303 LAFAYETTE ST - BUILDING INSPECTION CITY-OFFAL --
PUBLIC PROPERTY <.
' DEPARTMENT '/r - ��'
ICI\RSF U cv DRISCOLL /� /�' `� / (t 6,
MAYOR v 1�W,�wtHcrcu+!''IaF.er*S'�:,�itiS0Ht:st-1-rsO1970 l„�TTVV ^�
17:i 97&74S-9S9S♦FAx:97&7a0-98" ,p//� /�'-
APPLICATION FOR THE REPAIR. RENOVATION. CONSTRUCTIOIIIY
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: /fir- ( IQea Building:
Property Address: ?C3 /�e, Ica,yr,��
Property is located in a; Conservation Area Y® Historic District Y®
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: /'lei'- e-
Address:
Telephone:
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 (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
N�� rv�bd-� rnco�
Gai7� 2 t�r�
Mail Permit to:
f _
What is the current use of the Building? V2i
Material of Building? If dwelling, how many units?
Will the Building Conform to w? Asbestos? (/d
Architect's Name /Iz
Address and Phone )
Mechanic's Name
Address and Phone
Construction Supervisors License# d fa F41 A HIC Registration#
Estimated Cost of Project$ O Permit Fee Calculation
Permit Fee$ 33 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 pe►jury X
Date s v 6
of
y
pI .Iw
L I
FF •� a C7 � � `'
- -- a - o-- - - - -- - - - --- -- --.—
L -
CITY OF sALEM
PUBLIC PROPRERTY
DEPARTMENT -
rautaatcnr t>ttt9t:occ
NAvoa uo WAs wacrcessmw a secs,MxACMWM01970
M&'9W45-9S"a PAn:9W40."46
Worlmrsa Compeasatloa Imuraaee Affidavit: Buildet's/Can&" Item
Aontkaat Information eal is.4we r eidbly
Name Pr 1,4& N
Address: 7 5 zlrc w av( s f-
City/3tatc0p: S s, /144- aP??O Phone
Are y employer!Cheek the appropriate beat
1. am s employer with 41 4. ❑ I am a general conautor and IF03Romodelino
(emPloyers(fan Anwar paetrtimeNo lave hired the atdt-osnaceera =dM
2.❑ 1 am a sofa proprietor or parmao- lined an the awehed sheet.t g
ship and haw no employees There s haw working for me is any Capacity. _ W-101C 'comp,im eno(Pin workers'Camp.insrance S a are a corporsdan and its ddition
required.] , ofilcera have eaerairod their 10.❑Electrical repaits or additions
3.❑ I am a homeowner doing all work right of exemption per M(ii. 11.[]PWmbmg repairs or additions
Malt (No workers'Comp. a. 1S2,11(4).and we have no
insu�required]t employees.(No workers' 12.[ oof
c'mqL hmtmn sequized.1 13.[3 Other
OARYWPMATA OWN dmch boa M=001wMaeorredm War showhq j*Wo*w .
Hamaorsr wM adrb Mb�bdlaey sty a dobs as rack sad err hie GOW&o o0 duhdb rrekal�Otr _tCaaeaerr, ear dneh Ihb boa areal amaeAoe addAlaad shay aAorlae IAa agar der sub caaaaarr sad edr wabwe'eamF DOOM hdMandoa
.r an an empil*w lwjorwatlara slot 4Pro 1r/werte�n/'�eowpipnaBoa lwsrrwactlor Cry eerolopesa, Below tr owPo&7 aw//oi sAw
insurance Company Name �/ - /or
Policy N or Self-ins.Lie.err_ _ S�vG U, l e U�.� j7��
Expiruion Date.-4ZL
6 O
Job Site Addreae Zr ��� City/State/Zdp GY�i 7/�
Attach a copy of thi worken'compessadon Policy declaration Pap(showing }
160 Polley number sad e:pkatlea dab
Failure to AMC=wveragi as required under Section 2SA of MOL a. 152 can lead to the'
fun up to gi•500.00 and/or one-year imprisonment,as well u civil motion of criminal penalties of a
of up to 3230.00 a day against the viohuor. Be advised that a �ea in the form of a STOP WORK ORDER and a fins
laveytigatioos of the DIA for insuranca cove e a verification.Copy statement may be forwarded to the OtVW of
I do hereby card& and panakfa o/Per/wrp dray the la/orsrwdarMavl&/above 4 aw/cMOMMME
� o
Phone#* z- S'�
ojjldd are oa/It Do Mot write In th4 area.to be cowtpkW by cky or man odfc%(
City or Town: Permillueaw fl
Issuing Authority(circle one):
L Board*(Health 2.Building Department 3.Cityfrowa Clark 4.Electrical Inspector S.Plumblag Iwpeetor
6.Other
Contact Person: Phone Y•
information an(Linstrucuum
ytuyaohusetn General Laws chapter 152 re P*u all employers to Provide workers'cod".". a ny yc connect of
their employees.
Pttrs out to this me^an�pfeyq is defined as"...every Person in the service of another under a hire.
..press a=VhA oral at wrince
,,a define as an iadividtral,pardtashtt#
association.eorpaadm or other legal eonty'of any two or mace
An ORWISP emend eospluyer.or the
the foregoini than gttd in suns canggrieM.and mehtding the h:g+i f a the
of 0(an ism PUMUshwassoccistiaa sed�wha rosiest&Smin. of the
receives a dense. g buses having trot .three wodt as such dam meM
° at other w��P�m do msineaaoa.won o f
at on the Pounds at building RVINteoans t shag Ma beeaun at seep emploYmmt be deemed m be era employer•"
en thee aVWy state er beer!iscesoft avmy shag wMdd the be="a
MClL a Wm 152.12=6)a er to eentpraet bW~Is the cesseawea th far a"
al
renew of a am"K P ,"m eonpraaca with the bssoranea �°If ed'
sot who has am preaseed acceptabledkathe commonwealth'tat any of its politics'arbdividnns r
�pdtiooa'1y,M('L ehapeer 1s2,$25C(n wait Una aaepW+'e evidence
aroomPliaoce WA ere imwanca
into my
rw
�thie c h"'a presumed to&a a a�0fi1Y•»
APP��b r3eclting the boxes that apply to yoor siatation ate.it
Plasm iH att the workers'comps)nmo°affida re nuniber(a with their cartiffoam(s)of
necessary.suv*sub'Convae�(M)°atne(sb add<ns(n)and Liability
Parmersh"[Lim wi&no the
ina"I M. Litaissd Liability CMP!mas(I'� �aers If an 1=or W don haw
Members pszuW%am uot required m cacrybmitted to the of htdttstfial
as is requireL He W at i s� to the The aflldavit shout!
Accidents for a iOnfance P° a Howes is bab*requested,Met&a Deperea�t of
be manned to the city a man that the sWHtwaon the law a if you are required m ottttia a workarM'
bow vial,Accidents. Should you have any qM regarding
compeotatbs policy.plans ail this Deptwettteo<at the numbs Hated bekrvf. Sel4iowrod com their
panin should
eel!instaaan Reenter tnmtber an the
Has.
City er Tswa Offkisflt
see Pied leash• provided a spotse at the bottom
Please be sure that the affidavit it comp has m contact Yon regarding tits apPHCent.
of the affidavit for you m fill out in the every the O hiel of Investigations
number which will be used n a reference numbs. be additioM,n appHeant
Please be sure m fill in the permit/licede tteations any given yaer.need only submit one affidavit indicating current
that must submit multiple Perouf aWdw a Hcant should write-all location in
policy mfa�(if neeesnrY)and under" Site Addraa'• W
a marked by the city a town may be provided m the
town)."A Copy other affidavit dart has been ilefi r A stamped a licam . A new ain&vu must be tilled out eseh
applicant n is on file fa lbrtae Permits
proof that a valid affidavit� s lifanse err permit not related to any busmen a eommarCul Ventureyear.Where a home owns a eidzen is obtaining NOT re of rel to twmplow this affidavit.
(La. a dog HCena of Pan*m born leaves Cie.)am person is
The Office of iavestigatiOtu would like to thadt you inadvance fa your cooperation and should you have any gMeanons6
Please do not heaitsm to give us a aH.
The D.�eat'a address.telephone and fax nttmbss
The COMMawal th d Masuchuse"
of b& [gal Accident
Of fte d hmdlpded
600 W ahM OM Sneefl
Bagwa,MA 02111
Tel. 0 617-727-4900 cd 406 at 1477-MASSAFE
Fax N 617-727-7749
uvised 5-26-05 wwwjmaa pv/dla
J
CrtY OF SAI.EM
PUBLIC PROPERTY
DEPARTMENT
MAVCS �sowloNs+ms.sun�x...oa�+smn.
Coas&mdom Debris Disposal AAWsvit
i< 21 dmoudoa sod movadom wade
in eooard ooe wide du e e 44 t ie �mg CWk 7SO C MIt seedoa tt l.!
��' _ to Imod wG►do 000d[doa did da 1 A ns dbs AM
B�lrfndt d
clde a►adt iball DedisooNd atia a DO4►aaond weave di�ad Aoiltt�t ae deQmd byl�(taR.e
1ll.S15"
The ddx1s will be vmWoMd br:
The dobrie will be disposed olio:
(crams at hailil»
(a wma of bow"
�aat�m a!
�o s DG
v
'dn,rYJua