33 FLINT ST - BUILDING INSPECTION l i
sail The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR S
w Resed dMar Mar 2011
^ Building Permit Application To Construct,Repair,Renovate Or Demolish a
1`/I One or Two Family Dwelling
This Section For Official Use Only ' '
Building Permit Number: ti" :Date pphed _ .. .. . '
Budding Official(Pont Name) Si Date
-SECTTONL: SITEINFO N;
LI Prope Address: 1.2 Assessors Map&Parcel Number
Olc(70 �-5 /6 -
I Ja 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(it)
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❑
!•..SECTION 2€ PROPERTY OWNERSHiPt
2.1 Owne iof Record: `
p0111- <L'dt,thyl 1970
N e(Print City,State,ZIP
33 �f � 7�r - 979-6'/0- VY??
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION:OF PROPOSED WORK
(check all that apply) ,
. . _.
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units o2 Other ❑ Specify:
Brief Descriptiop.n,. J o�f Proposed Work':
F �I
i SECTION 4:ESTIMATED CONSTRUCTION COSTS
. ..,. . ,
Estimated Costs: '
Item 6fri 'Use Only
(Labor and Materials
1.Building $ I Budding Permit Fee:_$ : Indicate how fee is determined:
❑Standar"d City/1'own Apphcation Fee r
2.Electrical $ ❑Total P oleo Cos[{Rein 6)x mulUP, cr :?� x
3.Plumbing $ 2 'Oilier Fees $ � �
4.Mechanical (HVAC) $ List ' L
5.Mechanical (Fire
Suppression) $ Total All Fees $ - 5
Check No: Check Amount: Cash Amount,
6. Total Project Cost: $ ❑Paid inFull ❑Outstanding Balance Due:
SECTIONS:-''CONSTRITCITONSERVICES' •„}
5.1 Construction Supervisor License(CSL) /Y�3� /O_/12
,-�54N License Number Expimuon Date
Name of CSL Holder List CSL Type(see below)
/Lf//�inin 14v�
No.and Street `• TYPe- . 'Descnpion
mg a U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Tom,Stat ,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�y, /_ SF Solid Fuel Bunting Appliances
/ �R" ?( O—aqy I Insulation
Telephone Email address D Demolition /-
5.2 Registered Home Improvement Contractor(HIC) SS-6,;?.7
&,n ::O,W,1'� WC Registration Number Expiration Date
HIC Company Name or HIC Regpi rant Name
No.and Street n „` Email address
Ci /Town,S te,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.•u I52.§ 25C(6));
Workers Compensation Insurance affidavit most 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 78:-OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTO�R(APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize �Myq �r T.%t�/
to act on my behalf,in all matters relative to work authorized by this building application.
4AL SJ;Vtlyi 10-�27-1/
Pri t Owner's Name(Electronic Signature) Date
r • - , SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION:;
By entering my name below,I hereby Fset-the and penalties of perjury that all of the information
contained in this application is true an to best of my knowledge and understanding.
-� /0 a;
Ptint Owner's or Auth4ed Agent' ame lac ' is Signature) Date
;., NOTES." ; s
1. An Owner who obtains AJkddmg permit fb 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
MUMgss.eov/om Information on the Construction Supervisor License can be found at M3nEMASs.p,OV/dns
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"
M
The Commonwealth of Massachusetts Print Form
Department`of 1hilustrialAccidents
Office of investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information //�� Please Print Legibly
Name (Business/Organimtion/Individuat): i J a alR. JU&J / �MAL� oOr'4 5V-)&11rt
Address: V ,et,-J wCkg /F
City/State/Zip: /a — p4tj 01T�;3 Phone #: 7SI- 7�a-dad/
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with� 4. ❑ I am a general contractor and 1
and/or part-time).s have hired the subcontractors 6. ❑New construction
employees(full
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' g ❑ Building addition
[No workers'comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its l0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LEI P bing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
-Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. n
Insurance Company Name: 6tTorlttL �/`tx L 6GO
Policy#or Self-ins.Lic.#: 16h Y Expiration Date:
Job Site Address: 33 Lh� .�'T 'ewr, yypp- ol(i-70 City/State/Zip:
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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI/A for insurance coverage verification.
I do hereb cerd r the pains a enalbes gf 2e 'ioy that the information provided above is true and correct.
Si mature: - Date _ d,?7-/
Phone#: — -D
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ov
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 -
(978) 619-5685 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
U� Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District McIntire
Address of Property: 33 Flint Street
Name of Record Owner:Angela & Paul Sullivan & Leeanne Crowley
Description of Work Proposed:
Replace existing charcoal/black, 3-tab asphalt roof with new charcoal/black, 3-tab asphalt roof No changes in
color, material, design, location or outward appearance. Non-applicable due to being in kind
maintenancelrcplacement.
Dated: October 5, 2011 SALE HI O COMMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an Outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary.permits or approvals) prior to commencing work.
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