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146 LAFAYETTE ST - BUILDING INSPECTION dual— ZA wig ................................. . ................. Use I "GANK 21" NOW- n,N7-5 .....Signature "' tt away t- on --&;P,iIMA Hubcm-- Map . :,a arty Addr ......................... Q-01-:0 QQ So to .... ................................................ you MuP'Niiibii RT ........... Ois IN, 'L4-7 .......... ................. "900 �E�Pz*-�A I........... Required..I............. .................... ............................. ......................... $ isselmia,I k--&M am D- p ............ is �- sit AW 4 0" ' f -, 4 Name(Pont) 1 dAfi ere-r so ?TV% qn- mot in a cnm 3:-DESCRIPTION- R c p rop �J' " 8jjcfD&kjiOtibqvf ad"Work WANTAKIPONG too, WON, --- ILL vs W1 8utlding $ t Building Permit Fee $ indicate haw fee is determined ag TO Wi ....... MA MAP 2.-:E ===No J ......... WK �I -'(F r Su cession) - W Outstanding Sw Am ITO , ,': � � �-,3 .;= � r:-: ". Y "`�Y`.rk,"u,""' dx. as*. = r ._x,-:r..:'r.S'�>'tio•.'1Y� �?� a �c � -MSECTIGWS CONSTRU ION SERVICES ` ;r � tt b t rR t, '� ¢c-3`� J"> .1.FM T ti "�4,iZ ,p• t ` c S 1�LIcP,nsed Constiuetlon Stitpervkor(CSL) ,�r k .. } v�'ysy�[#}t}f c'`t dF F -5G y-te� ��.,Cr in d r •---r— y �c t.;rn¢ S d1 ... hr 2 *rT-h:1..S�� "s�� i �+ `•{ -i , t V IJlYl15e,NaminY� - � ; Exp�na�on Date '�y-. 1.� y 4-. � a n. t- > �.- rti. U � �-,: f .. r �•r t.;,ec.,5.1.r� � -�a i)atrrcrc of CSL Huller C q s't CSL Tyire lsee helow) -- -��4ddress 4, -, y` §' r { --e'" � -'v" --. ,•., 'U+�-+ UI11�tr1iNe1111t 1035 OOOCa pl:l u t "` ' �-, . 4 .Signmure - 4 RC Me`siderititU Roafin� Cuvenn ' "G x Td'ephone''' -; rt ntiWWfBduwb n- Resulcd Stdm SF:-.a- 7tesldaliahSulidFuel Bumm A" It.mu lnsiall�uun' �.�„ r`s ;, S1'Rt�es er Hoi'C ply._ F- Contractor(HIC)' y >Tx' r � � $ } '+ ;F{IC Ca tiny amc orH�C R N �' F r - Reg�stratt Number .-z '" � on t - .F SECTION 6 WORKERSr COMPENSATION INSURA-SCE AMDA VIT(M G G c 152.$ 25C(6)) j attdP' 3 Workers Compeasotron Insurnttce a ffidavtt�must be Completed ,submitted with thts iopticauun •Failure to pn>wde ' this uffiduvtt wtll twit in the dental�ofthe 1 f the budding perm(t. s ;, -r fa, SECTIUNy7a OWNER;AUTROItIZATIUN,TO BE COMPLETFA,WAEN'` _�,` : t ,� � r t . � � OWNEB'B;ARGENT=OR`CONTRACTOR►PPL``IFB`FORBUII:DQIGPBBMIT ---i '- Y t '� � `� '` .�j- v, f r A R•-F Y�4 � a � >,xt� 7 j ,b y; s �,:,> yt= �-vim lY .Y S i4, -:t' F -., I �` ti as Owner of the subject property hereby •anthaflZC of �X.- > � �..'' tic s xy [O aeron my behalf in all matters ne ielabve to work authoraed by this bwldmgrpermtt-0pphca[ton. r , r v� �_' � �#r- t rs _ ..' ry SECTION 7b OWNERt OR AUTHORIZED AGENT flECI ARATION' - 1 't _. ; � ..r•. J."c"' � t ? '3't - . '�� e��3� 'R. �.[-._- f ' La f ,I sl3^-` + `s r as Owner or Aufhoied Agent hereby dtxliire That the statements and mformabon on the foregwng applicauan ore true and accurate to the bestrof my knowledge and r 2 i ',(Si' '.un8er�the ' nsond° `Iksaf u - _,'' :�a -.'• - `; Y t An Owtter who obtoms a butlthng permtLta do fits/lter own work,or an owner who huffs an`ttttrcgtstered wntrauor (not regtstered,iatrlte FM It-*oveFnciit ntractor{HIC)Pfo�ntn).wdl not nave! cuss to the arbrtratirtn s ' pr�aginm or guaranty fuel under M G L c Y142A;Othentrtportant tnfortottlmn on the':IiIC!'rogram and } *f Consuvetion Supetvtsor Ijcenstng(CSL�cao he found in MR CMR ltegulauans 110 R6 and i lO R5 resp¢t ttvely "1 2 When substmual:Work is planner proVtde the mformWioa 6ebw ' t T Total floots'aren(Sq.R j rr �Y (utcludthg-gorage,.fimshed basemendatbcs desks ur ptiRh) Gross:livtng aiea.(Sq Flabnable room roam ` Number af,firepiaces # umber of bedrooms r.- E- Ntunb��otbathtooms _ rNumberufhtiif/bnths Type of.fteatin`gsystem n " ' ry Number of decks!posh, � y'type of aohng syskiti -_ � s Enclosed ,•- Opep t _ _ _ r 3` Total"Ehojec%Square Fooiage may be subsntwed for 1 ntai Ptn)ect Cost r n`< 4: " r r �►AI,B�aa' s�.iBo IO�Z Ie4 e'0 sgGG+S'pFq qq� ;p.. on.. Op�'3?ooy s 01� ra, 1'4p8 c � B°a.rt of fg°ildV. s? OE n dA ENt1!O° gR IMPRMlo�: CONTRCeeXpl� 11576q 7prds R RC VERR t �1012010 MARC E77E YPe. Individual Tr# 265036 23 UNipER OE7-re SAUGUS, ILIA 01906 ..Adinini i CITY OF S.U.E:`t, 2%L'f,ss kcHLSETTS BUILDLNIG DEPARTMENT d• 120 WASHINGTON STREET, Sao FLOOR �j TEL (978)745-9595 FAX(978)740-9846 KINBERLF-Y DRISCOLL MAYOR THOnlAS ST.1'iERRH DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO%LNISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A ticant Information Please Print Lepittly Name(Business:OrganizatioNlndividual): Address: City/State/Zip: S7M Al-S Phone It: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction Gtttployees(full and/or part-time).' have hired the stdscorttractors 2, am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions myself. [No workers'camp. c_ 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees. [No workers' 13 ❑Other comp.insurance required.] Any applicant that checks box nil most also fill out the section below showing their wort a s'compensation policy infurmation. '1 lomeausm who submit this affidavit indicating they ate doing all work and then hue outside contractors must submit a new airtdavit indicting such, :Conumyon that chock this box must anxlced an additiumt shect showing the avne of the subeammctors and their workers-oomp.policy information. I am an employer that is providing workers'co pensadon insurance for my employees. Below Is the poly and Job site information Insurance Company Name:— Pal icy#or Self-ins.Liq.p: U 1S Ol4 G Expiration Date: J 116 J Job Site Address: City/State/Zip: o�©� Attach a copy of the workers'compensatid0policy declaration page(showing the policy number and expiration daft).- Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a- line up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 coverage verification. I do hereby cerf nder the pains and pens Iles of perjury that the information provide above is true and correct a/ / , /n,�.1,123 / Sienuure: 6 Datc• Phone#: 3 L Official use only. Do not write in this area,to he completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Berard of health L Building Department 3.City/town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: ___ Phone#: CITY OF S. .EtiI, 1I.xSSACHUSETTS BUILDLNG DEP PtR'f.%I&NT 130 WASHLNGTONi STREET,3" FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KjXtBERi RY DRISCOLL MAYOR TrIO>.tAs ST.PIFRRE DIRECTOR OF PUBLIC PROPERTY/Bunl)LNG CO%L%aSSIONiER 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 hauler) The debris will be disposed of in (name of facility) (address of facility) signature of permit applicant 3/1 ) 0 ate debrivR:d,w