23 LEMON ST - BUILDING INSPECTION (9) -�� L17
'fhe Commonwealth of Massachusetts
JIlk Board of Building Regulations and Standards CITY
ttO Massachusetts Slate Building Code, 780 CMR, T°edition OF SALEM
�✓ Revised Junnury
/ I Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, .00x
One-or Two-Fumd Dwelling
This Section For lcial Use Only
Building Permit Num r� ` to Appli :
Signature: / '���+'✓ ��
Building Commissioner/In for of Buildings Dale
SECTION 1: E INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1;23 L Ipylc9J 151—
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
.u.,ins District Prupowd'use Lot Area(ut it) Frontage(11) �W.--
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❑ Private❑ Zone: _ Outside Flood Zone?
Checkif es0 Municipal O On site disposal system O
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
0147Tfkca✓ a-4 Caaal- -23
,�.4�ni�uc"vr/ LC�icaJ bT. ?
Name(Print) Address for Service:
Signal Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition
Demolition O Accessory Bldg.❑ Number of Units_ Other O Specify:
Brief Description of Proposed Work':
AaP Hx8 rC C l, h ck
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 8 I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S 13 Standard City/Town Application Fee
5C� O Total Project Cost'(Item 6)x multiplier x
3. Plumbing S — 2. Other Fees: S
4. Mechanical (IIVAC) S — List:
5. Mechanical (Fire S
Su ression Total All Fees:$
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S O Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CSyS�B(a 11 —80-10
DDY) M ¢r�A29
License Number Gspimtion Dute
f
Name ol'CSL-I folder List CSL Type(see below)3_
£) (2c�r^mN Alice F)pe Dewri lion
X w" /I i U Unrestricted u to 35,000 Cu.Ft.
R Restricted I&2 Famil LAvellin
Signature M Maw Only
g'7g^77r-/ ^�8/8 RC Residential Roofinx Coverin
-rclephone WS Residential Window and Sidin
SF Residential Solid Fuel Bumin A liance Installation
D I Residential Demolition
S.2 Regbtered Home Improvement Contractor(HIC) 3 6 41sO
�m O.y�Qri Afl..� y��o'U5 Registration Number
I I144'Company Name or HIC Registrant Name
X �3 t?o PNN- A-ti£ ' -Ip q -i O
Adips.. Expiration Date
Teicphunc
Signature
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
X this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........0 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED' 'y1 (so0(„46 O A0/v
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDIN(
1 /'talr./ta �` � as Owner of the subject property hereby
authorize IZV3,3 A��ALeA to act on my behalf,in all matters
relative to work authorized by this building permit application.
signature fowner Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
'� a� as Owner or Authorized Agent hereby declare
that the statements angtnformation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name If
Signature of ner or Aut rued Agent Date
Simned um enalties of riu
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 g1 have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115.respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
CITY of S.U.E%1, NLISSACH SEM
8LMDLNG 0EPA1LT%9E%T
120 WASHINGTON STREET. )ns FLOoa
TmL (978)145-9595
Rut(978) 740,95W
Kl\®EKLEY DRISCOLL 71 tW" S ST.FMAA<
MAYO!<
DtREcroa 0►pL eLlc pRorERTtt/n ILDIaIG co%tansslo%ER
%Vurkers' Compensation Insurance Allldavit: guilders/Contracton/ElMriclans/Plumben
anelleant Infarmatlon Please Print Lesibh
Wmelauane+e.Orgysuationlridividuill: IG6� /r1 /3�.�it1R,4lJ __
Address: S /Iksrrt Ater✓
44,u ot9 t3
City/StstdZip:. .V44s5i4 ✓i4 v 1'honeN 9 ?is ?'/ /6
Ar�e 1'oe se eiarployor!Ckseti the apprepalate Irma: Typo or project(requkedk
1. I art a employer with for O a. Q I am a Eeclaw contratuae and 1 K ❑Now continuations
employees(flall and/or part-der).• have hired the sub.corrracars
2.CR 1 am a solo pmpriesm iw partner. listed on Ih he awsahi d shed: 7. QRentodeling
.hip and have no employes These sutseomrsetors have L Q Demolition
working for me in any capacity. worlten'comp.inatusoce. 9. 03milwing addition
[No workers'comp insurance S. Q We am a corporation and its
revprirwL[
oftrs haw eta seised their 10.13 Enectrical repairs or additions
).Q 1 am a homwwnr doing all wont ri0M ofessimprion par MGL I I.Q Plumbing repairs or addisbro
myself.[No workers'comp c. 15Z 11(41 and we have to 12.Q Roof repoiss
insurance requirtd[► employees.LNeweskra' 1).QOdrr
comp insurance re:quiriaLl
•nnY+PYtkar err raeraa loess I I itwr eke Ile w iM nnntia baler�q taster wattew'oargetoiia Pdlsr irYwrr.
'1 Lamer iwite who wbo d ark affid"imdlydad ilry r"He all walk and Asa hlr at Nab eMrrWM nnrr o JWN a two a w&va Winston Peak
'('.wirarwn der Awk ibis Mo mud airuwrit air aliriwd.hr Awing do now,of As&64mon rra sail theis taataisa'ramp polkr isaannaoka
I nor aw empl yer that As pnvldbeg workers'comperss alsw last rrwcr fer sty eayfrysra sikrw is akr pe"rwd/d sdr
in/wmedom �q _
In.ura e1 %I nce Company Vam o �• To, >T`(JTUA U
Pnlicy a or Self•ins.Lie.M V w c 6 b a a66o Poi o Expiration Delr. / " e —so)
!ub Sin AJdre,e: �.3 r City/statr/Zip:
i970
.tnacIs a cop of she Workers,cowpoumbe policy dalmiles pop(shaving IIts poliky samlfr and asp rodsto data)
Failure to scctnrs covenp L required under Secdoe 25A of MGL C. 131 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonmem,as well as civil pmeldle is tlr ram of a STOP WORK ORDER and a fleas
of up to S230.00 a Jay ipinsn 1hie riolaror. Ik adviad that a copy of this Astemam maybe forwarded to the OI71Cs of
I n.c.n yahuns of i Its MA for insurance coverap verirkatwe
/Js hereby certify under the priwr and penshler o/per/eery that di Ybaw it Ime Yn1 awrrees,
�`L c? Date: y—�o R.i0
� O/J&'/aI Wf Yllly. Oa Aral WIIIe la tAY a/eS/e bI.Ylnp/I/e/by wiry w tars n//h•ia!
City or futi n: Prrmit/1.1crnsa 0_ --
I
Iwuing Authority(circle one):
I. Iluard of Ileilth 1. Rudding 0epirtment 1. (•iy/rowa Clerk t. fletlrical Impactor S. Plumbing Impactor
6.7)iher .
L-nitacl Parion: _ . _ Phone a•
CITY OF S.UXIM
PUBLIC PROPERTY
DEPART'NIENT
IU OfLaY N.1.'.L M
Vwrw i30wApIWbZ�1fT1FA� �./Y �rAtfAO/l7iTTSCH.Y
tom..9-11-1+54»s • FAX 978.74a964
HOMEOWNER LICENSE EXEMPTION
Pksm Prfat
Date �/-93-dO/O
Job Locatkm 23 srxcc-
Home Owner Address ot3 t cmmo
Home Owner Telephone 9?-g w<s o
Present Mailing Address ;;23 tc� s44rr wij, 6197o
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 who,does not possess a license,provided that the owner act@ as supervisor.
DEFINITION OF HOMEOWNER
Persons) who owns a parcel of land on which he/she resider 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 understands the City of Salem
.Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDLYG INSPECTOR
See other side for state code
CITY OF SALEM
i PUBLIC PROPRERTY
jM b
* �• DEPARTMENT
I'.II: M111 ' Mly.'II
�t .1.91 I.0 R'.�.I II\r..1Cr)IMkI'r •\It N.
Irl:'r.1•.'1}•Ji•J� �1'�\:'17/•i aS'J/1(I
Construction Debris Disposal Affidavit
(required t'ur all demolition;md m-novutiun work)
In •accordaime with the sixth edition of the State Building Code, 780 CMR section 111.5`
Debris, and the provisions of MGL c 40.S 54;
Building Permit p 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
I I I.S 150A.
f The debris will be transported by:
(name of hauler)
l•he debris will be disposed of in
tl"i�a Ity
oddresa of fmility)
I/nature of Armlt apphcont
data
t
i s - `:. •�obe - �_,� existing window ,
3 ' I
I i
IT�I +half robe
shelves
shelves
O
>n, r
rPi1•C� D
I EkISTIAG BED 3
i anging %j=ib 1"A 8pPYC <^1 L-7 c-y
u'ch ty ha"a?5V 2- %4ion.
_ EXISTING --=— �' OF s�s+��-•= a '�','
F BED 2 .' FTTaC, J`�eATaiya Fwal ', T:i ml mcossse 11
1� 34"cnr shr
-�-- -rj I I V,-SKRCAI-PROVE1 SOLELY FOR 'F _
n FE AND LOCA110N Or FIR` C t
. .
" ,R tl!r. i .i I�'"( lrlh f } gwind w! F a(_ PR�TECTI nnn�e t i0 A
;
1 - TcST AND INS P CTION,FOt C "�
2'8" _ 'FT!!THE RPE':.CS.
I i _ 1 23 hr
z s
v, t MASTER 4s u
BEDROOM
m 11 I y —
F.aisrins OfficeO
existing window m n°"sms Existing intedormatl
stairs I I N Z
u Desk � ---- --_ newsvintlow PROPOSED SECOND FLOOR EXTENSION
. .r. --- - 4'1'h x2'6%v dhw
Stack
ExistineFaterior R'all I 1
r II
_ 7690 t OVER EXISTING FIRST FLOOR MUD ROOM
Proposed Extension n FOR MATT AND CAROL KAMINSKI
Q AT 23 LEMON STREET SALEM
� (teas r-�I•- ARCHITECTURAL DESIGNER David H BIII e
-�- DRAWN 06.17.2008
SCALE 1"=4'0"
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PROPOSED EXTENSION TO MUD ROOM
SIDE OR WEST ELEVATION FOR MATT AND CAROL KAMINSKI
AT 23 LEMON STREET SALEM
DRAWN 06,17.2008
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PROPOSED EXTENSION TO MUD ROOM
SOUTH or REAR ELEVATION FOR MATT AND CAROL KAMINSKI
AT 23 LEMON STREET SALEM
DRAWN 06.17.2008
SHEET 3
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PROPOSED EXTENSION TO MUD ROOM
FOR ATT AND CAROL
FRONT OR NORTH ELEVATION OF EXISTING RESIDENCET2sLEMON STREET SA EMKI
DRAWN 06.17.2008
SHEET 4