0072 FLINT STREET - BPA-10-301 ;1 The Commonwealth of Massachusetts
RECEIVED Department of Public Safety
^ 4t�5FtECTIONAL SERVICES p -
I/J \la...,uhiuc•tts titate Building Code(780 C�1R)tie enlh Edition
City of Salem
r Pu2W% Permit A lication for an Buildingother than a 1- or 2-FamilyDwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
72 �Llr✓! 5 L^i SAQo (1I��1L— A1-fm Sr.✓-- pG-
:Nu.and Stnel City /To(cn Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition ❑ Demolition (Please fill out and submit Appendix 1)
7building
❑ Change of Occupancy ❑ Other ❑ Specify:
ans and/urconstruction documents being supplied as part of this permit application? Yes ❑ No ❑
nt Structural Engineering Peer Review required? Yes ❑ Nu ❑
n of Proposed Work: �Q/S S' nfc i'J/��•
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): y
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&AreaEPeror(sq. ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5: USE GROUP(Check as applicable)
r:F:
: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑
E: Educational ❑
Facto Cl ❑ ❑F-1 F2❑ H: Hi h Hazard H-1 ❑ H-2 H-3 H-4 ❑ H-5 ❑
Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ I-4 ❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3 ❑ R-4 ❑
S: Storage S=1 ❑ ' S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use: -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 11113 IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
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 Fal' Check if nutside Flood Zone❑ Indicate municipal ❑ A trench will nut be Licensed Di*posal Site ser
Pei ca to ❑ or indenlifv Zune:_ or on site r tem ❑ required dur trench ur'pecifv:
- permit is enclosed ❑
Railroad right-of-wav: Hazards to Air Navigation: xl:\ I li.ln ri;t •n+m i>�iiin Kr,i ", I'n r,�.;
Not dpplicahle 12' I.}Iructure,ci thill mipnrt i , ,roach ,irea' I. their recie(c cnmplefed?
n'( igt.cnl to Build enClo,ed ❑ Yes ❑ ur N, Ye. ❑ Nu ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
l iW,m .d C .ai r: L�c•Gnnipl�l: rcpe,d Gm,tructinn: OCCLIpant l ,,ad per l lnur:
I) (•. Ihcbudding cunlain.,n Sprinkler S% tein' ';puml Stipulation,: .
SECTION 9: PROPERTY OWNER AUTHORIZATION
amc.ind Address o Property O% ner d _ _ O
� - - 7� F�<< I°Svc.
Name (Print) No. and Street Cif\'/Yowl .,.r! �,. :'}a„ fj Zip
Properly the ner Contact Information��p ..�����
41441
Title Telephone No. (business) Telephone No. (cell) i \ "f C?e m itl ddre +.
If"applic,ble, the property owner hereby authorizes
Na& Street Address CAN,/Town Stale Zip
to act on the pro perty o%%ner s behalf, in all matters relaliye to work authorized by this L'Llildin6i2erniitip ilicatik)"-
SECTION t0:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It building is less than 35,L)W cup Mot endos.d s pace and/or not under Construction Control then check here O and skip Section It) !)
10.1 Registered Professional Res onsible 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
! AIt1-64
s �,
Compin Name: /I
IV!na es 33 8 L
ArJxEv�<T fFdo�4
Name of P/e�rson Repppunsible„hrr Construction License No. and Type i��ApplicableONO -
Street
�j f r UISY LAIlL< r. L
Addres City/Town
� 39 L rI DEwo! rraan uZ�ip
r r /t T
W5
Telephone No. (business) Telephone No. (cell) - e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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❑ No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cos[(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
Note:Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $ -
Fhancaler) $ Enclose check payable to
$ (contact municipalit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
me below, I herebyattest under the painsand penalties of perjury thatall of the information containedm this
and accurate to the best of my knowledge and understanding. / �7
Please print and >i name Title Telephone.No. Dale
72 /1nPo 4�' S � 01470
tilreet Address City/To%%n Zip
Municipal Inspector to till out this section upon application approval:
Name Date
.( f CITY OF SUX. Nls AxsSACHL-SETTS
BL'QDLNG DEP.\RTIE224T
_.. --120,WAiHINGTON STREET:3iO FILOOR
TM (978) 74S.9595
FAX(978) 740-98"
KI-,BE1t1ZY DRlSCOLL _- -
' MAYOR DIRECTOR
ST.PlE2tltrt
DIRECTOR OF PLBLIC PROPERTY/BL'ILDLNG CONOUSS10%ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.kliplicant Infarmatl0ta Please Print Legibly
NaineIBusirtesaOr{anusliorvIndavtdual): 44/6AfA L/Dt1:>IW4Ar- �Rwees &P
Address: Fd k6mtia n iu svl V
city/state/zip. 1V6,61)4t4tr^ O. tUYL Phone M- 79/ _ VV 4/s34
ire ou an employer'Cheek the appropriate bos: Type of project(required):
I. I am a employer with 4. Q I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time)." have hired the sub-cdxurcmrs
�- 2.0 1 am a sole proprietor or partner- listed on the attached shel : 7. Q Remodeling
ship and have no employees These subcontractors have {. &,kmolition
workingfor me in an capacity. workers'comp.insurance
Y P ry• 9, Q DuiWin{addition
I No workers'comp. insurance S. Q We ars a corporation and its
required.) olllcers have exercised their I0.0 Electrical repairs or additions
3.Q 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.[Nis workers'comp. c. 152,41(4),and we have no 12.Q Roof repairs
insurance required.) t employees,LNo workers'
comp. insurance required.) 13.❑Other
-Any 4PPDc20 that cllacb Dag al must alga 1111 aW the Milan,below showing their w•mhaa'cantpmomiat policy infurmauoa
't I.vteeuwsers who su6nit this affidavit indicating they are doing all work and that hire outride eonrmnws antat avilmit a new arllthvir indiaming awe
-f,a,tw.url cheek this bet nua a"whad an midioural sires Aawing on nwow of the aAsonuaaton ud their wvrhon•corny.policy isfxinauat.
/um f am etwployrr that b pro i+ b workr av nterbw!wa\ _rr�net joy my turp/uysta Rdow b the trolley and fob s!q
Insurance Company
Policy o ur Self-ins. Lie.p:
lob Sire Addreu: ,T �1� b City/State/zip:
,%ttack s copy of the worker'compensatlos policy declaration pap(showing the policy number and espintlon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
nine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a toy
of up to S250.00 a day against the violator. Ile adnied chats cupy,of this statement may be forwarded to the OIYce of
1aCangatiana ul'dte 01A for insurance coverage veriticatiun. -
/-Jo hereby Certify under the pains and penalties ojperfury that the beformadow provided above is true and,;orrrca
b •11 r r Dole! P,
P�orc ad �� -S G /—7
Ofcial sae only. Oo not write in thir area, is be:umplNed by wiry or town a/f&iuL
i
City or ruwn: - . eermit/i.lccmee__. I
(%suing.%uihunly lcircle line): - — - — _ i
I. ltuard of Ilvallh 2. Ruil,iing Department I.City/rown Clerk 4. Electrical haspcctor 5. Plumbing Impeetor
6. Other _
L,hnracl Penang: _ -- -- Phone e:
' CITY OF SALLM
L
.� , PUBLIC: PROPRERTY
DEPARTMENT
' III '/•V •l� '/�/� � I ,\ b•.V V: '/S h.
Construction Debris Disposal Allidavit
(rcyuired air all demolition and rcnuea0on \vurk)
In accurdance %%ith tllc sixth edition of the State Building Code, 7SO CAfR section 111 5
Debris, and the pro\isiuns of MGL c 40, S 54;
Building Permit N is issued with the condition that the dcbris resulting front
this work shall he disposed of in a pruperly licensed waste disposal foeility as defined by MGL c
111. S 150A.
The debris will be transported by:
Inamc ul hauler)
I he dcbris will be disposed
of in
(n+lnr ul rJCI ny)
iLLw,'5'-wU 01AIive-
l.uld c+. ur lacihlVl
.I�nalwc d p:nrn phiunl
IJI:
1 '
16/14/2006 07:08 -9787399375 PAGE 01
October 12, 2009
Please be advised that all Verizon drop witty and cables have bees mmoved from the
building at 72 Flint Shett,Salem.MA to prepare for building demolition.
Any qucstions pleax call me at(508)641-7947.
You.
4""�
Inn M. Pero
Local Managct—Vetizon
5 Stetson St.,Lynn,MA
508 641 7947
From:National Grid 17815221067 10/15/2009 07:18 #363 P.001/001
October 15, 2009
Larry RIS- Demolition
72 Flint St.
Salem, MA
RE: Service Removal for Building Demolition.
Dear Lary,
This letter is to confirm that,per your request,National Grid has removed the electrical
service and meter from 72 Flint St Salem, MA on 10/14/09. If you have any questions or
need further assistance, please feel free to contact me at(781)907-3519.
Sincerely,
Angelic
Customer Order Fulfillment
nationalgrid