245 LAFAYETTE ST - BUILDING INSPECTION �ItiSfi-eE fH, --E iND;A?PROVED BY T44E
.WP,XTD-R PMDB Tp.A.PEAMT BEING GRANTED
CITY OF SALEM
No. LI Z 00 y�`' \' Date
� -
'
Is Property Located In Location of f
the Historic District? Yes_No_ Building gq 0 =Z(j:jS
Is Property Located in
the Conservation Area? Yes_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, 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: llQQ \\
Owner's Name � v
Address & Phone 16 �� (�D'✓l
Architect's Name
Address & Phone ( 1
Mechanics Name
Address & Phone
What is the purpose of buil ng? 1��
Material of building? If a dwelling,for howl any families? CJ,L)
Will building conform to law? P ' Asbestos? mod/1)
Estimated cost ( cJ0 City License # N A to License # 7-QV 1
U, # o ,e iq , 'lure of A lican�
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
de,-+ � �A �Gi�rl✓7r���
MAIL PERMIT TO: K&002�q �v 21 a. MApiey MA N,112---
No. 2 y Z-Z 00(-(
APPLICATION FOR
PERMIT TOO
LOCATION
PERMIT GRANTED
2.6
APPROV�D /
(/ �jsr,�✓ / v
INSPECTOR OF BUILDINGS
OF SALEM. MASSACHUSE775
v6� PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
y SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
FAX (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
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S150A.
The debris will be disposed of at: I A locationfFof c t
of Fad' i'ty
Si store of Per t Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit App ant
Firm Name,if any
TO
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 cM, S 150A, and the building permits Or licenses are to
indicate the location of the facility.
fommonwr:aLfh of Massac�wetb
sa'
n n F /1 .1
� �:Jepailnaa f
n� 600 ryWssLylm �baaE
James I camood UoaloM /,/as'60� 021 It
Corrmrssroner
Workers' Compensation Insurance Affidavit
(avr..rrc�ecl
wirh.a principal place of business at:
2S6 Y�A1L)eJ a >k - A1�� -n�r rv�P� e c�ar4
. . toniae+r✓a4n
do hereby certify under the pains and penalties of perjury, that:
() I am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
EJa 1 am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general coniractOr or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I onnruaru wt a coot' of[his avtmrcne w%Ds ion aroed m the Office of Imoceavoru of the DIA for co+acare .eeiruacon and out(aims W$care
co erarc y revived unaer Section 25A of MGL 1 52 can Iced to Inc :rwosr,on of cr'vniroi ot"Oft co�suont of a low of no odi I,SODAD wWw ON
years' rarwnmrnt v wxn as cw ""ILiu in the form of a $TOP WORK ORDER ano 6x of S 100.00 a am $tarot ant.
7
d this day of '
v�
i_icc {sc /Fermittte building epalZn+e
/ Uctruing board
Selectmens Office
Ht2ith Department
^?: C L` X4C�_ . toe e0�, =0°� 775
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