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241 LAFAYETTE ST - BUILDING INSPECTION (2)
PUBLIC PROPERTY DEPr1RTNiEI�TT KIMBERLEY DRACOLL �) MAYOR V 13D WASHINGTON S1xEE7 SALLsK AucnaHt:sEI'rs 01970 1FL 978-73S-959S 0 FAM 978-740.9846 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: ��Q f�cr�L Building: Property Address: �11 S4 . property is located in a; conservation Area YIN Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land L 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use 2-- New Demolition Existing Approximate year of Area per floor (sf; Renovated construction or renovation of existing building New Brief Description of Proposed Work: Ste, I� S� A 0L r o J2 (�y L� _ �/Q�kymV✓l �� ---M311 Permit to � What is the current use of the Building? &�,-fiil Material of Building? r�9 6 k � 11 � If dwelling, how many units? 2 Will the Building Conform to Law? Asbestos? °� .o Architect's Name Address and Phone ) Mechanic's Name MA V D r S o i N C— Address and Phone x0A)L 2 S Construction Supervisor License# HIC Registration# Estimated Cost of Project$ r"' 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 Permit to build to the above stated specifications. Signed under penalty of perjury of N O y N V 3 3� Vps > -- CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT iCA1aERI.aY i)R1fCOLL MAYOR IM WAUWCTMSTMT a SAUK MAMCM;WTM0lW0 Tau 97tt•745.95" a FAx:97a7to."" WorkeW Compensation Insurance Affidavit: Bnlldera/Contractors/Eleetridau/ph mbera AooNcaut Informal on 1111110 print Ledbly Name(Bu.ioewOrgaaiauonl2a"Anl): AAA t/fL0 C O I N C— Address: 1-1 Pe4t06 `1 � city/state/zip: r•1�+ © 1 g 6 a pine# q 7 7 ei 77 71 K- Are you as employer?Cheek the appropriate boss 1.❑ I am a employer with 4. Q I am a general contractor and IF[3RcmodaIjng (required): employees(fish and/or part-time).• have hired the sub-cons actat trucdon_-. _. 2.❑ I am a sole proprietor a partner• listed on the attached sheet t g ship and have no employees These sub contreotan haw nworking fame in a�capacity. workers'comp,insurance. ddition [No worers'comp, insurance S. ❑ We am a corporation and its req Electrical repairs or additions officers have mmrcised their ❑ s 3.01 am a homeowner doing all work right of exemption par MOL 11.13 Phrmbing repair or additions Myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Raotrepairs insurance required.]t employees.[No workers' 13.❑Other comp. W inrance required.] ��r appikwm a.e daadm boa el roar eieo ins am 60 ncdon blow AMIN nWr.a keu Hamawne who aubma"seldova igdlntlo,&W on ddna as wak and Aa ern aoWaa cOldlufte orm mie useWn&vk tCoaaaeton 60 cheek tide boa now saaehW as dditions!.bet dowioa do owe or do ad drk w,ar6ee•comp poft iorematlai. afil am oo tr that Is providing workers cowptnroafow intraraadoa inearanec jor my employees Below/s thePOAW and/ob.rlfo Insurance Company Name: Policy M or Self-ins.Lie.N Expiration Date: _ Job Site Address: Ci /S Attach a copy of the worken'eons nsadoa ry tate2ip: Pe policy deelaradoR papa(showing the pocky number and eaplradoR date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil pemldes in the form of a STOP WORK ORDER of up to$250.00 a day against the violater. Be advised that a copy of this statement maybe forwarded t0 the RDEIt and a fine of Investigations of the DIA for insurance coverage verification f do hereby cerdb under the pains and penaldes ojperlaty that the Information provided above is aaa and correct —LLL2 9L61° OJ chd use only. Do not write In this area,to be completed by eby of town o,QfelaL City or Town: Permit/Lleense M Issuing Authority(circle one): ' 1. Board of Health 2.Building Department 3.Cityfrowu perk 4. Electrical 6.Other Inspector S.Plumbing Inspector Contact Person: Phone p• r Information and Instructions Massachuuas General Laws chapter 152 requites all employees to Provide t service oaf another trader any'compensation for their ct o f Pursuant to tires ststun. y�jKs is defined as ...every person coated employees' an express or implied.oral or written ny_Or_ as'an individual.Partnership-associs�4 On er°�legal deceased or or the An esPteYp is defined g tits�representatives of a mpto employer, of the foregoing enpad in a joint enterprisea association a odor legal entity.emPi°Yi°i emploYtxa However the receiver or d inche tntstse of m individual,parnership. artragate and who resides tbaein,or the oWW"ofowner of a dwelling boom having the dwellingthat�ys n thasp��dothree or tau wont on such dwelling home err building appurtenant trees shall not because of such employment be deemed to be an employer•» m on the g shall withhold the Issuance er MGL chapter 132.12=6)she states that-every state er load 1leenalug agency renewal of a bittern or permit to operate a business or to eoastruct bdldlnp Is the commeaweatth for say ble svMemo of eomptlnee with the lassrrsnee aoverago regdred.» wits epta o has not produced &tatter-Neither the commenweahb not airy of its political subdivisions shag applleent Additionally.MGL chapter 132,$arrea of public work until acceptable evidence of compliance with the insurance enter into any conoad for the parfornence requirements of this chapter have been meted to the contracting authority» Applfeaab oon affidavit completely.by ehtxlting the boxes that apply eoyour situation attd,it Please fin out the wod3cOW c my�ansetor(s) .add end Phone somber(&)along with their employees mi ) aeceaeaty,supply name(&) or Limited Liability Partnerships(LLP)with en employeesloyees other than the maursoce. Limited mambas Perners,erne not required terry ins�e' en LLC or LLP does have to workers eompenmtibn submitted to the Depsflmem of lndustrw employee.•policy is required. Be advised that this affidavit may be pan Accidents for confirmation Polley isequ re insurance coverage Also M site to sip and date the aAldavtt. The affidavits ing mpmod.not die �d be returned to the city or town that the application for the permit Or law a if Y is ar are reQ tO°III a w°rkers Industrial Accidents, Should you have eras questions teaerta . Compensation Policy.Please cell the Dap�stm m` ltsinet° wed below. Salt-boarred should enter dick self-insurance license minder on the city or Town O®elab d a space at the bottom Please be sure that the affidavit is complete and printed of Investigations legibly. The Departm to contact you ent Provide applicant.g the of the affidavit for you to fill out in ee e whichmber ffke will be used as ahreference rutmber= �ti n.rn app� Please be sure to fill in t porter licadons is any given year,need only submit one affidavit indicating current that must submit multiple permiNi sou "Job Site Addceas"t applicant should write"all locations in_—(e1tY or policy information(if necessary) or marked by t city or town may be provided to the tows)•»A copy oft affidavit that bus been officially stamped or Ike by Anew aAudrvit must be filled out each applicant as proof that a valid affidavit is on file for Alone Permitsvrnem ear.Where a home owner at cwzcn is obtaining s license or permit not related to any business at commercial y to burn leaves eta.)said person is NOT required to complete this affidavit (i.e. a dog license of Permit The Office Of Investigations would like a thank You in advance for your eooperatien and should you have any quarions. please do not hesitate to give us a call. The Deparuww.s address,telephone and fax number. The Commonwalth of Masgaehusetts Npuft neat of Leuven'Accidents Offla of Isvadpdons 600 WaahinOw Sbvd Boato4 MA 02111 Tel. #617-727-4900 ext 406 of "77-MASSAFE Fax N 617-727-7749 uvised 5-26-03 WWW.mMgov/& ACORD CERTIFICATE OF LIABILITY INSURANCE °"'�' " n 10/10/2006 THIS C8MFIaWj9—W0 AS A MATTER OF INFORMATION PaODT - ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Richard "rtoiino Jr Ihsurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1200 Salem 8t •121 ALTER THE COVERAGE AFFORDED By THE POLICIES BELOW. Lynnfield, MA 01940 INSURERS AFFORDING COVERAGE NAIL i v�amED EvsuRERA Arballa Protection Mavros Cc Inc INaSI Trawlers Insurance 14 Gardner 8t jlN6UPERa Peabody Mass 01960 11NaIRER11 INSUfff1iE COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTH SaRD TYPE OP 80URI1NCE POUOYNUImeI mumeowm PD Y P'ODI111reY EXMAWW LEI A Dea9T UNNUTY 8306789098-06 07/15/2006 07/15/2007 EAcn ocw-ENCE $1,000,000 X CaLeAERCIALRENERiL UTY PREAl19F9(ES PCCvwIu) 11,000,000 X X cwMS MADE �occlm MED EIP tA,y Pn.Pw.�1l $1,000,000 PERSONALIAOV INJURY S1,000,000 GENEBALADDREDATE s2,000,000 GENL Afp{tEOATEUMMA ES PER PRODUCi9-COMProP A00 $1,000,00D Poucv JE°"ODT Loc A�O�pEga LyIEIJP, CpABINI])9N LIMIT $ (ES ACJENX) AMY AUTO ALLOWNEDAUTOS BODILYINJURY S Pa PNIOP) $LHEDULEDAUT09 HIREDAUTCS BODILY INJURY f (Par SpNM,tl) NONOWNED AUi05 PROPERTY DPMAOB f aAnAtaE Lw�D, AUTOONLY-EAACCI S ANYAUTo OTISiJITHAN EAACC s AUTOMY: AOD S ExcEmNT®RELLA UAaLT, EACH OCCURRENCE $ OCCUR ❑CLAIMSMADE AOOREQATE S S DEDUCTIBLE f RETEMION S f xorommDafsENSATIONAND 6kub 3774bO3-8-06 10/15/2006 10/25/2007 1 TORYUMITS ER EMPLOYERBUABIlTY ELEACHADCI E S100,000 ANYPROPRRTORNARTNfRE1�CUTNE OFFlCERAEABER IXCLUDEM EL DISEASE-EA EMRAYf:E s500,000 ITYM Um10l�vNR E.L DISEASE-POLICY UMR S 100,000 SPECIAL PROVISIONS MM OTHER - . DESCI®R011 W OPEMTONS I LOUwONSIVEISCLEs I EXCLUSmNs ADDED Br ENDORSEIffIRISP6aAL PROYIa01a For information purposes only. ti. CERTIFICATE HOLDER CANCELLATION This certificate is for information only. awls ANY a TIE ABOVE DEII I POLM.IES es fAlICH1ID BEFORE THE ETSE+ATIDN DATA TIaAEOF. THIS! ISmIBTD DrnIRFn wIL EHDEIIYOR TD MML_DAYe wwTTen Im1 m TIa Ce(TB w NOLDBR IIAraD TD TIM lDi. BUT FAIUAW TO DD SO SHALL Please call agent at 978-423-8995 with my aMther clwastiDns. DaD/E TO Oml0AlI0N OR LIABEJIY OF run ia'm UPON THE Vim, In AOFNID Oe REPRESENTATIVES. AMRRIRPID p6PRESBfTATIW Richard Bertolino ACORD 25 CTTY OF SALEM ' PUBLIC PROPERTY :t DEPARTMENT agree tasa►�owlrs�snnr•s.rn�x..�etawnnsotsrt t'Ms7L746430•!Na 17&74&" Coas&mdos Debris Disposal Al Wavit (required Ate all demolidos and mavades wodt) is aeoordom with dw sittdt edddos ddw Stft B Coda 780 Ga section It S OASK aid dw ptovislaw*(UCjL.a 406 S% gtundieg pft=m a to tamed wUh rift 000dtdes dtst dw de6rb teeull mg lunar thk wok shell be disposed of is a ptoperl,►deetmed 0 dtepesel 0ieilttlt s deamd by tom.e 1 l 1.S t30A. The ddwit wiU be transported blr: (Yme ottrridl The ddxie will be disposed of in: COM o[t'+eilittr) (addesss of ISeiliry) utwnw's alv�aLt�polie�at 1, due