0009 MASON STREET - BUILDING JACKET 1
Certificate No: 153-09 Building Permit No.: 153-09
Commonwealth of Massachusetts
City of Salem
Building Electrical Mechanical permits
This is to Certify that the RESIDENCE located at
Dwelling Type
------------
9 MASON STREET in the CITY OF SALEM
_..... —
Address Town/City Name i
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF
OCCUPANCY
UNIT 1
This permit is granted in conformity with the Statirtes and ordinances relating thereto,and
expires unless sooner suspended or revoked.
Expiration Date ((j/��yf}rr.� ,,�,
li
Issued On:Thn Apr 9, 2009 —. ---
— --- ----1-
GeoTMS®2009 Des lauriers Municipal Solutions,Inc. ----- - ----- -- ----- - - ------ -- - --- - --
Certificate No: 153-09 Building Permit No.: 153-09
Commonwealth of Massachusetts
City of Salem
Building Electrical Mechanical Permits
This is to Certify that the Residential Building located at
Dwelling Type
9 MASON STREETin the CITY OF SALEM
-- --------------------------------------------- - - ---- ---------------------
Address Town/City Name
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF
OCCUPANCY
9 MASON STREET UNIT 2
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires unless sooner suspended or revoked.
Expiration Date '
Issued On:Thu Apr 9,2009
GeoTMS®2009 Des Lauriers Municipal Solutions,Inc. ------------------------------------------------------------- --------------
Certificate No: 153-09 Building Permit No.: 153-09
Commonwealth of Massachusetts
City of Salem
Building Electrical Mechanical Permits
This is to Certify that the REHAB--CL- -IN --------------
IC located at
--------------------------- - - ------
Dwelling Type
9 MASON STREET - in the CITY OF SALEM
----------------------------------------------------------------- --------- ----------------------------------------------------------------
-----
Address Town/City Name
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF
OCCUPANCY
9 MASON STREET UN1T 1
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires unless sooner suspended or revoked.
Expiration Date
Issued On:Thu Apr 9,2009
GeoTMS02009 Des Lauriers Municipal Solutions,Inc. -.-----------------------------------------------------------------------------
9 MASON STREET 1.53-09
(GIS# 3827 COMMONWEALTH OF MASSACHUSETTS
Map _ 26
CITY OF SALEM
ILot 0066,_
l ategary.. UPIAIR/REPLACE
}Pernut# 153-09 ! BUILDING PERMIT
Protect# . JS 2009 000184 �r '
Est Cost _ $30,0 00:00
Fee Charged: $215.00
C
Balance Due00` PER MISSION IS HEREBY GRANTED TO:
FConst Class: Contractor: License: Expires
U_se Group - POTORSKi THOMAS Home Improvement Contractor- 103378
ILot Slze(sq` tt) 5499 8`856
Zomn - i Owner WELLS FARGO BANK,N-A
.— g _
,Unr�s Gmtiedi*" I ��zaa- ,-, F4polzcant: WELLS FARGO BANK.N.A
IUmtsLost AT. 9MASON STREET -
�Dtg Safe# ^I _
ISSUED ON: 14-Aug-2008 AMENDED ON: EXPIRES ON: 14-Feb-2009
TO PERFORM THE FOLLOWING WORK
2 BATHS,2 KITCHENS&SILL WORK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
Underground: Underground: Underground: Excavation:
Service: Meter: . .Footings g
q+"
� Foundation:Rong ,/Of rT0i '__-' Rough:lSY\jvRougaOt
FinalFinal: ia: h Frame:c:
Vt��_ oCllw
/ /
FkeplacelChlmncy: k
Vn
D.P.W. Fire Health
Meter: Oil: VVInsulation:
Fina
l:ok CoHouse N Smoke: --r-
l
Water: Alarm: Treasury: /�I (� g ASS¢SSOr t,, 1'/0 .
�Sevver: Sprinklers: Flue:: --
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VlqtATWN OFA T j.
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Cheek No: Amount:
13U14DING REC-2009-000220
a '
745-9616 UL 385
C,coTMSc9 2008 Des 6auriers Municipal Solutions,Inc.
�ONDIT,I.A CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
A �Fa SALEM, MASSACHUSETTS 01970
TELEPHONE. 978-745-9595 EXT. 380
FAX 978-740-9846
KIMBERLEY DRISCOLL
MAYOR
July 7, 2008
To Whom it May Concern:
RE: 9 Mason Street
According to our records, it has been determined that the property located at 9 Mason
Street is a legal grandfathered non-conforming 2 family dwelling located in a
Residential Two family zone R-2
This is to determine use only and in no way is meant to confirm or deny whether said
property is in compliance with all building, plumbing, gas, electric, fire or health codes.
Singly,
V '1
Thomas St. Pierre
Zoning Enforcement Officer
T _
- ---- Lhc l'ommtmwealth ul \la.s,.tihusrlt, I t
t Bojid Ill Building Regulations and Standards %I( slit II' \1 I I 1
(�� \ J \lassaclwsetu State Building Code. 7S0 ( 'MR. 711' edition
1uilding I'cilim Application To Gmsutict. Repair. RenMate (h I)ClitAi,h a N 1 11, :1 /:ur „r.r '
lhrr- nrTnrr-l�'rrnriltlhrrllinl
�� \ I his .Saenon For Otticial l Ise Onl)
Bnllding Penou Nunther Date Applied: Y _�
Bw fldin C,nnrur,auo.o In,pe.nrr of I!w)ding+ U.ue
SECTION 1: SITE INI-ORMA FION
1.! Prupert) \ddress: 1.2 .ksseesors >lap & Parcel Numbers
C - M
\I rr\u nherI'.uul wuhci
I.i ., dun .uta,.icpirJ ,tr«tl.+.e.__Nef_
1.3 Zoning Information: i -!A Properly Dimensions: -- ---- --
Zoning Di,tn.t Prormsed Use Lu; area rill IU Fruniaee Ilt,
1.5 Building Setbacks (f )
Front Yard .Side Yards Rear Yard
-- --
RryurreJ Provided Rryuu eJ PnnrJeJ RryunrJ 'n r,iJcJ
1.6 1$7iter Supply: r13.G.L e. 40. §54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
J Zone: _ Outside Flood Zone'' \tunicipai �On ,tic.Jislr r+al ,c,tcm ❑
Lliable1f0 Pm ate ❑ Cheek d,ve s❑
SECTION 2: PRO.PERTY OWNERSHIPt JI
�2,1 Omer ofRecord-
"
Address for Ser%ee
Num/c 11'n�n�U�� �
Sr¢nature Tolephone
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
f iJcwCrrnatructiun ❑ Existing Building Owner-Occupied ❑QRepaiis(,,J \Itrranrmis) C :Wdllnnt ❑�Demoliuon Accessary Bldg. ❑ Number of Units__ ❑ Specify=4fet Descriptumof Pngraved YVurk 5-- -1-1-�
I
SECTION J: ES,riMATED CONSTRUCTION COSTS
O
Esnmated Casts: Official Use Only
Ilem il.ahurand %l:uenalsi _
I BwlJme �Y — 0 Q�(y I. !3uilJmg Permit Fee: 5- Indicate hu+s fee a defer uunrJ.
-- ❑Standard Citym,wn :\pplwauan Fee
Eltetncal �1 C Total Project Castr (hem GI x multiplier _ x
t. I~ 'lumhmg 5— 4�Q0 ?. Other Fees: 5 _
4. Nfechunical (IlkACI 5 —d List: _.-
---- ---7 - ------ - -
i Mechanical iFrrc S I_
Suttre„nnn nf.;l All Fee,: S —
('heck Nil Airt,unr ('.r,h limowlf
b Fatal Project COSt S 361 000 1 ❑ Part in Full ❑ Oubt.inJrng Bal.in,e Dar -
30a�� An C , i f�
SECTION 5: CONSTRIL.c LION SER% ICES
5.1
Nanwot l St. I fAdcr
Udic"
Cd 11 fl T t
EGO.
11 Rc,I 11,'Ca 14 I......I, I),,,I!,
pholiv .... ....I 11&,,-.
5.2 Registered Ilonne Improvement Contractor (lilt I
3 787
III( ('imipain isamcm IliC Rcci,ojul Name
/hOma4
liddrcs, 37
o_j AU qI D.ac
"Jevli 0 9
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (.M.G.L. c. 152. § 2506))
Norkers Compensation Insurance At idaviI must be completed alld 1Uhfu I tied with ihi s .ippl anon.
(his affidavit will result in the denial ot the Issuance of the building peroul.
Signed Affidavit Attached? Yes .... .... 0 No
SECTION 7a: OWNER AUTHORIZATION TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of ihe pi(,peit-v hereby
au[hi 11�/e to a'Ll m ri),, I o1al: 011loCJS
C!A1%i! to work authorized b.% th.i- building perrrutapllicdtion.
Signature of 0i,,ner Date
SECTION 7h: O%NNER' OR AUTHORIZED ,%GENT DECLARATION
0 0 e�51`
as Owner ljrAuthoii/cd ligentheichydeL1,11C
A4 J
that (he statements and information on the toregoinc application are true and accuia(e, to the bes( ,q my kno%oede'e and
behilt.K 4 h Wn_V—
Print Name
.Signature k)1 ( caner,)IALI(h(,ii/ed agent Date
I Si 'ncd under ate purrs and penalties ul perjuryu I
NOTES:
1, An Owner uho obtains a building permit to do his/her own hock. oranowner who lures all Loueui,tcie
inot registered in the flonie fmpro%cment Contractor (HIC) Program). wall nu! ha,e areess I-, the mbittaiwil
program or I;uaraniv tund under M G.I.. c. 142A. (Mer important intinma(ionon the IHC Pmgi,ioi ,tllj
—4
%k hen uhstannal %wrk is planned, pioiide the intoi mantin heloii,
Total Iloors area 1 Sci H.P (mOuding garage. firij,hed Icck, ,,r
6w,, hirrig area i.Sq Fr I Haboiable noom :nuns
Nutylher ,,t tocillaces--_ Number ;I hcdr,,-,,n,
N,milbc, or hathw,-rn., Number of hall h.oh,
Iwc ,,thejIfne ,i,iem Nuinhei .r JCL k,, ji,,i he,
1 1--,I,t] Pr,,,Jccl Squ.ire he uh,muied 1nr F-o.il Pfolce I U,.It
i
,. � l CITY OF SALEM
PUBLIC PROPRERTY
' DEPARTMENT
.I\Ill;K:I'\':)KIS('.I It 1
\1\"ott 120 WASHI\t;ION S'I,<LLT # }\t 1`�4,M.\l1.\CI it it-.'I'i s 0197.-.
ll-.1.:978-7$5-95`3 • 17.\x:97%-741'-'IS46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
� l flicant Information Please Print Leeihly
V a177C l0ucinusvOrganir:uinNlndtvuluall; �10/Y/GS :�! �r3 �Skt
Address: 9 O k�L Er�ir� hloE —
c tY;statc;z p Phone t"-
Are%you an employer! Check the appropriate box: Type of project(required):
I.❑ 1 ant a employer with 4. ❑ I am a general contractor and 1 6. ❑ new construction
employees(full inL'or part-tinge).' have hired the sub-contractors 7. KRerrlodeling
?.� I ant a sole proprietor or partner- listed on the anachcd sheet. t _ -
ship anJ have no employeesThese sub-contractors have - 1f. ❑ Demolition
working for me in any capacity. workers' comp. Insurance. 9, ❑ Building addition .
IKo workers' comp. insurance 5. ElWe are a corporation and its 10.❑ Electrical repairs or additions
I required.] officers have exercised their
right of exemption per MGL I I.❑ Plumbing repairs or additions
3.El ant a homeowner doing all work c�152, §1(4),and we have no 12.❑ Rouf repairs
mys<:If. iKo workers' unnp.
insurance required.) t anployees. LKo workers' 13.❑ Other
comp. insurance required.]
-niry .glphcuut tbot chccks box 9l nlust also till 0u1111¢acclien blow showing their wurkcti cumpenSation pulley iwiumauum
` I tomatwrv:ra who xdtmil this.,Mdavil indicating they are doing all work And then hin outside cutltmetom must submit anew al'fdavit.ndi.lmg.uch.
-C,ntnauty tins check this box must utachpl an additional.nccet Showing the namo of Ill sub-contractors and their workors'comi pulley info nlatiun.
141111 all rarpluyer that i.r providing workers'c•otnpen.vntinn insurance for my employees. Below is the pulicy and lob vile
information.
Insurance Company
I'olicv a or Sclf-ins. Lic. *: ! . ..._ Expiralion Date: �/ n
Job.S lie .A c.
ddress: / �ASo1V =JJ—' - City;sl"Zip: - -
.\ttuch a copy of the workers' cumpcnxation policy declaration page (showing the policy number and expiration date).
Failure to secure covcrage as required under Section'_5A of.%IGL c. 152 can lead to the imposition of criminal penalties of a
fine up (o S1.500.00 an(1/or one-year imprisonment, is well as civil pcnallics in the furtn of a STOP WORK ORDER and a fine
of up to S250.00 a day aguinst lite violator. Ile advised that a copy of this slalcment may be forwarded to the Office of
Invaogaouns ul the DI:\ for insurancc coNcragc \crilwation.
/do hereb�erll, !• the painins t�enr!l p !the in/brtnuliun pea eider/above is true auJ correct.
�i I t1 t G I):ttc.
o tic ial ruse oaly. Do not n•rire in this area, to be completed by city or lawn O idol.
itv or Town: _—. -, Permit/License X_
Issuing.\uthority (circle one):
I. Iloard of Ileallh 2. Building Department 3. Cityi fown Clerk 4. Electrical Impecror 5. Plumbing Inspector
6. Other
Contact fcrso t: ._ . ._-. Phone it:
Information and Instructions
Massachusetts General Laws chapter 152 tequires a I I employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more
,,f the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
fecetver or trustee uI .ui individual,partnership,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152. §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any -
applicant who has not produced acceptable evidence of compliance with the insurance coverage required,"
Additionally, biGL chapter 152, §2547(7)states"Neither the commonwealth nor any of its political subdivisions shall
cuter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants -
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed,below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space ut the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennio'license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address" the applicant should write "all locations in (city or
towny" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file f'or future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dog license or permit to burn leaves etc.)said person is NOT.required to complete this affidavit.
I he t)(lice of luvestigations would like to thank you in advance fur your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Ucparnnenl's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
R.ciscd 5-_'0-05
Fax # 617-727-7749
www.mass.gov/dia
•' = CITY OF SALEM
^. PUBLIC PROPRERTY
a,K DEPARTMENT
III •,'8-V;. gVS . I ��. 1i7y.'4_ ,.i4,,
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance \6th the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Dcbris, and the provisions of.'v1GL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
[� R n + e 015Lo5 1
Inamc (it hatder)
I he debris will be disposed of in :
_ _�e a t Sao A
(name of facility)
N0 (11 ReAnf,tj
' I,iddre�<ul'pwlilvl -
gnatwc tpcnnrt apphcunt
,late