260, 256, 259 LAFAYETTE ST - BUILDING INSPECTION IM:A M 1d"ST-9E fIL{8--AN9 APPROVEG 8Y T44E
.1ASPEGT0-R PFWR TD A_PERMIT BEING GRANTED
CITY OF SALEM
NoL Date V
A
Ward—�_
� mriecA' Zoning District
Is Property Located in Location of `
the Historic District? Yes No_ Building 1 U
Is Property Located in U
the Conservation Area? Yes_No
BUILDI P RMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Rero f, Install Siding, Construct Deck, Shed, Pool,
Fie lace, 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: _ n
Owner's Name a r ��a � , , , - r 7� ��.. // 07
Address & Phone 9o� .;�� , � (�i7A) ."37�/- �152 c 2-
Architect's Name
Address & Phone
Mechanics Name
Address & Phone II
What Is the purpose of building?
Material of building? b uRi If a dwelling, for how many families? J
Will building conform to law? Asbestos?
Estimated cost_City License ft State.License a CS
Name IImprovement
Lic. f
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
F
1
1
No\aL-E
APPLICATION FOR
PERMIT TO
erm u
�4�r ,y�,�,'� /Jrig✓a�
LOCATION
PERMIT GRANTED
`2 19
APP OV�D
0
INSPECTO OF BUILDINGS
Commonful:a(1Jt of IllaasaAAchuss�e ,
7 JJ.pa.Gn..tef�elaalrial./lecw.ls
boo w.d;.16 SWd
a.ma 1 uarOwi &.1••e M... " 02111
Workers' Compensation Insurance AffIdapit
. . with.a principal plane of business ac
do he reby•cestily under the pains and penihies of parlay, thm
1 am an employer providing workers' compensation coverage for my emPhWees working an
J this lob. //�`L
"InsuranceCompany Policy Number
I am a sok proprietor and have no one working for me he any capadry.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and hove hired the
contractors listed below, who-bave the fellowitg workers' cornpensatfon policies:
Contractor Insurance Comparry/Policy Number
Contractor Insurance ComPstty/Policy Number
Contractor insurance Compavy/Policy, Number
() I am a homeowner performing all the work myself.
• I Yno"Wac eau s cm a("wcansm w.be ier wfte WON Once el Imedeaoam of ON 0IA iw corerare nrlicaew Owen blot/w Moore
cowearr as sewwre enoo Sedan 25A of MGL 152 can kid ce Ow invewiw of viA Oenade eacaewrt of a h"ea n wi 1.SOO.00 rWer ow
rears•ivPwwnrnrnl a no a cm ocnawas in One form of a STOP WORK ORDER ma a fic or $100.00 a an atairc we.
Sirned this • '30 day of
. icer.setiFtrinittet ouildin; Department
:jccruinf Eoarc
Seitamens Office
ne.stth Deprr:men:
PUSUC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM,MA O 1970
' TEL (978)745-9595 EXT. 380
FAX (076) 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,S 150A.
The debris will be disposed of at � g
Location of Facility
-ICJ-OL(
Sigratum of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
r
Firm Name,if any az
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.