1 LAFAYETTE ST - BUILDING INSPECTION�
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"��� BOARD OF BUILDING REGULATIONS
' ' + - ��` License: CONSTRUCTION SUPERVISOR
_ � � `'s� 35�-`
, ��h-'� Number. CS 086143
� � ���' � Birthdate: 11/01/1964
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' y,�.�<, Expires: i1/07/2007 Tr.no: 86143
- Restricted: 00 �
- � MICHAELG BERNIER �- �
_ . 76 CHANOLER ST - ��y�
� NEWTON, MA 02458
Administrator
_ .__.__ __. ..__ . _.
..._... . ,. . .----
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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MAWAK
M®A*01MXW S'r M*SALIN, M 0l"o
TR:971.745.9595 a FAX V11.740-9W
Workers' Compensation Insurance Affidavit: BnildenlContraetorsMeetrldans ph mbm
Applicant Information ase n e t r ism
Name( l: -D K :nc.(l(,&a-,
Address--P— 3nx H V0ki0ve-e_ '
City/StW0P:_/An,4 maa-�- Phone
Are you an empisyw?Cheek the appreprleb best
1.M I am a employer with 1 4. ❑ I am a gmaral contractor and I Type of Project( :
employap M anther part-time).• have hired the wb•contractors 6• ❑New caoa rneden
2.❑ 1 am a sole proprietor or partner. listed on tbs anached sheet,t 7. Remodeling
ship and have no employees Them wb• Otdractaa have 8. ❑Demolition
working tar me in any capacity. workers•CGUIV6 h10Urascs.
(No workers'comp.irtsuranes 3. ❑ We are a corporation and its 9. 0 ung addition
required] offican have exercised their 10.x]Electrical repair or additions
3.❑ I am a homeowner doing all work right of exemption per MOL 11,®Plumbing rept as addidons
myself.(No workers'comp, o. 132,11(41 and we have no 12.0 Roof repairs
insurance required]t employees.[No workers' 13.0 Other
wmR mannaoce required]
;Any 4yplient dist ehaeb hos at swat 4110 tID as the weds bdM ttswina aWr wke
Hamaowm sats luhmb this attld.va mmatl0a they o dales 41 aadt ad am nen am"cosomw I M"ar o am iladw �
tCooftedws the clock dds baa mart smwhai on adowa sb4w th0a4nEMONNOMEMMMO� a dA alma oats ab.eonww=sed their whoa•ram}
loot ave rnlploya that bpro vldlag workers eowPenaadow
lnjo►wation Wwaneejor mqr rsyt/ `eL Below 4 rhsP-&7 and j ,W b,
Insurance Company Name:_ T
Policy M or Self-ins.Lie.N Expiration Date
Job Site Address 32 � G�S FUY - 0-7 City/S4trJZip:�i4/�v�,
Attach a Copy of the workers'compensation policy deeista en page(&hawin the
Failure m secure covers u g Pommy number anti exishutlon data).
coverage required under Section 25A of MGL c. 132 can leadto the impoddon of criminal penalties of a
fate up to S 1,300.00 and/or ora-year imprisonment,as well u civil penalties in the form of a STOP WORK ORDER anda,Rae
of up to(250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance covCrage verification.
/do hereby erratJjr mnder the pally and prnairla ojperjary tlut the injormaden provided above Js.Mw and carred
ba
Phone
OJjlchd are on13t Do not write IN fhb dreg,to be compktd by city or lows oQkkL
City or Town: Permitlutems M
Issuing Authority(circle one):
t. Board of Health I.Building Department 3.ChYfrows Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person:
Phone q•
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I\II;P.R LEY URISC6i 1.
\'1-")olt 120 WAiHINGTONS'ITEET • SALFV,\'1AS5.1CiICSIf(150197'
TE1:978-745'9595 • FAX;978-74C4846
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
—�_-- (name of hauter)
The debris will be disposed of in
(name of facility)
-� (address of tacilay)
— - �- signature of panuit app�cant
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ate
Jchri:h:T.��ic
T
—0 PUBLIC PROPERTY
DEPARTNIF.,'�IT
KDOWA EVORMCOu
MAYaa to WASkUNGr0N$ME=•
&M&A,N..tstcNcstrrs 01970
141:978.745-9S"*FAx 976740.g146
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name:,s/LWf,4c f 'Building: vyyr7
- Property Address.-- ---- —---- -- - --- - -- - -- - --- -
Property Is located in a;Conservation Area YM Histiorko DWMlat YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 17
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
j-e4-64P4 YTo
— Mail Permit to: - - --
What is the current use of the Building?
/,;k caSin/ess
Material of Building? If dwelling.ho many units? Ey,
Will the Building Conform to
Law? —
Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project S �—0 ' Permit as Calculstion
Permit Fee$ 2 S Estimated Coat X$7/$1000 Residential
-- – ----- - – -- Estimated Cost X$11/$1000 Commercial
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby appy for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury v
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