85 LAFAYETTE ST - BUILDING INSPECTION (2) IO Wf-19E f4L- APPROVED BY T44E
MP TL)R ,PFiJOR TP A_PEANT BEING GRANTED
CITY OF SALEM
Date
�,V4!C i! •,',
7
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\�ttmne
Is Property Located in Location of
the Historic District? Yes_No_ Building S S Z9�Ye%f lr/
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: !Gs 7e ,ee17QYaTtoz.-
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name g eilerryrryiii�'�
Address & Phone 25� r�� /SST z?Lzaz�01 1
Architect's Name 611e11 P D`DOris>P��
NTERED
Address & Phone 7d %ived (781 9?2`z-///'Z
Aub G 5 ZUU3
Mechanics Name ew -
Address & Phone 39 St'� f73
What Is the purpose of building? / Owzl7
Material of building? R1t1elc 4AW- �/ If a dwelling, for how maay4erailies?
Will building conforrn to law? yr-S Asbestos? Are)
—7
Estimated cost ,�OO,oaT D� City License # N P' State License #
C �c 1(001 l$ e. Improvement Li
� " Signature of li ant
CS e 772�� SIGNED UftIDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
i
cv
Q n� 9�
r
MAIL PERMIT TO: �3 9 SerfW t y
.Y WG�
ti'
No. 211 - Zoos(
APPLICATION FOR
PERMIT TO
�J�/p/M� ',r�l7no✓yJ�,b,�
LOCATION
95- �& t
PERMIT GRANTED
9� /1/03 2.0
AP VfD
INSPECTQ OF BUILDINGS
NEW ENGLAND DESIGN ASSOCIATES, INC. 16918
f
DATE INVOICE NO. DESCRIPTION INVOICE AMOUNT DEDUCTION BALANCE j
8-26-03 Building Dept. Building Permit 5005.00 .00 5005.60"
i
C DATE NUMBER HECK CHECK TOTALS
Commonlut Ak of 4a6aaeheceefb
J' ePO.rlmenl a f J,�7Gial J7[Cia,�17
nn 600 waaLi".31 ael
James I Camooes /Joalon, /I/6Sa3dla .1b 02111
Cormtssaoner
Workers' Compensation Insurance Affidavit
Ale,yr-
I, —
..t.ivil
with.a principal place of business at:
�9 SQ/sd 4<ys� �/• GUa�2res�cit !�/�
lam, 1
do hereby certify under the pairs and penalties of perjury, that:
(� 1 am an employer providing workers' compensation coverage for my employees working on
this job.
t�lii b CrrSfi�tY �Qoua
Insurance Compant Policy Number
I am a sole proprietor and have no one working for me in any capacity.
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
• I understand dtat a copy of this sute t wi l be foM1 voed {o the Office of lmcadtaoohl of the DIA lot eoeerate�iOOn 3"that(ante to aeettre
co• a¢ as revived no,,Section 2SA of MGL 1 S 2 can lead ed the inpoydon of crjr,m, oe"tk%corsatint of a fie of w w4I.S000D ands one
roan'inxwnmme v+.ra ae eiv9 denaltitl i+ the loan o(a STOP WORK ORDER ano a fie of S I00.00 a day aia+at M
(� 1?iir D0�
Signed this � day of
Licensee/Permitt building Geparc ent
Licensing board
Selectmens Office
Health Department
TO VERIFY CCVERI.GE INFCR., ,ATION CALL: 6 i 7.727-4500 X407 404, 405, 404, ?75
Workers Compensation Policy
I Carrier : Ohio Casualty Group
Term: June 6 , 2003 to June 6, 2004
ICOVERAGE A: WORKERS COMPENSATION
IThis coverage provides statutory benefits for employees whose injuries
are sustained in and arose out of the course of employment . Benefits
include cash, medical, rehabilitational and survivorship .
I, Basis of Premium - Estimated yearly payroll for specific
classifications . '
ICOVERAGE So EMPLOYERS LIABILITY
L. This coverage protects you from suits brought by injured employees to
recover money damages distinct from claims of a workers compensation
nature .
I, Bodily Injury by Accident -- $ 500, 000 each accident
Bodily Injury by Disease -- $ 500, 000 each employee
Bodily Injury by Disease -- $ 500, 000 policy limit
Basis of premium - Estimated yearly payroll for specific
classifications .
I- Classification: Code Rates Payroll Premium
-- - ---------- ---------------------------------------------------------
Carpentry-NOC 5403 16 . 60 if any $ 0
I` Carpentry-Installtion 5437 6 . 96 if any $ 0
Executive Supervisor 5606 2 . 65 234, 806 $ 6 , 222
Salespersons-Outside 8742 . 29 163 , 415 $ 474
Clerical 8810 . 18 133 , 586 $ 240
Total Premium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 6 , 936
Employers Liability Increased Limits _ 69
Premium with Experience Modification OF . 87 - $ 911
Premium after Experience Mod $ 6, 094
Terrorism Coverage . 03 + $ 160
Expense Constant + $ 244
Mass Assessment 4 . 50-. + $ 274
Estimated Deposit premium** Subject to audit $ 6 , 772
.� _._ _ -- T�ee�onvmmtu�ea/.IJ� yL../[�Laao¢cluu�4e�a •
BOARD OF BUILDING REGMLATIONS
License CONSTRUCTION SUPERVISOR
NumRer,CS� 077268
Bi "11/29/ �951
77268
Ek �
II
Restricted T62),0
PETER NEKOROSKI ' p _, ,
-5 LYME STREET -
SALEM, MA 01970. Administrator
u 2-77Y OF 5ALEM. lTl Fib.�fa�.n.•�� . . .
PUBLIC PROPERTY DEPARTMENT
• ° 120 WASHINGTON STREET, 3RO FLOOR
< SALEM,MA 01970
TEL. (978)745-9595 EXT.380
��rnra FAX (978) 740-9846
STANLEY J. USOVICZ, JR. -
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
S34 I acknowledge that as a condition
In accordance with the provisions of MGL c 40, ' from the conshuction activity
't#
all debris resulting
of Belding Perms properly licensed solid-waste
of .
't shall be disposed pep y
governed by this Building Permit sP
disposal facility,as defined by MGL c III,S150A.
The debris will be disposed of at: Lo�a bon o Facility
"`f
Signature off Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
einerl?el
Name of Permit Applicant
Firm Name, ' any
Address, City & Stafe
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIll S 150A, and the building permits or licenses are to
indicate the location of the facility.