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90 LAFAYETTE ST - BUILDING INSPECTION (2) _m O o _. � . : :,.... �..�. ., 0 ... ..�� I51A!.3�4 t i _ C — A cn 0AA b I r!'�''�•a117 ,.o:.i�.}=4itxtsMW' . r.. j,,-, ..- . ...,fey . .att�,i;,r;:r7t! e{i' I •1 ,, <.,mac + 7�+'-1� �, , !��.;� �FE� �t.�,�-�a ,,.Ia _ � � ••,, . J�Ri. ,r ;:F { [ ;elpm'{';a ir:�rairihi., . isi.AY: • . .. Vs(`% irY.>v C ,: F!?i7„ f4Mi .`+:L' ,,,1.e:•.. �,i ,w,.:.., 1'+e.t,� }iIt✓f1� .. f p:o sl rrtirIt Ly }a¢'gpsp:x.a jfj + •�r YfYff; :; ,yl}'99}>,YPl V}S,. _.. F'? to�., Y fy/wax��C AMai �s" ` \ ,� ��Y Y �!NN M, i � f DATE: Citp Dfa�ETTC, aS�aL�U�EttS a PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED Location of Building 9© LA/`A- & l l i= SST Building Permit.Application For: '(Circle whichever applies) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool Addition, Alteration, Repair/Replace, Fo--,gdation Only, Wrecking Other._ROOF RaDn t- } 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: Ownerti Name:/nCtj'6 90 //- Contractor:T-rJ ROorn�jn =—NC, Street l7.TY.9LDo 57' aD cit, ✓,1/E street CA86 5`T-- city ,&IaW 14A State Phone (617) 620 .55/7 State Phone( ) Architect: City of Salem Licit Street City State Lic# HIP# State Phone ( ) Homeowners Exempt Form_ ycs no Structure: (please circle) Single Family, Multi Family# Other Estimated Cost of job S 70 Will building confirm to Iaw?_ycs no Asbestos?_yes no / yf3(3�YZ 4oOi� APAI2 Description of work W be done: / ' Dra Submitted:_yes no Mail Permit to: W t! Ell�F— MA r lure o Application,SIGNEII UNDER THE PENALTY OF PERJURY CONSTRUCTION TO KCOMPLETED WITHIN SIX(O MONTBS OF PERMIT ISSUED DATE Department use only: Penni!# ning Maput T Permit fee$ COMMENTS: CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3Ro FLOOR SALEM, MA O1970 TEL. (978)745-9595 EXT. 380 FAX (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34, I aclmowiedge that as a condition of Building Permit# all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility,as defined by MGL c III,S 150A. The debris will be disposed of at: Location of Facility / 1„ Mature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) R,3S5 fq.vZOP— Name of Permit Applicant Rc� 90 1,ArAYc 40, Firm Name,if any l7,-rG9L.00 57. 00 SO,46EVillt XIA Address,City& State 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 ca S 150A, and the building permits or licenses are to indicate the location of the facility. r -= \ The Commonwealth of Massachusetts q- ` - Department of Industrial Accidents b -- = OIOesB/Imestlgatleas - 600 Washington Street 7`h Floor g r Boston,Mass. 02111 Workers'Com ensation Insurance Affidavit: Buildin lumbie lectrical Contractors name: R J S S /ft/✓?_t?e_ address{7 :.Cy/ALo o S I '*M o city scef"We- state' 14-IA zip phone#617.62D -.625? 7 work site location(full add press)' /0 ZA FA1V6_f_1,Fl•S SQL 1 M A, d) (9 ❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers' compensation for my employees working on this job co n m . O© l .. A' 'tiF address• I_A&7. Jr-T t" ;.� j ' tea ' r i' "` "'• `4' xk'', 'f" "" «�.,t city: 86—Ve2-t-a /7/a , :6( -11.. -, -❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: com an name: addres • + _ city - pho�yn��e��4ft 4;insulsnc '•- - '�' company name P.)ke kilo add city: - phone*4 mail Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone# pm- official use only do not write in this area to be completed by city or town official city or town: permilflicense# []Building Department []Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other