105 LAFAYETTE ST - BUILDING INSPECTION 14*14161AUST13E fILfD#ND APPROVED By T44E
MSPFCIDB PRIDR TD A_PERMIT BEING GRANTED
\ CITY OF_SALEM
No\�L\ - v5
Date
q
r '
Ward
Zoning Disbtct
Is Proper►y Located In Location of
Me HisWc Dlatdct? Yes No_ Building
Is Property Located In f
the Conservetlon Anal? Yes No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build accor&g.to the following
specifications:
Owner's
0
e s Name �_ U�16 .0 y� 1 p g
Address & Phone /OS 1 P. ra41n 4 a.e S f _ (614 ) 6 q- G.3 3
Architect's Name
Address & Phone
Mechanics Name=
Address & Phone (IjA -ru 1`o. �w , oholsrA .
whet Ia the purpose a buikfing? =rtS�rA,\ 1 4 o S Q -ra of ooT-
mide"l of WNW EXkcinr• 6• �_ � N a dweang,for how many families?
WNI building conionn to law? Asbestos?
anse Cb
ed cost \a CRY Uo a State Wanes a CS '0�b '3 (
�� 1
� �roee• �C6
ant r�0
a/ Signature of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
ORK TO BE DONE
Tn S-{,>a
� 14; n�i � q qll le �h c4-w ro-if
0— arl
MAIL PERMIT TO: �D, S SDI -e ���
No. 0�
APPLICATION FOR
`\ PERMIT
V
LOCATION
PERMIT GRANTED
19
APPRO D
INSPECTOR Off BUILDINGS
l.OM OArOr16KA of mamac"f&
-` � '-.U.paal.e.al a,,7rlfablef�a::a/a•
600 W.L;j6 SLj
�aow 1 Gaaeea Ba, M. ." 02111
Co.rassoeaf
Workers' Compenzatim lourance ANidsvit
- • wkb.a principal pba of bodnew ae
�o'rs L's-N1,•A-ru1 •C�y; C1ru.tSi.� m tw sc a z� o . -
• � fasasorw.ratN ' •,
do hereby'cerdty under she pains and peniM a of pally, sloe
() Iaemployer providing workers' compensation covep{e for my employou working eat :
JUL
'ES�u11 os.
Insurance Company Police Number
1 am a sole proprietor and have no one working fdr me In any opadly.
0 1 am a sole propriesor, general contractor or homeowner (drde one) and haw hired d a
contractors listed btlow who-have thi following workers' compenaadon Posdow
Contractor Insuranie Compaq/Poft Nueaber
Contractor Insurance Company/Polity Ntnnbte'
Contractor Insurance Company/Polley Number
0 1 am a homeowner performing all the work myseN.
•I veomone an a emy of 06 uaraem wa be fwn.aoed a on Ofrs.it M.adra- of.w DIik is co.eraw vurftedw w cow Nary■soon
ronratr a avast ewao$Kim 21A d MGL I S 2 can kid w ow:raearoe of o+eirsr oseoda conaednr of a aar of me ni I.SM aW or w
+son'inwoom rm a vo a dra ou wa in rha brae d a STOP W ORK ORDER aww a iw of r 1t10AC a an spho ran.
Signed this • 01 ri 0 &N _day of o ,
:icerseei'Fcrmiltee nuildinf Department
iceruinf Ecart
Selectmen Office
u1th Geparmer:
PUBLIC PROPERTY DEPARTMENT
- 120 WASNINQTON STREET, 3RD FLOOR
SALEM,MA O 1670
TEL (976)743-9593 EXT.360
STANLEY J. U60VKZ, JR. FAX (976) 740-9"6
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions OfM43L c 40,S34,I aclmowledge that as a condition
of Building Permit 0_ . all debris resulting from fe construction activity
governed by this Building Permit shall be disposed of is a properly licensed solid-waste
disposal facility.as defined by WX a III.S150A
The debris will be disposed of at rA
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following in&MMUM
(PLEASE PRINT CLEARLY)
Name ofPermit Applicant
Firm Name6 if any
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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.