42 MASON ST - BUILDING INSPECTION (3) c0 yd . 00
4 -I 338 CS S 62
The Commonwealth of Massachusetts
Board of Building Regulations and Standards IHSPEC ION ICE
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demoli fl A G 12 P 3; 4
One-or Two-Family Dwelling
This Section For OTici se Only
Building Permit Number: Date pplied:
Building Official(Print Name) Signature Date
SECTION 1.:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
q,2 AA. soN s7 SAI EAA
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 krg Informati ^`,rhA� 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
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 Zone: _ Outside Flood Zone?
Private❑ Check if yes[' Municipal VOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow er'of Re ord:EN AV �+ ,RI T S'ALOA A O/411 o
Name(Print) J City,State,ZIP
zjS A ASON ST, 9 - - 911 Sf2V P20Wka6S.G AA
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) W I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descripfonof Proposed Work' alehoyarAe
ih a
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1. Building $ Zf000,00 1. Building Permit Feee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 5)x multiplier x
3.Plumbing $ QQ mo 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
00 Check No. Check Amount: Cash Amount:
bOOD6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
1 fa 1 J
S 1=1J r
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
eGs - 6s3 syr
License Number Expiration Date
Name of CSL Holder
L ' Vl ; i/. f A/ Lis[CSL Type(see below)
No.and eet ( `v (= Type Description
N&6Z)�y U Unrestricted (Buildings up to 1;nnn cu.ft.
City o/f wn,State,ZIP Restricted 1&2 Family Dwellin
M Maso
RC Roofin Coverin
Sidi—WS Window and
SF Solid Fuel Buming Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1a7G 77
aJb-I3vi b4 Ca.r /JQabPef Pz4 ao/<
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
/I Crfvrp )ecd
No.and Sir t' Email address
Ptabo7yr A0 a/96o S19-F49'-70,k,
City/Town,State,ZIP Tel hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.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
1,as Owner of the subject property,hereby authorize U Z' &
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Si ature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby atte nder th ins and penalties of perjury that all of the information
contained in this application is true and c rak
e b t of my knowledge and understanding.
Print Owner's or Authorized Agent's N lec omc attire) �71 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 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
wnvw.mass.eov%ilea Information on the Construction Supervisor License can be found at www.mass.govid_—_—. ds
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"
I
City of Salem
'44. City of Salem
�� Office of the Tax Collector FISCAL YEAR 2015 FIRST QUARTER
93 Washington Street
` Salem,MAol97o PRELIMINARY REAL ESTATE TAX BILL
° ° PAY ON-LINE @
www.salem.com
Bill Number: 7421
Failure to receive this bill does not relieve the customer of the responsibility to pay.
Amount not received on or before the due date are subject to interest.
Interest at the rate of 14%per annum will accrue on overdue
MALAVENDA SHANE A payments from the due date until payment is made.
20 CONCORD WAY
PORTSMOUTH,NH 03801-3404
City Hall Office Hours:
Monday-Wednesday,8:00AM-4:OOPM
Thursday,8:OOAM-7:00 PM
Friday,8:o0AM-NOON
Phone- (978)745-9595,exf 5622
Collector of Taxes Make Check Payable to: ISSUE DATE: 0 710 1/2 0 1 4
Bonnie Ceti
A,' Your Preliminary RealPsmteTaxforthefiscalyearbeyming City of Salem PARCEL NUMBER 26-0207
E-1 July 1,2014 end ending June 30,2015 on the Parcel of REAL ESTATE P O Box 4125
described below is as follows: BILL NUMBER 7421
W PROPERTY DESCRIPTION Woburn,MA 01888-4125
Lfl 4 LOCATION: TAX SUMMARY FISCAL 2015 PRELIMINARY TAX
V— O Ei 42 MASON STREET _W IS 199.44
St $1,19944 IStQuarter' $1.
N W Class. 104
a
Book/Page:26920-261 Due August 1,2014 Preliminary Tax
Q 0.' Deed Date:06/12/2007 2nd Quarter Preliminary y $1,199,43
W W W Due November 3,201014 Payments made $0.00
D- P4
Total Pre $ 98.87 Total Due $1,199.44
LA = iy
Z MALAVENDA SHANEA
H zo CONCORD WAY
Due &Payable 08/Ol/2014
H PORTSMOUTH,NH 03801 JUL 23 26
W C .
W
w 8Y: __-
03722D82015600007421100001199447
CITY OF Si'd-EM, lNL- sS cHUSETTS
4 Buu_D[NG DEPARTMENT
T i
' r I 120 WASHIINGTON STREET, 31D FLOOR
TEL (978) 745-9595
Rlix(978) 740-9846
KI:\IBERI-EY DRlSCOLL
",\LAYOR THOMAs ST.PI&eR13
DIRECTOR OF PUBLIC PROPERTY/BCQ.DING CO\L\BSS(ONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Altnlicant Informatinn Please Print 1 e Ig'bfY
V;t n1C(Husinuss Organiratiom9ndividuali: lJV� �t��•/� (-�f/t/��PM ���
Address: // 6l.tl f ie
0l460
City/State/Zip: b C_ Phone #: �,fe8
Arc gnu on employer'!Check the appropriate box: Type of project(required):
I.❑ 1 am a employer with 4• El am a general contractor and I .
employees(full and/or part-time)," have hired the sub-contractor 6' ❑New construction2.�am a sole proprietor or partner- listed on the attached sheet. t 7• remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for mein any capacity, workers'comp. insurance. 9. ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I ant a homeowner doing all work right of exemption Per MGL I IF] Plumbing repairs or additions
myself.(No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (N'o workers' 13,❑Other
.
curnp. insurance required.]
•Any applicurl due dwcke bus 01 must also fitI nut the%ccliun below showing their workm'compensation Paley innm n rratlu .
'I lnmenw'N"who suhmit this Whir wit indicating they arc doing at work and then hire ounslda cuntractarx mtet mihmk a new of!davit indiuling such.
$'nnrxwn thin check this box met anachat an addiliurod Awl showing'Ile n-un,of the subeo nraeMrs and their woken'comp.Pultcy information.
I out art eurpluyer that Is providing Ivorkers'cumpeusatlun inrurunca jot my employees. lielu lv/s dia policy and fob Nile -
infirnuutian.
Insuraitcc Cmnpany Name:
Policy 4 ur Self-ins. Liu. d: Expiration Date:
tub Site Address: City/State/Zip: -
Attach a copy of the woricen' compensation policy declaration page(showing the policy number and expindon date).
Failure to secure coverage as required under Section 25A of,%IGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisnnmcnt,as well as civil penalties in the term of it STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Ile advised that i copy of this statement may be funvardcd to the Of•lice of
In rstiganiuns ul'tltc DIA for insurance coverage verilicatiun.
71duh,erebyce ii fir c M ains mrdpenalties ofperjury drat the injorrnullunprovided buveA'true andc•atrect.c Uuta: _� f
Phone J� afo!?— 2260
Official use surly. Du not write in this area, to be cumpleted by city ur Irrvn a�Jlc'/u2
City nr 1'uwo: _.__ . _ Permit/I.lcensc N
lasuing Authurity (circle one): —_ - _-- ---
1. Ilourd of llealfh 2. Building Deliatinicut I.City/furor Clerk J. Rieetrical luspcehsr 5. Plumbing Inspector
6. Other
Contact l'crsnna Phone !t: I
CITY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
j °f 120 WASFIINGTON STREET,31D FLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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:
-J-)e , KjvlVie5t4M C� y5 "SONS)
(name of hauler)
The debris will be disposed of in:
IRAMSf-RZ �>z41106
(name of facility)
(address of facility)
Signat f applicant
ate