6 FLINT ST - BUILDING INSPECTION (3) ( � 1 RECEIVED
o The Commonwealth of Massachu
s c Department of Public Safety t�IG•Massachusetts State Building Code(780 CMR) 1013 DEC 12 P 39
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official: a
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
5L -#-?- Sa(Q on, l't'1 W 01776
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration d 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
i
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No M/
Is an Independent Structural Engineering$Peer Review required? Yes ❑ No
Brief Description of Proposed Work: 6Cx (a r C,C�h-�-�/I ✓t'O r ci Ge_p_,e + t,v;✓Ad0_-t S
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4 Cl A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-111 R-2❑ R-3❑ R4❑
S: Storage Sl❑ S-2❑ U: Utility❑ - Special Use❑and please describe below:
Special Use:
SECTION 6.CONSTRUCTION TYPE(Check as applicable)
IA O IB ❑ IIA O IIB O ILIA ❑ IIIB O IV 13 1 VA D VB Cl
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: - Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
26_CtiQ,-v Xoa v 0 to MW obi I o
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
C�r s- ?0r7-�� IISNorth S+ Sa(.erv, fKA 01970
Name Street Address City/Town State Zip
to act on the property owners behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
f buildin is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
/4�A- 1q—SI2 r✓iL.LS /KC
Company Nam'e7
S =lY1 rI S- LO✓Z c� 0�7 ��J3
Name of Person� nnsi le for Construction License No. and Type if Applicable
-] I i) V O/ . J I �c7�k 1^ A4 4— 0 t —J v
gr `
Street Address1 City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes 13 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ S 1 6 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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. �'.p,y�
Ch�i�b.er7�x Pcz s, 1c� r+ 9-N_- t _ oq _i
Please print and sign name Title Telephone No. Date
l iVo✓ I S'A . 60-1/.w-, t4#+ oIctZo
Str Ad es City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF SMY.M, TNLkssACHUSETTS
BL'II.D4NG DFP.IM.ENT
• 130 WASHNGTON STREET, 3' FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJIDERLEY DRISCOLL
MAYOR THomAs ST.PmRRH
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG CONL<RSSIO.iER
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 c
111, S 150A.
The debris will be transported by:
. �' -4-�'w.�-KY.K 4 Cam.�.�v�L•
(name of hauler)
The debris will be disposed of in
S CL l,t yv� � /"0.✓�5 / �� v ✓1
(name of facility)
(address of facility)
signature of re
applicant
LZ13
date
dc6riufY,doe
i CITY OF SM E:M, NLASSACHLSETTS
BUILDING DEPART%CLNT
120 WASHiNGTON STREET,3tD FLOOR
TFL (978) 745-9595
FAX(978) 740-9846
KI,%tBERLF-Y DRISCOLL
,MAYOR THo?.w ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING co%L%assiONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibiv
Name(BusirKss.Organizalion/Individual): _ �'d" ,D.✓Ji CO-$ Inc
Address: L/ S (V 0/-tvL S-
City/State/Zip: S0.0 M A-- 0 /9 70 Phone#: -7`f( —0`l 6i'y
Are youan employer?Check the appropriate box: Type of project(r d):
LB t am a employer with q 4• ❑ I 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 I Z ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
mp.[No workers'co insurance 5. ElWe are a corporation and its 10.0Electrical repairs or additions
required.] officers have exercised their
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 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' 13.[]Other
comp. insurance required.]
'Any applicant that checks brat nl must also fill out the section below showing their workers'cumpmeation policy infomutioa
?I rommcownets who submit this aflidavb indicating they are doing all wont and then hire outside co n alms most submit a new affidavit indicating such.
:Contractors that check this box most attached an additimal shoot showing the name of ds,wb.comroc a s and their workers'aomp.policy information.
l am an employer that is providing workers'compensation Insurance jar my employee& Below is the polley and Jab rite
informafiam
Insurance Company Name: i/'GLJ-Q-�'E.✓S r1
Policy#or Scif-ins.Lic.il: Q �4�M gJ Expiration Date: g' 3 ' ! I
Job Site Address: (D Fb t ,, j t �a City/State/Zip: �I e-tnn 0AA0 1 970
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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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 cerryy a er he palms and penalties of perjury that the information provided above is true and correct.
tat :
Phone#:
Official use only. Do not write in this area,to be completed by city or town ofJlciat
City or Town: Permit/License q
Issuing Authority(circle one):
1. Board of ifeatlh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
L
1 \ . THE COMMONWEALTH OF MASSACHUSETTS
.EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT
DEPARTMENT OF LABOR STANDARDS
19 STANIFORD.STREET,BOSTON,MASSACHUSETTS 02114
DELEADER CONTRACTOR LICENSE
A &A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
LICENSE: DC000440 EXPIRES: Saturday,June 07,2014
IN ACCORDANCE WITH M.G.L. CH. 111, § 19713(b)AND 454 CMR 22.03,THIS LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR STANDARDS TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF
ENTERING INTO OR ENGAGING IN DELEADING WORK.
THIS LICENSE IS VALID FOR A PERIOD OF ONE YEAR.
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR WHEN ENGAGED IN DELEADING
WORK IN ACCORDANCE WITH M.G.L.CH. 11.1 § 19713(b)(2)AND 454 CMR 22.03.
HEATHER E.ROwE,DIRECTOR
a lgomrmw�uoealC/oc�/��auaac/ru:relfo in( Massachusetts -Department of Public Safety
Office of Consumer Affairs&Busi Tess Regulation Board of Building Regulations and Standards
0 -IMPROVEMENT CONTRACTOR Construction Supcnisor
egistration 101609 Type: License: CS-057733
xpiratlon:. 612612014 Private Corporatio
CIMSTOPHER 40RZY--
A&ASER.VICES INC'r - I 115NORTH ST = r•
Salem MA 01970c
Christopher Zorzy
115 North Street '
Salem, MA 01970 - c--� 5 " "L 5 Expiration
Undersecretary I �''�""' 05/26/2015
Commissioner
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Christopher Zorzy s 20120426000aa0
4�' • _ '3' T A&A Services Inc Exp 4/26/2017
115 North St
t �HR*SZoR�)bPi Salem, MA 01970 :ice=--11O.lc;ev
, r IJetthew JGibsan
- xa,z�:caivd�a,ogars
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December 1,2013
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To Whom it May Concern, I
As a Trustee of the 6 Flint Street Condo Association I approve the installation of 8 Sunrise Vinyl
Replacement windows to be installed at 6 Flint Street, Unit 2, Salem, MA 01970. 4
If you have any questions,please call me at 617-775-7788. r
Sincerely,
Janice Palumbo
Trustee
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6 Flint Street Condo Association
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Phone: 978-741-0424
30
Fax: 978-741-2012
2012
www.a-aservices.com
115 North Street
Salem,MA 01970
July 17, 2013
City of Salem
Building Dept.
120 Washington Street
Salem, MA 01970
To Whom It May Concern:
Enclosed please find the permitapph tion for Zachary Young, 6 Flint Street#2,
Salem, MA to replace windows.
1 have enclosed a check for S60 based on your fee schedule $11 per$1,000.00
plus a$5 administrative fee. The total for the job was $5,167.00.
l
Please send the completed permit to A & A Services,e� Inc. at I I5--Nlh Street,
Salem, MA 01970. J
If you have any" questions, please contact me at (978)'741-0424.
Thank you,for your Sistance.
Sincerely,
�J r
Barbara ZLY� lit
Office Manager
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