2 LEE ST - BUILDING INSPECTION (2) $2S GA SjA
The Commonwealth A
Board of Buildin andards CITY OF
Massachusetts Stafe Building Code, 780 SALEM
�: 1 Revised Har 2011
Building Permit Application To Col c et0r, Renovate Or Demolish a
One-or Two-/%cunily Dwelling
This Section For Official Use Only
Building Permit Number: ate Applied:
Building Official(Print Name) Signature Dale
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.I a Is this an accepted street?yes no Map Number Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq I)) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided �RqmdProvided Required Provided
1f8` 3s'
1.6 Water Supply:(M.G.L c.do,§id) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zonel
Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Lecord: Sc //Mqq T4,
Name Print �—�
( ) City,State.ZIP
t � 7!?-3(7-SOO P_ -moc0,oAe (�) kof ;1
No.and Street "telephone Entail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied" Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other M Specify:
Brief De cri lion of Proposed Work':_ "-1 ?�� ' X_— t l
T
-1
r
SECTION Ji ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ j S V�) I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ `— 2
. Other Fees: $_
d. Mechanical (IIVAC) $ List: cy
5. Mechanical (Fire
Su ression) 'Fatal All Fees: $_
Check No. Check Amount: Cash Amount:
(i. Total Pm.ject Cost: $ j (�� ❑ paid in Full ❑Outstanding Balance Due: ---
e l/
O� ? -l-I 7
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Lic"en`se jQ$C);'�•t.17t
License Number Expiration Date
Name of CSL floldcr 1 ) :S) (,�
List CSL"type(see below)
No.and Street Type Description
U Unrestricted(Buildings u2 to 35,000 cu. It.
R Restricted M2 Family Dwelling
Citylfoavn,State,ZIP
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
HIC Registration Number Expiration Date
1i1C Company Name or IIIC Registrant Name
No.and Street
Email address
City/Town,State,ZIP "fele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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 ........Jt5f 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained inC11,ealronis true d a orate to the best of my knowledge and understanding.
Print Owner's or a orize Agcntt''s/N/ame(Electronic Signature) [)at,
NOTES:
I. 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
www.nlass.eov/oca Information on the Construction Supervisor License can be found at www.ntass.eov/dps
2. When substantial work is planned,provide the information below:
"total floor area(sq. ft.) (including garage, finished basement/atfics,decks or porch)
Gross living area(sq. fl.) 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 wolfing system Enclosed_ Open
3. "total Project Square Footage"may be substituted fix"'total Project Cost"
CITY OF SALEM, MASSACf NSETTS
BUILDING DEPARTMENT
F
� 120 WASHINGTON STREET,310 FLOOR
�\ry
TEL. (978) 745-9595
FAx(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDINGCON /IISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT::
Date y l orb' L(
Job Location d Lee y j MA
Home Owner Address tee S 1Q.0-\ / z1A A
Present Mailing Address L(? �_ S f Sa IQA l AAA
—T
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
t CITY OE7 &' l C'y,I, >%C-1SS:ICHUSETTS
t7L'1LONG DEP.IR-n[ENr
{,41e ^tt l_'010.1SHLYGTON STREET, 3w FLOOR
T EL (973) 715-9595
KIMBERL.EY DRISCOLL FAX(978) 7-k)-934S
NLAYOtt
ItiriOSG�3$T.PIe.Rll$
DITELTOR OF PUBLIC PROP ERTy/8C1LDLgr CO\LN11551ONER
Construction Debris Disposal ArtIdavit
(required for all demolition and renovation work)
In accordance with the si.rd, edition of the State Building Coda, 730 QWR section 111.5
Dcbris, ;utd the provisions of tMCIL c 40, S 54;
Building Permit 4 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 rA lGL c
111, S 150A.
The debris will be t ansportcd by:
;y
(num ut'hauler)
The debris will be disposed ot'in
(nanm of facility) .
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S. Mortgage interest paid by you,acquisition or abandonment of secured Note.If no name is circled when more than one name is listed,the-number will be
property, cancellation of debt, qualified tuition program payments (under considered to be that of the first name listed.
section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions,and pension distributions.You must give your correct TIN,but you Secure Your Tax Records from.identity Theft -
do not have to sign the certification. Identity theft occurs when someone uses your personal information such as your
name,social security number(SSN),or other identifying information,.without your
Want Name and Number To Give the Requester q permission to a[fraud or other crimes.An identity thief may use your SSN to
For this type of account: Give name and SSN of: get ajob or mayy file
le a tax return using your SSN to receive a refund.
1. Individual The individual To reduce your risk:
2. Two or more individuals(joint The actual owner of the account or,if • Protect your SSN,
account) combined funds,the first individual • Ensure your employer is protecting your SSN,and
on the account' • Be careful when choosing a tax preparer.
3. Custodian account of a minor The minorz If vour tax records are affected b identity theft and you receive a notice from
(Uniform Gift to Minors Act) - Y � Y
4. a.The usual revocable savings trust The grantor-trustee' the IRS,respond right away to the name and phone number printed on the IRS
(grantor is also trustee) notice or letter..
b.So-called trust account that is not a The actual owner' If your tax records are not currently affected by identity theft but you think you -
legal or valid trust under state law are at risk due to a lost or stolen purse or wallet,questionable credit card activity or
5. Sole proprietorship or disregarded The owner' credit report,contact the IRS Identity Theft Hotline at 1-800.908-4490 or submit
entity owned by an individual . Form 14039.
6. Grantor trust filing under Optional The grantor ,For more information,see Publication 4535,Identity Theft Prevention and
Fonn 1099 Filing Method 1 (see - Victim Assistance.
Regulation section 1.671- Victims of identft theft who are experiencing economic harm or a system
4(b)(2)(i)(A)) Y P g Y
For this type of account: Give name and EIN of: problem;or are seeking help in resolving tax,problems that have not been resolved
through normal channels,may be eligible for Taxpayer Advocate Service(TAS)
7. 'Disregarded entity not owned by an The owner assistance.You can reach TAS by calling the TAS toll-free case intake line at 1-877
individual 777-4778 or TTY/TDD 1-800-829-4059.
8. A valid trust,estate,or pension trust Legal entity, Protect yourself from suspicious emails or phishing schemes.Phishing is the
9. Corporation or LLC electing The corporation creation and use of email and websites designed to mimic legitimate business emails
corporate status on Form 8832 or and websites.The most common act is sending an email to a user falsely claiming to
Form 2553 be an established legitimate enterprise in an attempt to scam the user into
10. Association,club,religious, The organization - surrendering private information that will be used for identity theft,
charitable,educational,or other tax-
exempt organization taxpayers The IRS does not initiate contacts with tax a ers via emails.Also,the IRS does
11. Partnership or multi-member LLC The partnership not request personal detailed information through email or ask taxpayers for the PIN
numbers,passwords,or similar secret access information for their credit card,bank,
12. A broker or registered nominee The broker or nominee or other financial accounts.
13. Account with the Department of The public entity If you receive an unsolicited,email claiming to be from the IRS,forward this
Agriculture in the name of a public message to phishing@irs.gov. You may also report misuse of the IRS name,logo,
entity(such as a state or local or other IRS property to the Treasury Inspector General for Tax Administration at 1
government,school district,or prison) -800-366-4484. You can forward suspicious emails to the Federal Trade
that receives agricultural program Commission at: spam@uce.gov or contact them at www.fie.gov/idthe"f/or 1.877-
payments IDTHEFT(1-877-438-4338).
14. Grantor trust filing under the Form The trust Visit IRS.gov to learn more about identity theft and how to reduce our risk.
1041 Filing Method or the Optional 4' Y
Form 1099 Filing Method 2(see
Regulation section 1.671-
4(b)(2)(i)(B))
'List first and circle the name of the person whose number you furnish.If only one
person on a joint account has an SSN,that person's number must be furnished.
E Circle the minors name and furnish the minor's SSN.
'You must show your individual name and you may also enter your business or"DBA"
name on the"Business name/disregarded entity"name line.You may use either your
SSN or FIN(if you have one),but the IRS encourages you to use your SSN.
List first and circle the name of the trust,estate,or pension trust.(Do not furnish the
TIN of the personal representative or trustee unless the legal entity itself is not designated
in the account title.)Also see Special rules for partnerships on page I.
*Note.Grantor also must provide a Form W-9 to trustee of trust.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons(including federal agencies)who are required to file information returns
with the IRS to report interest,dividends,or certain other income paid to you;mortgage interest you paid;the acquisition or abandonment of secured property;the
cancellation of debt;or contributions you made to an IRA,Archer MSA,or HSA.The person collecting this form uses the information on the form to file information
returns with the IRS,reporting the above information.Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to
cities,states,the District of Columbia,and U.S.possessions for use in administering their laws.The information also may be disclosed to other countries under a treaty,to
federal and state agencies to enforce civil and criminal laws,or to federal law enforcement and intelligence agencies to combat terrorism.You must provide your TIN
whether or not you are required to file a tax return.Under section 3406,payers must generally withhold a percentage of taxable interest,dividend,and certain other
payments to a payee who does not give a TIN to the payer.Certain penalties may also apply for providing false or fraudulent information.
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"I HEREBY CERTIFY TO MORTGAGE MASTER, INC THAT THIE PLOT PLAN
DWELLING IS LOCATED ON THE LOT AS SHOWN AND THAT
IT DOES CONFORM WITH THE CITY OF SALEM IN
ZONING REGULATIONS REGARDING SETBACKS FROM
STREETS LOT LINES." SALEM, MA
"I FURTHERR CERTIF THIS DWELLING IS NOT
LOCATED IN THE OD HAZARD AREA SHOWN
ON FEMA COMM 009CO417F DATED DRAWN FOR
DULY 3, 2013, sb pH�
p Al RYAN MASCIONE AND
sr N ' AMBER MASCIONE
v" �75 R 5128113
STEPHEN s . .S. DATE SCALE: 1"=30' DATE: MAY 28, 2013
THIS PLAN FOR MORTGAGE PURPOSES-NOT FOR 15DOVER RRIMACK ENGINEERING SERVICES
BOUNDARY DETERMINATION. BOUNDARY INFORMATION PARK STREET
TAKEN FROM EXISTING RECORDS. M22567 MASSACHUSETTS 01810