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303 LAFAYETTE ST - BUILDING INSPECTION (2) What is the current use of the Building? nU" Material of Building?i6 �'^ srov M dwelling,how many units? Win the Building Conform to law? Asbestos? Architect's Name Address and Phone ( ) Mechanies Name Address and Phone Po C3 0 Rio&s— Pe fl Go 0-/ O a C19� construction Supervisors License# R70U 3 HIC Registration# Permit Fee Caleulatlo Estimated Coat of Project S 5 GO -� n Permit Fee$ ) © ° Estimated Cost X S7IS1000 Resldential Estimated Cost X 541/111000 Commeroisl— An Additional Ss.00 is added as an Administrative charge. i 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 a above t fed -7 1 ' specifications. Signed under penalty of perjury X Date /z7 0 S ` W � r � a v 3 a PUBLIC PROPERTY DEPARTMENT 4 /:I.�NFFJWY DRLSCIMl �rwYOa 130 WA%umcnw hit =•&•�`'-s%rwLAo&s6ll3 01970 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: C (y suilding;------ . - ----- - Pn�perty Address:--------- ----- --------- - ------- - L l G, Property is located in a:Conservation Ares Y/N H OlaMd YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land ` Name: R PELL 7 T1 J3 cZ Address: ��(c-wi '✓�'1✓� G 1�1 G Telephone: - - F- / 3.0 COMPLETE THIS SECTION FOR WORK IN EnSXING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Rriet Description of Proposed Work: N'�e r'c� �C•Tc��1 r_ (v ►G STC I 1 E ry CGcsl lT� g¢jS E o-q�C I . C Y�) bs,rq eTS , "u --- Mail Permit to: ��,- 6�G� 1-IC'��5- P E ,4 c�o� v dv� 0 1 C1(0 - -- -- A CTTY OF SALEM PUBLIC PROPRERTY DEPARTMENT .hobo atsr txntstxru It4vwra In•awt.*oatMSr%v"a Sh wt.ltasssaamitis011TJ T►L M?45-"% a F.%x:9W40AW Workers' Compaallatloa Easursaee A(Wavir BuilderL4Coatrw"wLlElftvidansq%meers Aa211eant Informadoa so Print r *e Vartte latraitteaaAOtRaeirariOntlrrbv�q: :10 Hn� /J/Q/�r�`f9D�J Adata:__0� . City/SzMWzip: , 41 aft'l Pepe Are yoo as eapksyer?Cbeek the appreprk w bore Praia"(�� I. 1 rrtr a employer wick 4. 1 ant a JD eenitaetor and! ELM of set employees(rull antd/or lawtitne).• have hired the sub•eorsractors 6' 1•ae coraxrtretsas 2.0 1 am a sole proprietor or partner• listed ere the attacked shoat•t 7. ❑Remodeliaa ship and hsys no attployaae Tbon bow rL 0 Demolition working for me in any capacity. workers'COMP• innrrarroa (No welters'COMP. . name S. 0 We am a corporation and its q' ❑ �adtlitim rorptiretit) otTleen have examined their l0.0 Electrical repairs or additions 3.❑ 1 am a homeowner Joins all work riSW of exemption per MCL 11.0 Plumbins repairs or additions Myself NO worfecn'comp. e. 132,#1(4),and we have no 12.❑Roof repair insurance required j ► emPloyers(A'o workers' comp insurance t wdmLj 13•0 Otlrer ;A,ty+PPhao dwo cltsaie tea rl now also an aw dw notion Iwb A w owiy their awhon'ce ngarrwba p•li•y Winnow" Posheownens Cob submit a is aAlearii Gtlothti ttwr an doing am wad end than tdta nMbeewaaara mw awbnb a now amdwn rower"+One ehadt this bas sues aroahttd no addidmal Am showing too Mesa of Oa rab•watrana 1Yp'h•n'••�•tbkr i a and that awtl ssm oo. unt A jY deue easiolopor that&pren4silesg winitonso coapensaden Guonger jot any employers Bdow Is Aki poHa7 wrr/job sft Insurance Company Vanw. Policy y or Sa1G-ins. Lie.M _ .. Expiration Date: lob Site Address: Cityislaietzip: %track a copy of the workers,compeasatltin pulley decWtolloa page(showing the policy number and expiration date). Ifloluro to wcum coverage as required under Section 25A of-%IGL a. 152 can lead to the imposition of criminal ad penalties or& (I lie up tie 31.500.00 wwor onst-year imprisomncni,.s well as civil pertabias in the form Ora STOP WORK ORDER a a tort of up to S250.00 a Jay agrinil IIu violator. Ile advised that a Copy urthis siatamcnt may be turwarJetl to the UOice ur bbr;.ngauutn of Lhe DIA for insurance cncragtl verification. /Jr.herrbF Celli&uu and peas I Ojpr 7 tker the lajormW/on p wrided e / eat rnd courts <i�•n:rtur� ? /2 7 O/Jlrief art ua//t /�ra wait/M tkb airs,to br romp/dsh/Ay[Nyar Ieest oprt%( City or Town: Pcrmit/Llecsss M_ IsauinR Aulburily (circle one): I. 114pard of Ilealth Z. Building Depunneut 3. Cilyffowo Clerk J. Electrical Inspector S. Plumbing inspector G. Other Culllael Pcnon: . ._ Phone p: a Information and Instructions Mass achamsetrs Generai Laws chapter 132 tequirft all anPloYea o provide workers' e�anmpe�+t�any eonrraet n fat their etA� Pursuant o this aanue.au enV i o is dafhwd tee ...every prates is the service espress or imo'A oral or written _ am oe adm o opmad" other�entity. m to two or mote atftsdt/it errs"term irdN' �P�►� k�representatives of a deceased employer.owever t� receiver or eta wn of as atdividasl.pattobship.assoetatmoa of other legal estigr.�PbYvtg °yeW of alo lamas baving east mare the s tkwe sperastema teed who tatidet dwrais.os the eoeupatd owed ofbouss aosdbt who enPlaYa Persons eo do m n.aisoesss cumstructioa or repair work oo such dwsUisg haw or an the grounds or builditag aPPtabatM thgrew"One beea see of salt seeplaymalt be dreamed 0 he as employer. h1GL chapter 132.+12SQ6)also atsas tom"s°U7 stab sr bell liesssing army tkatt with"M tM basanee sr rsaswd sea festers K Permit b ePsrab a btsltsm K b eosatrset bttildbgs Is tM dtamwwssW far ssly tatsA seesPtsbb svMdssee of camprsaee wkh the im ars ace eovsnp appllessa wM W test prod am asy of its Political suiwivisiaess A" Ar�tlosaliy,MOL chapter r321 s� ublic work uanl accepts in evidence of compliance w irk the ins urmee enter buts a"contrast b the contracting sudtority" of this chapter have bias Praemmted Applicants • aRidavlt eomplatelY•by checking the boxes that apply o your situation tend.if Please fill out time workers compensation s along with their certiticate(s)td ns au=Y.supply S)narneW'address(ea)and phone number( ) ng with it employs"other than the insurance. Limited Liability Companies carry of Limited L1a ns ti Partnerships Ps l oat not required b workers, msaursmee !t an LLC or L[P does lbw ample e k ppolicy i Be advised that this a@idavk may be submitted o tM Department of Industrial employees.•policy b ttion ooed�e coverage. Abe be sun b sign sad date the amdaviL The affidavit should Accidents for thecit or confirmation the application for tha permit or license is being requested. not the Depattemanr of be returned te the city or tows that PP the law or if you an required o obtain a workers' Industrial Accidents. Should you have any questions regarding y should eater their compensation Policy plate call the Dopet®am at number listed below. Self-bmu d compantaa xelfinwrsmcs license number on the City OW To"ORklab .t I i The Department has provided 8 space at the bottem please be sure that the affidavit is complete and printed { n of the affidavit for you to fill out in the even the Office of Inve estigatiaas has to contact you regarding the apPliwtt parmitilicense number which will be used as a reference numbet. in addition,an applicant Nlcasa be sure to fill is the that must submit multiple pensit/licerrse applications in any given year.need only submit one affidavit indicating cwTant licof y information l if necessary)and under"Job Site Address the aPP po Ucant should write"all►oa arises is__(ciq town).-A copy of the sfndevit that has been officially stamped or marked by the city or own may be provided tothe each applicant as proof that a valid affidavit is obtaining fib far jitlicense Penn nit not related to any business ofommercciallvventure year. Where a hams owner Or cluzen'Abum lsav said person is NOT required to complete this affidaviL (i.e' a dog license or Permit t'hc OI t ire Jt e for your cooperation and should you have any questions. Investigations would lie to thank you in advanc Ieaae du not hesitate to give us a call. The pcpanmrnt's address.telephone and fax mambas The Commonwealth of Massachtisem Department of IadustrW Accidents Oma of Investlpftd No washinow Shear Bostoe,MA 02111 Tel. 0 617-7274900 ext 406 of 1-977-MASSAFE Fax 0 617-727-7749 tav iacd 5-'_6-US www.mass.6ov/din CPPY OF SALEM PUBLIC PROPRERTY DEPARTM- ENT ,..vs at at''aa.+`t� ]Lt��• l!t tL�sw�:auti�ttaT j�LF11.1Q�YNYwatlb%4r. Construcdos Debris Disposal+ AtYidsvit (required fix all derwtit m and&OW110tiaa warts) ln.=Qwanea with the six&edition otthe State 13u W1"Coda;DSO MlA smdon 111.5 pelvis,and dw pmvisiam of M- CL a 41%S Sk SWIAV4 Parmh A _ _ is isnted with dw condition due the debris rauldnS ftm ibis wait shall be disposed of in a property licensed waw disposal ftteility as dented by%tGL a t 11.s IS0/1. The debris will be transported by: G�r4�rA� �vY9s7� taaw.�t t,attt.A rho dcbr►s wilt be disposed orin : . (a:unteuYfxtGty)� - ,...r:rs,t. ..W i DEC-03-07 11 :02AM FROM-E A STEVENS CO 1T81-397-7ST2 T-713 P 001/001 F-994 ACORD. `GERTIRPATE OF LIABILITTIN URIA:NC 11/28/0 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE E A STEVENS CO INC ND. EXTEN HOLDER- LER THE THIS AFFORDED BES YTTHE EPOLICIES BELO- 3 8 9 MAIN ST BOX 188 COMPANIES AFFORDING COVERAGE MALDEN MA 0 214 8-5 0 7 6 COMPANY A CENTRAL INSURANCE COMPANY INSURED B JOHN PANTAPAS - COMPANY C P o BOX 4065 PEABODY MA 01960 COMPANY D COVERAGES . .; _.. : .. .. _. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 THE INSURED NAMED ABOVE FOR THE POLICY PERTHIS IOD INDICATED,CERTIFICATE MAY WI HS ANDINSUED OR MAY PERTAIN. THE NSURANCERM OR OAOFOROEDITION F ANY BY T OPOLRACT OR IC ES OE OTRIBED HER OEREINNIS SUBJECT RESPECT TO ALL THETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS POLICY EFFECTIVE POLICY EXPIRATION LIMITS co TYPE OF INSURANCE POLICY NUMBER DATE(MMIODNY) DATE(MMJOTY) LTR DI12 23/06 12 23/07 GENERAL AGGREGATE s2 , 000 000 GENERAL LIABILITY 7989264 PRODUCTS-COMPIOP AGG S2 , 000 000 X COMMERCIAL GENERAL LIABILITY PERSONALS ADV INJURY 51 , 000 000 CLAIMS MADE ❑X OCCUR EACH OCCURRENCE S 1 , 000 , 000 OWNER'S S CONTRACTOR'S PROT FIRE DAMAGE(Any one pre) S 5 O , 000 MEG EXP(Any pnP PP,fcn) S 5 , 000 AUTOMOBILE LIABILIT' COMBINED SINGLE LIMIT S ANY AUTO BODILY INJURY S ALL OWNED AUTOS (PAI pA.On) _ SCHEDULED AUTOS BODILY INJURY HIRED AUTOS (PBI Acclaonp NON•OWNEO AUTOS PROPERTY DAMAGE IS AUTO ONLY,EA ACCIDENT S J GARAGE LIABILITY OTHER THAN AUTO ONLY. ANY AUTO EACH ACCIDENT S AGGREGATE S EACH OCCURRENCE EXCESS LIABILITY AGGREGATE S UMBRELLA FORM S OTHER THAN UMBRELLA FORM WTORY LI IT ER WORKERS COMPENSATION AND EL EACH ACCIDENT i EMPLOYERS LIABILITY EL DISEASE-POLICY LIMIT S THE PROPRI ETORI INCL PARTNERS)EXECUTNE FL DISEASE EMPLOYEE S OFFICERS APE. E%CL OTHER DESCRIPTION OF OPERATIONSILOCAnON ENICLEVSPECIAL REINS C CANCELIATIOM: .; E;BTIFICATE:.HOLDER - . .. . . .. "' SHOULD ANY OF THE ABOVE DESCRIBED POUCIE9 8E CANCELLED BEFORE THE MOR-PEL REALTY EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, AYAY> TTE ST BUT FAILURE T AIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY 303 L MA 01976 OF ANY I PON THE COMPANY- ITS AGENTS OR REPRESENTATIVES. SALEM AUTHORIZED ESENTATI p p MB A oAC4RD PORPORATION:4461 .a4C411:11® CERTIFIC�►TE QF INSURANCE °ATE'"M,°D,YY) 12 L'_07 -- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO`I PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATfc EXTEND PARENTE INS AGENCY AT ER THE CODER. IVERAGEIFICATE A FORDED BY T EDOESTPOLICII S BELOW. OR 94 LYNN STREET COMPANIES AFFORDING COVERAGE PEABODY MA 01960 COMPANY 22TCN A AMERICAN ZURICH INSURANCE COMPANY COMPANY INSURED MACFARLAND, ED B 36 WASHINGTON ST COMPANY PEABODY MA 01960 C COMPANY D CQVERAQES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDMON 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICYEFFECTIVE POLICY EXPIRATION LIMITS LTR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD\YY) DATE(FAM\DD\YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL UABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS MADE=OCCUR. PERSONAL&ADV.INJURY $ EACH OCCURRENCE IS OWNER'S&CONTRACTOR'S PROT. FIFE DAMAGE(Any one fire) $ LIED.EXPENSE (Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE S LIMIT ANY AUTO ALL OWNED AUTOS BODILY INJURY S (Per Person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Per Accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: ANY AUTO EACH ACCIDENT g AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ AGGREGATE $ UMBRELLA FORM OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION AND STATUTOFiV LIMITS X A EMPLOYER'S LIABILITY (6ZZUB-0660L91-6-07) 06-21-07 06-21-OB EACH ACCIDENT $ inn DOD. THE PROPRIETOR/ INCL DISEASE—POLICY LIMIT $ PARTNERS/EXECUTIVE OFFICERS ARE: X I EXCL DISEASE—EACH EMPLOYEE S 1 00 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESIRESTRICTIONS/SPECUIL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE C€RTIFICATE HOLDE[i CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE MOR-PEL REALTY ETPIRATION DATE THEREOF, THE ISSUING COMPANYWILL ENDEAVOR TOMAIL 303 Lafayette St. 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Salem,MasS. 01970 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LDUDUTY OF ANY KIND UPON THE COMPANY.ITS AGENTS OR REPRESENTATIVES. AUTHOMMD NEPRESENT AGORO 2S.S(3J93} vACOR()C0f7PORATION 1993