.❑ 1 ant a sole proprietor or partner• listed on'the attached shcet. t �• ❑Remodeling
ship and have no employees These sub-contractors have it. ❑Demolition
working fin me in any capacity. workers'camp.insurance. 9. ❑Building addition
INo workcri camp. insurance J. ❑ We are a corporation and its
required.)
officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I•❑ Plumbing repairs or additions
myself. (\o workers'Gump. c. 152. §1(4),and we have no 12.❑ Roof repairs
insurance required.) f employees.(No workers' 13.❑Other
camp. insurance required.)
�nny appiie:un tlw clucks base el must also rill out the section bviaw showing their wadm'compenaadan policy information.
'I iomouwncrs who submit this atrlrinvit indicating they ate doing all work and then hire outside contractors mint submit a rxw afedavit indicating such.
:('ootraetun that chuck ibis bus mint anachod an additional shrst showing the nurse of the subavm»clors and their workan'wmp.policy information,
l um an employer that/s providing ivorkers'cuntpensadon insurmncefor my employers. Below/s the'vial%y andJub site
Jnforaration.
Insurunce Cunipany Naute: sd/ __--
Policy it or Self-itts• Lic. N: Expiration Date:
Job Site Address, F/114+" S4-. City/Start:/Zip: 4��Q/ovVlr /14 aL1o0
Attach 2 copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Suction 2JA orMGL c. 152 can Icad to the imposition ofcriminal penalties of a
iine up to SI,500.00 and/or au-year imprisonment,as well us civil penalties in the form of STOP WORT(ORDER and it line
of up in S2J0.00 a day against the violator. Ile advised that a unity of this statement may be furwerded to the 011ice of
Inrrsiigaiianv ui'ihe DIA for insurance coverage verification.
/da hereby cerdly larder the puins and peauldes of prrjary that the infurnrut/an provided above is true and currec•L
si•_n cure '16 ���' Dafe: 1.9_
Phunc y: !p 7 S"
k
f7f/iciul use only. Donor tvrire in this area,to be cuusylefrJ by city car town a/JJriaL
l
City nr Tuwn: _ _ __ Pcrmlta.1ccmc N_—.
Issuing Atahurity (circle one):
I. Board of Ileallh 2. Iluildlnq Departinrat .1.Cityffuwn Clerk A. F.leetrieal Inspector 5. Plnnihing luspecnor I
b. Oilier I
i Contact I'erion:.._ _.. _ Ph°oc :Y: