232 LAFAYETTE ST - BUILDING INSPECTION (2) , �
,
.��a.� � �
�,����,.� �a��� $� ��
.INSiP,E�?�.F'RIDA TP A_pEANUT �,EW�'a GRANTED
CITY OF SALEM
N��\ _ ,\� i��
V V -� '� � Date 17 D 5
,���
` si:.
�a�', '��. '�e ..
\�``�
�
Is Property Located in Location of
the Historic DlsMctT Yes_No_ Building Z8Z ��'+A���IfL .�i-
Is Property Located in
the Conservatlon Area? Yes No_
BUILDING PERMIT APPUCATION FOR:
Permit to:
(Circle whichever apply) R of, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replac Other.
PLEASE FlLL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to buiid according to the fotlowing
specffications: -
Owner's Name L�� I,�n.J�w\ / �W.rQ.� � 1`�.�v-L.�c.r.s�J��.
Address & Phone Z3 2 ��F+��.( E I f'� S �?� � `�5� Z 3$ '�
'' . > ArchiteCt's Name
,;
Address & Phone ( )
Mechanics Name 4
Address & Phone ( 1
wnae is a,e Purpose o�nuiwir�y��c� s,`�a-w�
�i a�ria�r,gz 'W oo� n e dHre�+oy, br how many famNies7 /
WIII building cwntortn to law? �4,,C _asbestos? f�0
Estlmated cost e5�00'O� b0 Clry License x N P' Sla Ucense 8C �9 �
Ha�e Improvea�pt V
�� �� �f �F ignature pplicant
SIGNED UNDER THE P
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
�P��� � Rcr�na�e,�. �Aasz.v✓tn.,.��
MAIL PERMIT T0: Z 3 2 �w�,ct.��'�Q,S� , �AU1.�M � VU� .
% �
� �• °�� �
,r ;'
N��.� - �5 ..,
APPUCATION�FOR Y
PERMIT TO ' . _
LOCATION x. . . '
�
��
PERMIT GRANTED � '
� '" 0 L h �
APPROV�D ` _ � ' 4
.
� . , �
S ECTOR OF ILDINGS - •
�. �
i
.Y � ��
3 The Commonwealth ojMassachusetts
�� ��� � _ 7 Deparlmentojlndustria/Accidents
�� _ O/OCeOlImreB�etlBOs
600 Wnshington Street, 7`"Floor
. � ;,� Baston,Mass. 02111
v� Workers'Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors
T.�
i . . - . . ;_. � � ': :. �,.:. � �:�.. .:.: .�n .,._ ,
name�U C 0. �e ��Q�t./� _ ` ,
. W Y`
' c� �V� stae: 1"f� zi :�� � hone# �3 I $3 �
� wotk si4e location(full addressY
❑ 1 am a homeowner performmg all work myself. Project Type: ❑New Construction❑Remodel
. � 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
--- --- -O-I-am an employeFprovidirtg workers'.compensa[�omfor my employees working on�ts��� ��� � � � -
. 8 ,. A i �tJ'°°.sSx pF ,y „�.,i�_: «b �r:�'M#'�at'4hv S,:TeM' T�'` 'x"t4{y.J �e R.y,'"��6�:
� • .. •�5� x mi f � y�zc �` "+ a. > :�x„'� ��,...�`� ✓� k,^�a`�"2�€,,��' A t?; t �; x �
8dd Fs> 9 �' �h �x e h_ " Ic*"`( !3 s s r,. F.+� ^. : rr � CJi�o�
I _ � N p'� i K d f;.t' , .. �. (' �r�('k� v^ .r#,�}q�•t 1 Y. �%�{,„ 4�`��{(�
CIN� ,v XC•�.,.i�yfiT�S�?P�Y pf`�0lirs.�t�S-��Zi�'.3-v.�XC�'[`ST �����:�jn y5.}+}..-•
.. . '.;�a ..y y�.n.sr .-'.', «f�'^% °� 'a �;.+"�'+,..�` ?�L�'y
insurenceco. � � r `� . . .''
� z . ,. ..� -* .
: . �
eolicv I! � � �'•
❑ t am a sole propnetor,general contractor,or 6omeowner(clrc[e one)and have hired the conVactors listed below who have
the following workers'compensation polices:
comnsnv namr � �
address: . . . . . , . .
r.
. � _. '� ..s� ` e ,�,�!c..
� . , 4 . r h ."4 w;;:a. :�i �{Sc Ffis.0 ,:l�tY �,w .#`�' �" s+-a�i�µi�p .e+°`-Y'�$�'+�'s�'� a+F'F�'�"w°�:'��
�a v� vr
�os ran� - ���� �-, � f j �`"�r�&;;..,x:�.a`�i.'�r.�,;�;'s m�,i"!;
4 d ¢
�• � �. �� . �-+4^ .�'�d !h� %v.„� b:4�i 3
comoiov namr'� � � � � ,�, t� ��
. � � . � . —r�.
81�di'lS4. � 4 �:,i;y, a �`�:.:� '�t'4 �,. �� '{� rt��`�k� � �' b�
�r x a r at I,� ,f r ' ax £_ �*< ,�`1^ �, n � f H s 3 �+-'+�
citr. ' ' � . ^� ti..a a.� a �e.�^*�.s`�€-�-�N�����,�`���X��'���y v�i,*���,.�y .�
1 - .y�EyR1. erG�Yv_.. 4 _,f��.< � 1 T�2 Y"'+'P
•n u .,�.WaT'+f YA��.�r�ir.l` �M1,r.Kw . . '�.
i ,�t �.'�y t md ai�5r s nat�*�i ...•..j.ui:'"w ,..,'$`
Failure to securc covenQe es required uoder Section 25A ot MGL 152 can kad to the ImpoaiUoo otcriminal peoalfip otn Oue up to 51,500.00 enNor
ooc yean'impriwoinent a�well aa civll penaltla In Ihe form of a STOP WORK ORDER and a One of SI00.00 e doy egalost me. I uodentand 16at a
copy o(Ihu sla ent may be forw ed to t6e Olifce of Investigations o(tht DIA forcovenge vediica[ion.
/dn hereby erti under the p ins a d pe i oj �j �haf the injormation provided above is nue and correcl.
Signawre Date Z��Z rA�
Print name ��`'U Phone#_��� ��J� $3�+ �
olficiel use ooly do not wrih in IAis area to be compleled by ciry or town oHicial
cily or town: permiNittnse M 08uilding Departmeot
❑Liceosing Boerd
❑check if immedie�e raponse u required �Selectmen'e 0lifce
❑Hnit6 Depertment
conlactpersoo: phoneq; DOt6er
IrcvzN scV�E�xn1
I
II — .__
% _ ,
�,
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires ail employers to provide workers' compensation for their
employees. As quoted from the"law",an employee is defined as every person in the service of another under any
contract of hire,express or implied,oral or written.
An employer is defined as an individual,partnership,association,corporation or other legal entiry,or any two or more of
the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver
or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a
dweiling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of
another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds
or buiiding appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local ficensing agency sdatYwit66otd-t6e-issnance ar------ -
renewal of a license or permit to operate a business or to:construct buildings in the commonwealth for any
applicant who has not produced acceptabie evidence of compliance with tAe insurance coverage required.
Additionally, neither the commonwealth nor any of iu political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of wmpliance with the insurance requirements of this chapter have
been presented to the contracting authoriry.
Applicants �
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
� supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for cbnfirmation of insurance coverage. Also be sure to sign and
date the at'fidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested,not the Department of Indusfial Accidenu. Should you have any questions regarding the"law"or if
you are required to obtain a workers' compensation policy,please call the Department at the number listed below.
,�� s � �
�� ' '�s`
,. :. . 4. ; � ;� .
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Depaztment has provided a space at the bottom of
the affidavit foryou to fill out in the event the Office of Investigations has ro contact you regarding the applicant. Please
be sure ro fiil in the permidlicense number which will be used as a reference nuinber. The affidavits may be returned to
the Department by mail or FAX unless other arrangemenu have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
piease do not hesitate to give us a call.
The Department's address,telephone and fax number:
T6e Commonwealt6 Of Massachusetts
Department of Industrial Accidents
mnce a�mesu9�bns
600 Washingtoo Street,7ih Floor
Boston, Ma. 02111
fax#: (61�727-7749
phone#: (617) 727-4900 ext. 406
,,
� + CITY OF SALEM� MASSACHUSETTS
� PUBLIC PROPERTY DEPARTMENT
./ � � 120 WASHINGTON STREET, 3RD FLOOR
}. SALEM, MA 01970
�� TEL. (978)745-9595 EX7. 380
- Fnx (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition
- —- - ef-Building-Permit#— , all-debFis resultiag-from-the-cunstruction-astivi�—
I governed by tiv's Building Permit shali 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: ►V'�1L��� (l�f/,�c�1 ���OJ�F(�� �� � •
Locarion of Facility
��f'=�
Sig�ature o ernut App Date
FiJLLY complete the following information:
(PLEASE PRINT CLEARLI�
�,����, IQ .G41�e�u
Name of Pernut Applicant �
�O�nQ, �1��Q.k,S
Firm Name, if any
1 . .
. . ,. V�32 11J • S�r0�,2��d'• ��Av���SLv�Q,daC
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 disposai
facility as defined by MGL cIII, SISOA, and the building pecmits or licenses are to
indicate the location of the facility.
�.
.�
�,h+s�s��fi+,.��o ,�aPaov�fl er r+�
.I�ISP,F.,CT� �'�1OR 7P.A PEAMIT B,�WG GRANTED
��� � c CITY OF SALEM !
No. � ,�,�` �\�f � Date /�' a �
, s�.is:.
,;�;``'i . l�c - .
�.�
Is PropeAy Located in Lxation of
the Historic District? Yes_No_ Building ? LYN� 4-G— i
Is Property Locatad in
�� ihe Conaervetlon Area4 Yes No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
FiepaidReplac , e �-^�/ %���%J l
PLEASE FlLL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PFtOCESSiNG
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specffications: -
Owner's Name �G�� �`O�' `` �7�r ,
Address & Phone � �'���� Sf. ��� ) 3 l� `�� �
� ArChiteCt'S N3me �hD�a.S !� �dh ��e !'
Address & Phone �S� Lo�c L`'�✓�' � S�'� S�a-3 'd Yy�
Mechanics Name �/�- �2� ��� l�i3/� ��`�/L''"� '
Address � Phone � � � G'•����r S �'. (4�F) 37 3 . 3�-�3
wnac�s me Purpose o�nu�air,y� '� �s�^��
Mefedg�p� pWI�I19? /���Gf �e�y f�b�r 118 dW6YiI1q, for how many Iem8ies9
WHI building confortn to law? �� Asbestos? A�0
esnmacea co�/�%, 6Do �clly u�ce�N P' state ucense x 8�.�.3�
��as- � �r��nt
��. f
� Sig e.of App icant
SIGNED UNDER TH ENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
�nn,v� l l'�.rM1er-Lr. ��:��� Nrj . S,.�P,f��,,,---��5
)�N�l�i�n S ����-
MAIL PERMIT T0: ��0/6 �2 �Pi�[�_ __
� .�.
� �,. ,
' :r,,
No. �\ -�� .., . �
. ,Q
APPUCATION FOR ,
PERMR TO . ,
� �: � � � � , '
LOCATION� �� .
4 p \
.
�. �`-'� ,
PERMIT�GRANTED . ' I
. � _�= �� 2(? '
AP ROV�D ' _ ` , � N
s ,,
x
ECTOR O UILDINGS • � _
�
�
� — �\-; TheCommonwealthofMassachuse#s
'' ��� �� _ Depanment oflndustria/Accidents
�� - , _ 9IBCeo/Inlrestl08B0as
600 Washington Street, 7`�Floor
� '-=' � Boston,Mass. 02111
������/Workers'Com ensatioo losurence Aflidavit: Buildin lumbin Iectricai Contractors
A � t � _. � k.�. . " ; , � � ,. � :
� � : . :
� name: � �� �'�/ ��j�C��
address: � � �'• V'/�,fZn+c^ . S `�:
citv V'r��(M� stare� �� ao� Q�u> � phone# s���3 �3- 3aa3
work site location(PoII addressl� � C`'/�/� '� �• �jy+��
❑ 1 am a homeowner performing all work myselE Project Type: ❑New Construction[�Remodel
❑ 1 am a sole�ro�rietor and have no one working in any capaciry. ❑Building Addition
------O�am an�mpioyeF�rov�dtng workers'-compensatcart for my emptoyees workin�on th�nisjob — — —
� � �'/_"t t t 'p" ,y 3�x^� gs�' 4 aw' .,.."",,..� , 3�r w+ y�,
C0111o8�v nAll11! - �'C.1✓C��[�ivQ P�']�rGS �.� f�����OVC� a�P �X,`"�"�'�d'A �� � ��'� §`�=
a � z, � r�.ae � x � � �,9a .� ��>�'€,� �d ; �rt $g.,,,z�..a�""��r'�
addrese: � � �r t,.., ��' " , . . ,
../ /���/�.Ef' r �.� r. f aK� u �rk c+.w a +e'.— 4,m s��. r � .
{j2 �q 2
citv �r tDv e�� , �✓(.tr ° � QF IJJ y x- �-'�ppE��.nrl'� f '��a S�"�w,3{-z��0�.�*���:^�u'`�r �"g`� �.
• .' "f t J a- r &a�- a,
C!� � �� . ' ' ,T ` ;x ^#t 7ar� pnY,+'�x u .>x � x-.yU^a,.s� '+�#.<.0
f^sarao�,�_S'J�,. mlicv Y
❑ I am a sole propnetor,general contractor,or 6omeowner(cbc%one)and have hired ffie conVactors tisted below who have
[he following workers' compensation polices: �
wmosm namr . � � �. �
. . . . . .�. . .
addresa: � � '
—�,—�-^ . . . �,¢ �
• . - � ' � � ' a f �; , . �,... �
i t
..,. . . rP 2: d :ti.�. z .�.r a�iti ? ;.req�'�t f* 1ce t �"aIA�:S'}�'����^Y�f� fi x"K',�, ��'�'�'��
in e�� : t� ` ��.5:; ..-., '"µ:a�s4�,���'�,s.s „_,�.: .',`�,
, '. - <� �� v�. -,. � t x � ,,.
comnenv name: �� . . ..�.ro `� .. .. "',�"'. '�'"t" .r-a ��a � ��,w� r a,�.,� � x„r� :
� �::
addrcv: " �.:�e k`�' "'� t„,.t`'����,i;�t£' ��s a;�$°n''`+��,s �''J'��,
� F
� ,
"` 3
e.�. '� i:*x,�», :#^ei v"�t,�r 4e�.rs�'" ��kav1�'l�'i .ro'�'Y���'�.�a�k.".°f��` "��'3'3,��"'�psy�,� .
�Yry / nin � kjr.T.�.fw�.�. �rir�tla.e�.ru .. -1) . '- � P 5
«'+i«.Na��� . .
ina .- 4 ..a � � � ss , z � + ��-
,� .-xx., �,:.�,x^az,2. .�. Gs>W.�,wwla ,.,i:� .5 .4 �
Faflure lo secun coveroee 4v requi�ed under Sectioo ZSA of MGL 152 cao Iwd to f6e Impwitbn ofcriminai penokin afa(ioe up W SI,500.00 and/or
one yean'impriaooinent as well n c oelttes in 16e form oto STOP WORK ORDER and a Iloe ofS100.00 a day agaiort me. I uoderetand that a
copy of�his ataument may b ard � �o Ihe Offitt o v tigetbm of DIA(or covenee vedticatioo.
/do hereby rer�i der th �ns axd pe ' o erju at I ormalion provided obove is lruye an-d� wnea.
Signawre Date f - /� �f
Print name �,/.�-1/�P l `y���i d^'� � Phone# �'��- �73 - 3 }�- 3
o?cial use only do not write in Ihis area to be comple�ed by city or town oliicial
city or town: permiNicenae M ❑Buildiog Departmen�
❑Licensinq Board
❑check if immediate response iv required ❑Selatmen's Ofiice
�Nealth Depanment
conlact persoo: pdone q; ❑O[6er
IrevisN SeP�.3IX01
,
,
' Information and Instructions
eral Laws cha ter 152 section 25 re uires all employers to provide workers' compensation for their
Massachusetts Gen p 9 ,
m the"law" an e !o ee is defined as every person m the service of another under any
uoted fro ,
empl�yees. As� mP Y
contract of hire,express or implied, oral or written.
An employer is defined as an individua►,partnership, association, corporation or other legal entity,or any two or more of
the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer, or the receiver
or trustee of an individual, partnership, association or other Iegal entiry,employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of
another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds
or building appuRenant thereto shall not because of such employment be deemed to be an employer. '
MGL chapter I52 section 25 also states that every state or lo�a-ficensing ageocy shaltwtt6trohtthe issnance o� —
� renewal of a license or permit to operate a business or to wnstruct buildings in t6e commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, neither the commonwealth nor any of its political subdivisiot�s shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have
been presented to the contncting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as all affidaviu may be
submitted to the Department of Industrial Accidenu for confiitnation of insurance coverage. Also be sure to sign and
date the a�davit. The affidavit should be retumed to the ciry or town that the application for the permit or license is
being requested,not the Department of Indusuial Accidents. Should you have any questions regarding the"law"or if
you are required to obtain a workers' compensation policy,please call the Department at the nwnber listed below.
s . . �� �:
l;�fa ,i- �.�ro .v .� ." r ... , �.: ; . � . ' � _ ,. _
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Depaztment has provided a space at the bottom of
. the affidavii for you to fill out in thesvent,the Office of Investigations has ro contact you regazding the applicant. Please
be sure to fill in the pertnit/license number which will be used as a reference numtie�: The affid'aviu may be returned to
the Department by mail or FAX unless other arrarigements have been made.
The Office of[nvestigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
�•. .
�. : - �. . . _.
._ .,� ,.. . ._
The Department's address,telephone and fa�c number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
OIOce d Imrostle�bns
600 Washington Street,7'"Floor
Boston,Ma. 02111
tax#: (61'n 727-7749
phone#: (617)727-4900 ext. 406
CITY OF SALEM� MASSACHUSETTS
� PUBLIC PROPERTY DEPARTMENT
. � � � 120 WASHINGTON STREET, 3RDFLOOR
] ' SALEM, MA O 1970
�'�� TEL. (978)745-9595 ExT. 380
� FNc (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
I In accordance with the provisions of MGL c 40, S34, I aclmowledge that as a condition
----- o€-Building Per�►it#— ,all-debris-resulting-from-the-eonshvshon-actiui�y
governed by this Building Permit shali be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III, S I SOA.
The debris will be disposed of at: ����"'� i ��,
Location of Facility
Yure of Permit Applic t Date
FULLY complete the following information:
(PLEASE PRINT CLEARLI�
i i�� �2 ���
Name of Permit Applicant
ICen,�`L�(,�e /. �`v"`e :�/�ti'`^.��
Firm Name,if any
.. , .. .. . ... �r:� � ....��r�n—a.r � 1 " �rGvvCC/� t' . .. . .
�
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.
� �� / \ / \
1 ) � i � i �
� �_ EXIT
� � � Ili " � Ili � P � TOILET
SD � � SD I I I I ST �, �" i �"�
MEN'S sr sT W��I�EN'S SEC��ND FLOAR j I i � ' � � ��� t�
A C C E S S I B L E A C fi S I B L E I I I I I i � � ; s ` � �' ��`'_;.;2 , �
/� /� o �., 3S� g ... h
� W.�I. �IIy.��J. � � I � � I i . �� p O �.
�y
� I � � �I � � �I � .. �C �r� C,'� . c . .
I I I I I I EXIT v
� � I I I�I I I I X � NEW SOFFIT � �� � � ����+` �
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� � �� � �' �nvti � „
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