176 LAFAYETTE ST - BUILDING INSPECTION -PL 61"TfEf4Lf�IAfPROVEG BY T44E
MPZCTDB PP" TD A PE MIT BEING GRANTED
CITY OF SALEM
No. Date
s: si
Is Property located In Location of
aw Historic District? Yes_No Ilnilding 17&GAFgyL O
is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, eroo Install Siding, Construct Deck, Shed, Pool,
Repair solace, 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 3///
Address & Phone /qla c5w►1MAe as l��y 4` d
Pn Architect's Name
Address & Phone
Mechanics Namei�/f�G'/�y��h���/�5
Address & Phone
What is the purpose of building? �f SiD�nlfiL
Mat w of twkIN? &L It a dweling,for how many families?
WIN building conlprm to law? Asbestos?
Estlmated cost /o, UG• City UCK"N N A State UCer" e
flame Isprovemen
hiature of Adp&ant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
_D /rt/5Z&I �ifll�l A�Nf2ED QNMK/� ��idG �ST /YI Olf ®�Gl�l
QF 6r1uA/dg , CIMLO aj iuG flies 40r S*Xlt, 9L
w.»A O�uatt�Ion1 S"
MAIL PERMIT TO: /ql�
No.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
3f 3e/D�o 2O
AP OV D
INSPEQTOA OF BUILDINGS
CITY OF SALT , MASSACHUSI[TTS
• M PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STAIEIET 3no FLooA
!ALIEN, MASSACNUSWG W970
9TANLCV J. UIEOYIC=, JIE. TIELIE►MONIE: 978-745-939S BxT. 390
NA►oIE FAX: 979-740.9044
Salem Buff dt o]k�,�,�nt
Debris Dlsoe�a91 ii'n�
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a property licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
(Location of Facility) Aj
Si azure of App ' t
ab
Da
i
nie Conusoarweaftl i qfM4i5WhUSdb
Depfudwe d ojlndushfdAwMenb
Duo O1
6"Wasddnataa&Wd
Boste ss MA 02111
-
WorkeW Compentadon Insurance A®davit: BWbknlContract"z .ledridan Mumben
ADeficmd hftsdo Piase Print Llstibh►
Name
Address:
ety/Statdzipe tea D Pheoe tk �7P�-3v't-1 L-:411
Are y an Cbeek tkt'appnprlate bar' Type of Pr'ol��eo
,� 1 t [)I am a Fwal conewer and I
1.L!d I am a employer with� 6: ❑New oomuoaiom
employees(w and/or psw i a}a bavebketl dw sdl a raebe
2_❑ 1 am a Sole; Mpti1" of patmaw limed on the attacked sliest t y p
ship and nave Be employed These wb ootraeeots haw a ❑ Daalidaa
wa�>ixmeisatgtcmWAV. w a1' ,tttauaoba 9. [ll gaddidon
[No wodms'comp,inaraaoe S. p we ae a�otpilrstjoaAatd its_ to p]3lechial traits or additioro
ofSan esai weir
3.13 I AM a }bomeownr.doing an Walk njitof -i>dM�. 11.0 Plumbiognpava cr addition
myself[No MORkew-comp� C 132. l( s>s "�iebsve'no 12 p R60frepain
oomro9°ka"t• cowbi6' 13.E]Ofhet
�
•Any gipaem<drt eleebuoa p not also ffa qRA[• • a hf ,�wr p'mwautloa wear fsfnalaw
tltomowsan'1a@*nookaf &Vftbaco s&awdataa•n wakmde!ubbroemiimAYaio�IiAwsukmkonmdBdrvitfa11 - -Mock
%Conuaetan dotdretd obai=9 deraad a eMdmd&MAW*dr n W WOr .ddtar.w&IW eaep war iMfixMw ion.
Ian arimpbystAatloPrevlArdwerittra'eoaapr eRbursno�afira9'dtlofija aei�ba�Mrpellejas�Joiafal
bwfwwudoL
Inearanm ComptwyName 4&4. Z Afrn/A L
Policy#or scr-its.Lie. #- /✓O AM 3153 3 3-<-9/ 02 S' Expiration Dane S/a le �
Job Site Ad lsm - !7 ( L�-G�nff n� .sT city - , S i Am
Attach a copy of the workers'eompeandoa poley dedwadoe pass(aMowdg tie pOft a�eaptratloi dde)6
Fa3ae to aecara oSvera�e o regnved tmda Section 23A of MCi3,a 132 ca lead b tbs iooposidoa ofaimieal pwaldd of a
tine up to$l,30o,0o xWor oao-year imprisonment,s well as civil peaskb in do fmm of a STOP WORK ORDER and a fine
ofup io$250.00 a day against the violaoor. Be advised that a copy oftkb statement may be forwnded a the Ofae of
Investigations of the DIA for instance coverage vaifiation.
I As Amby wsdnlAepahn and pwaddes ofpa/uq Am do Infarnualoa provlld above b aw aid ewrwas
Z�
OBleAd rut m4L Dose(*WM Gr&h ems,aS kr eoaW1ef iby eAywA aw taleld
City or Town: Pa luuc ne of
Issuing Andmwfty(drde one):
1.Board of Health 2.Building Department 3.Cityfrowe Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Persom ]?beat#:
Information and Instructions
.... ...:..:... ._ _...., fortbeQemployeea:
dassacbstsettsGeneral l.avra ehaptee 152 regwires�ll ea lopre4b�P S ��ctofh M -
i b t h swum an is defined a ...eveq person _.
aped or vap"esd or writhce-
yro�.corporation a other legal entig4 err any two or more •.
An morWN it
tiro le;alrcptaives 4f a daeeaed empleycti a
receiver f L Moc.ion of other legal clay,employing eroployeta How"
owner odes bon"bavlo<� t�0e 04 who resides aereis.or the occupant of mod'"
dwelling boots of smdmg who employs pasom in do mamtmmM eonshtictien or�wot#.at s0e1 duelling home
err on to>Dou"�arb building a�pparumot
mach daII notbecaote of inch employmeabe deemed b he in empbyeG"
MGL clnpar 152,125W)oleo states mat"any date er load Secoslog agesey and wlthhdd the knarta or
record of a BMW or permit to operate a businesser is coaft td bWWhW b the eomoaoswreadh for now
odeomp>taoce with th Wmrase Cveg re0 ed
� �� ede
� ,� yaA data"Neidw me counuoawoo ON a7ofi4 PON"mbdivhsima &W
gw the pafom�a ofpeblie wodt wadi!acceptable a We=of ewupfience w� ios
me urama
Vi e cuo say o d to m00049996ga '
�ememt of th&chapter have been preamaed is
thebous mat apply b yotm»button cod.it
Pleas fill the me' atfidsys ooaglep,by empubeg with their cati9ca*x)of
nenasKy!,tmpPly mh.�nnacsor(a)name(al addtm(es)no I phone mpba(t) s 01 wib no employees oaken mess cos
bvarsooa LimitedLiabg* 0�nsLimitedLisbttu'YPatssashipa0
arena now b ,°o 0°�e0' if an L1.0 orLLP does have
members ores pojicy is n9abe� Be advised that this affidavt'�maybe submitted b the Dgwft d cf hafasWd
AceIcM of immaace mvaaga Aka b4 to ad�a date the atl4davlL The affidavit sheaid
be returned b the city or bwa mat the applic a far the permit�came s befog requested,sut the Depacm workers'
of
hidnsmial'Aoeidesd. Sbgald youbave mY gnestiom r the law ar if yom are-ul ' 1 b abmin a worTcess'
poles pleats call the Depstmatt d the muibR hated below. Self-insured a=opanies sboald ermer metr
seiFinsmasin fieema issi O°to lb a
City or Tows Ofndds
please be time that me atgtdavit is oomplede and Prated legibly. �
The Deat has Pied a space at the botbm
of the affidavit for you b®out in the event the Ot$ce of Investigations ba to concoct You mP dioi me apPlicam
Please be son m fill in the permi�ceme>tmaba which will be used a a refacoce number.'In additiosmdica ciarent
that nag submit multiple permNicense applications,m any Brea Yam'need bo auburn one affidavit
policy information(if neeasary)and under"lob Site Address"ibe apphcaa should verse location dia city at mm may be s �WIY Or
rovided b me
town"A copy ofine afffidavrt tlitabaa beta o�cisQtir stwycd oL � --Anew affid"mnstbe f W OW each
aVP>l�a proof matt a valid affidavit it no file for mOse Hermits not re>es.
sed b any business or oosiinerclal veabre
err.Where a bome owner or citisee it obWft a Memo or Pamir
(ia a dog titian err permit b bitm leaves cos)said person is NOT requirod b oonrplete tbL atfidavtt
The O®oe of'investigations would hlto to dwelt you in advance for your cooperation and should you have anY questions,
please do not besitab to live ns a salt
The Departments adduct,tekpbooe and fan samba:
'the Commonwealth of Massachusetts
Mparbnent of Industrial Accidents
Office of Invettdpdons
600 Washington Street
Boston,MA 02111
TeL #617-7274900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia