128 LAFAYETTE ST - BUILDING INSPECTION G j
Si Si �E f iidDy APPROVED BY T44E
px i .UAECT.CI ,Pfd117iAP PFJA1T.13,EWG GRANTED
I 1111
rCITY OF Si,LEM
No.
Date
Ward
Zoning District
Is Property Located In Location of
the Hisforic District? Yes_No_ Building
Is Property Located in
the Conservation Area? Yea_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof Install Siding, Construct Deck, Shed, Pool,
dR epaieplace, 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 according to the following
specifications:
Owner's Name �10 n OV
c
Address & Phone t an 1 9,20 7���
Architect's Name kvol4h i C Vi-a
Address & Phone f791 I 5 Q CO a 1 1
Mechanics Name
Address & Phone L
What Is the purpose of building?
Material of building? I-Drnill If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated coat (�T City License #�3 State license # Q L
Home Improvement
Lie. I ram,-
Signature of Applicant
SIGNED UNDER THE PENALTY
fy6 OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: Pn)ZVI-4010 POOS�
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OF gAL.EMp lY►p,58Ac c ryun � ,
4 PUBLIC PROPERTY DEPARTMENT
• ^ 12.0 WASHINGTON STREET, 3RD FLOOR
< • y SALEM,MA 01970
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�bs'�,�✓ TEL. (978)745-9595 EXT.380
FAX (976) 740-9B46 .
iTANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,SA I aclmowledge that as a condition
Of Building Permit# all debris resulting from the construction activity .
t governed by this Building Permit shall be disposed of in a properly licensed solid-waste.
disposal facility,as defined by MGL c III,S150A.
The debris will be disposed of at: ` f 1�
cation of Facility
/ _ d
4igmnature L0fPerm4i't '?a_ut Date
FULLY complete the following information
(PLEASE PRINT CLEARLY)
Name of permit Applicant
Firm Name,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.
d.'
Commonwt:aUh'o1 p3eac"¢tb
s �ePa,lmanl oj9,�l.�f�;r��.nt,
600 W sLrjt-SWel
BarnesJ.amcoel l�sloa, /llaa,ae�uu.lF, 02111
Car+ sstona
Workers' Compensation Insurance Affidavit
I,
wiih.a principal place of business at: . n
do hereby certify under the pains and penalties of perjury, that:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy plumber
1 am a sole proprietor and have no one working for me in any capacky.
{) 1 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/P.o1icy Number
() I am a homeowner performing all the work myself.
i unoentand tot a eddy of rho wtement wa be iorwarocd m the OffKe 01 Im 6%avont of the Dla, for co. ante w�am tot ra➢un m secure
co srarr w rewitto under Section I5A of MGL 1 52 can lead to the irnoos,uon of crinirut oe"Ots cors15tint of a fuse of up trei I,SOOAD atwor one
roan' ranwnment v uu v eiri "x ,Liu it the iorm of a $TOP WORK ORDER and a!race of S 100.00 a tfal' ataiYt tee.
Signed this day of
LiccnsceiFerr,inee Euiiding Department
uce-tsinf board
Seiectmens Office
�,�fth Deparment
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