232 LAFAYETTE ST - BUILDING INSPECTION D CITY-OF-
PUBLIC
PROPERTY
DEPARTbiEi�1T
KIsSFJLLEl DRISCOLL b
MAYOR 120 WASMNGTON h MMr•SM.EK MACSACHL5in-M 01970
I'M--973-745-9S9S 9 FAX 97&740.98" C'
APPLICATION FOR THE REPAIR,RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: 2 Q Building:
Property Address:
property is located in a; Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: g2
Address: -z7 32
Telephone: 2
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
add Description of Proposed Work:
Mail Permit to:
r `
t
What is the current use of the Buildin P�
Material of Building? e�'f dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Construction Supervisors License# 65 D130 HIC Registration# 1AQ
Estimated Cost of Project$-5&0 Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building
�P/e/rm�/into b o the o le/ ��1¢,nja
specifications. Signed under penalty of perjury X ae� ( OVA
Date
a
N
O
r
\s a
�j I � I
a � a
X
SHENDEL BAKAL
I I�
Monaco Johnson Grou
Design B Renovate
Marblehead _ f (781)589=1969 j
i 4 ✓/fC WV'//Y%EWiuocw+ry �.�..���w...._...
- Board of Building Regulations and Standards
+ I HOMIFiWPROVEMENTCONTRACTOR .
Registratlon:,/iIOWxpiration:Type:MONACO JOHNSON GROUP
CHRISTO?HER MONACO '-
3 ELM PL'
rv1ARBLEhEAD,MA01945� Administrator . .
�� .�+,, Te �imitnm/wiaa�u o�✓��naac�urrl(a
. BOARD OF BUILDING f
License: CONSTRUCTION
Number: CS 013075
Birthdate: 10/26/1954
,... Expires: 10/2612007 ,„ f
Restricted: 00-
,p CHRISTOPHER A MONACO
i} 3 ELM PLACE
MARBLEHEAD, MA 01945
Commissioner
I!
r —
_ �� & , 6
Board of Building Regulat ons and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 110147
Type:_Fa4PstrzhgL,
Expirati 10I9/2008
MONACO JOHNSON GROUP
CHRISTOPHER MONACO
3 ELM PL
MARBLEHEAD, MA 01945
Update Address and return card.Mork reason for change.
oPS-CAI 0 50M.05106.PC6490 [ � Address i`;1 Renewal ! Employment Lost Card
✓�ic'IJo9JvrJeorc�/ieal�, o�✓�aJa�lc�utdB�d
_ Board of Building Regulations and Standards License or registration valid for Individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 110147 Board of Building Regulations and Standards
Expiration: 1 01912 0 08 One Ashburton Place Rm 1301
Boston,Mn.02108
Type: Partnership '.
MONACO JOHNSONGROUP
CHRISTOPHER MONACO .
3 ELM PL C. .,«...,,.,.�,
MARBLEHEAD,MA 01945 Deputy Administrator Not valid without signature
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CrtY OF Smmm
PUBLIC PROPERTY
DEPAMTMENt
Me.�
AVCS tawAmmwmm2now sWr►N...oa�as,s.tff.
11ac.7a7464M 0 PAS 97&74&"
Canst mdam Debris Dbposat AMINVIt
(maired 6 at damomom and naova"wadi)
1s aoesWmm with ttss a,4 la �og C� !
790 CUR Section 111.
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Bs 54
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snap be Otis s P,b ltao�vroma dyad tlapttlt as doQned by DidtS.s
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The detfris wiD bG transported try:
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due
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
andatusv atmcatt
a/Airost IM VAgmV6rMSMW♦SAtrad,MXUAOCUrrealWo
Tb.978,743.9M a FAX-9W40-9846
Workers' Compensation Insurance Amdav[t: Bai[dwwcontraetorWM*cMdana/Promben
Annticaut Informadou Please mint i zibly
Address: )0
vft�
city/state/Zip: ifl",g LLZL � Phone V- �3�' 066,C
Are as u play l Ckeck appropriate boar
l!1 am a employer with= 4. Q I am a pmral contractor and I Type of projeas(r"dre4.
employ=(ho and/or part time).o have hired the subeootracgas 6. Q Neer canannedaa
2.Q I am a vela pemprietor err panes. listed an the attached shoat.t 7. [3 Remodeling
ship and have no employees These have L Q Demolition
working far me In any capacity. workers'COUP•innueuce.
No workers'comp inwranee 3. Q We ere a corporation and its 9. Q 11uilding addition
requite&) , o>nems have exercised their 10.0 Electrical repairs or additions
3.Q I am a homeowner doing all work right of exemption per MOL 11.13 Pbrmbing repair at additions
malt[No workers'comp. a 132.I1(4),and we have no
insurance re4ubed•1 t empleyeea[No worker' 12.Q Roof repahs
camp insurance 13.Q Other
fAnY WHOM err deda boa e1 must On an an the"Was twbM dfe.las that Mmbw omp..do I7adal lahma .ItarteoMaemMeern*nit0111&Mdnrtt"codeszamdebt'magkadAAnseacoddenwaaee I Must 06"aawaai ovis b000ks FAIL
rCamatma art ch"We bat am sambet a admaw teen drwbg tee mug of tee ab cos menu i d their Makma•camp iaarmetle►
f an an eaydrya tArat brprovlafLtt workers lnjonwadara eawpeawsbe lnr+traneijoi rep SAYA yeea Bear Is gibe poft andja&rip
��
Insurance Company Names. �— ,p
Policy 4 at Self ins.Liu N /2 7Z(mo o o Expiration Date• o
._ Job site address city/stata/lip �� ��
Attack a ropy of the worken'eompemudon policy declaration page(shorting the policy number and e.pks&.slate}
Failu m to secure coveage as requited under Section 23A of MOL a 132 can lead m the imposition of criminal penalties of a
fine up to 31,500.00 and/or one-year imprisonment,as well Is civil penalties in the form of a STOP WORK ORDER and a Axe of up to$230.00 a day against the violame Be advised that a copy of this atitement may be forwarded to the OAiee Investigations of the DU for insurance coverap verifisdon
of
AD)� n f ap /Pa""Mm ojpvr/ary that the lajaeradon provided above Is aura and eorrtd
DI w iz 6 oG
00ci f era oal3t Da not writs In Ah areal,p be eampkies!by eby or sown ofJfe/o(
City or Tows: Permit/Lleeate p
Issuing Authority(circle one):
I. Board of Health L Building Department 3.CleyfrOwa Clark 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Persoa• Phone S•
Information and lnstrucuum
Laws chapter 132 requires all employers to provide worker' compensation fa their empieysee.
Masser is defined as"...every Puna in the service o[another under any consul o[hits.
husew General
Pursuent to this statute.an saspfeper
express at implied,oral as wrinow,
asweiaCa4 aarparadtea o°�legfl w'ry'o any two a most
Ate�seplo w is,defined as"as individual.Wton�hip the m.co r or lion K 1 of a deceased employer•of the
of the foregoing engaged in a mtepeiae. employee. However the
aoocludi s or abet peel�•C°splOy1°g
receiver o trustee of as indnvi"penaesh* red who resides therei4 or the amps of the
ownerof a dweiliag bouns having Oct rarer tbm thras haso"to do owntonaeM wart as such dwalliog haw
dweWu*hew of amrbr who ampbYa thneseot shall net because of employment be deam°d to be as empbyar••
0 on the grostide ter building apPn�nt er toed tleeasbag agerry,d"wkhhek the hse"us s or
MGL.chapter 152.4�6)also saw that"'very sat War
t operate a bushws or a eessOud btdidirp b eM m�erwaahte ter e
renaral of a tl b" ter p ma auht ed,SeCOVU&M evldrate of campoanes with tb basrrare eoveep rainy ed'":lull
apdwooally,M(iL chapter 2=7)sum"Neither the eommonssealth o[wmpBanee Wit d jet political h ne
eoauret fbr the perfamanes of pubhe wok until awepub
enter 010 le evidence regal enum nwo
s of this chapter ban been presented to the courting authory"
ApPOC"ta checking the boxes that apply to'Yaar situadaa and.if
the workers'compensation affidavitsca(
with their astit3eaa(a)of
please till out s)namapb addross(es)and phone numbe(s)along with ir employsas arbor thaw the
necessary.insuran -supply Liability Compt!n+sa(LLB tee Limited Liability Partnership(i LI')
_ , If ffi LLC or LLP doe haw
advises wakes COOO° of bsdustiial
ntemberr a paetnetei are net r& Bea the this affidavit may be submitted to the D"ubneot
employees,a of and data the affidav% The+ abQnb
Accidents for ccull"nerleatcoveragr Also be are a alp Wing requesuid,sot the Depu meat Of
re
turned anned to the city at town that the applieaaan for the pebig the la or Ucam isif you an required to obtain a worker'
Industrial fib. should yet have any gttagtara
regard
their
conwmmdim poft.please sell the �number listed below. Selftitesured companies ahteuld suer
self-iaavaoae Heroes mnnbar'aa the
SHOP
Ciq or Town Officials a ours at the bomom
se b
Pleae sure that the affidavit is complete and printed legibly. The Dep u°se°t provided
of the affidavit fa you a!ill out in the event the Office of investigations has a contact you regarding the applicant.
Please be sure to till in the pemiVIiaeme number,which will be used as a reference mnmbw- In addittoa.ter applicant
picatloos in any given year.need only submit one affidavit indlcaft current
that must submit multiple PemWiiaev°ape the a ,least should write"all locations
in —(city or
policy informadoti(if noceseery)at h unbar Job udl Abates:' or marked by the city a town may be provided a the
town)."A copy of the affidavit that has been oflki�Ifaurs stamped a lkmw& A new afudrvir must be filled out each
spphcaos se proof that a valid affidavit is on rile[a license or f no related a any burlier at aammereui venters
Yew.Where a home perms or burn l is chainingto lea this affidavit
(i.e. a dog liemu or permit to burn leaves am.)said person is NOT required comp
ns would like to thank you in advance for your cooperation and should you have any questw"
The Office o{ytvatfgatio
please do not hesitate to give us a call.
The Deparument's addrae6 telephone and fan number.
The CownwaWOM Of MMwbn9ft
Depumeffi of lndtl*td AmderM
offte d11evadgaloOf
600 wasliMSM gftd
Baden MA 02111
TeL #611-7274900 W 406 a 1477-MASSAFE
Paz#617-727-7749
Rcvised 5-26-05 www.IDmSov/d1i