303 R LAFAYETTE ST - BUILDING INSPECTION 'PLdW0B"T11EfAA94AD APPROVED BY T4IE
=PFCIOB.PWOR W A''PEAW AKINR GRANTb
CITY OF SALEM
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Is P omly LocaW in S ou
Ma C w@rA"Ada? YM Plo Permit to: —
BUILDM POW APPLICATION POW
(Circle whichever apply) Roof, Reroof, InsWI Siding, Construct Deck, Shed, Pool,
RepairlReplaos, OUner
PLEASE FILL-OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSIM
TO THE INSPECTOR OF BUILDINGS: '
The UMWSVW hereby applies for a permit to build accortLig•to the tftwing
� ..
Owner's Name fy) or - Pe � 2�a i T7
Address a Phone 3 3 (Z L R(- a e i -4 <- L 9h )� 4 4 - (; 9 Y>-
AmhitWs Name N
Address& Phone W //n
Mechanics Name �� e� / / �/,ZL, y� L,
Address 3 Phone `l Flo e c w s r 3 So 1 ems.. (91 n 1 7 Y 8 j'3
What Is Oa pgms it buNdYip? t)a r
mmmm W bWdrg7 N a dwNMq.for how many kwan?
wa b Adhg om nn to haw? Aaaaoa?
tEwn ftd cod ,o> — CNtr Liatw• atar LbwnN♦ C S y i-��
soma E .�vaaase _
ru. s 6
SO-Oure o Applicant
' THE PEP"TY'
OF PEPJM
DESCRIPTION OF WORK TO BE DONE `
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�� � �PDAf/ ��/� �' YU1✓A/�-Pil u'L1'l��C'o�i�y
MAIL PERMIT TO:
I
No.
APPLICATION FOR
PEFWr TO
,p,o9
LOCATION
PERMIT GRANTED
7) Rov�D
INSPECTOR OF BUILDINGS -
s
QD
CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
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 aclmowledge 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: `/ F19 re Ace , Aj R"'b S v Re w` I�s C/ ; �f k-
7 Location of Facility V e b + ,—
l�
Signature of P 7
't Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
�5�;' c- /�-e tiz'-)
Name of Permit Applicant
V� �- gi'I
Firm N e,if any
Aftess, City dt 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.
The Commonwealth of Massachusetts
G��. = Department of Industrial Accidents
office 811fiveseaven
600 Washington Street, 7`a Floor
Boston,Mass. 02111
y.../Workers'Com ensation Insurance Affidavit: Buildin lumbio Electrical Contractors
name:
address:
city state zip: phone#
work site location(full addressl:
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ 1 am a solprietor and have no one working in any capacity. ❑Building Addition _
❑ 1 am an employer provtdmg workers compensanon for my employees working on Ihls fob
dd
i r
r =g. e•X'r at-��',�6-�" +f� 'avt `rv4��+"��� _ #.. f,✓$ ,•. ** . '
blti �trH.
QItV• ,` � � �&..o.`n .,t3^ie ,��.�^Y�vYyt+xra.#e 53 �"4�,.�,� �nrdy H1 '"*x ^+. �ro*`Ytxt �+5���3�
x,> 34�"a;
in - r .a.
�❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
comnanv name-
address:
city oboe+&W, T
xa
*7 #u b 'i,. $.-,p ''y�i `F3'Y}'iI Z' �yl+`}
m tan
mtt » :Mx'tf5=X srR=y�4q{P"faa4+ al�ta33 #7tiq+ & e t, "= �.'', :r�r
company name:
address: _ :1
009
clip. 6
., _,.'x 1 ;,� +,'y`. tbf s$,' '. kft'�'4`'�"`"�+*w ` 3-}� �e 1•.+3k—
Failure Insecure coverage a+required under Sectiou 25A of MGL 152 can Ind}to the Imposition of criminal penalties ors fine up to SI,500.00 and/or
one years'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand tbst a
copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties ojperjury that the information provided above is true and correct
Signature Date
Print name Phone#
Lcontactrpenon:
nly do not write In this area to be completed by city or town oNclal
permitilicense# ❑Building Department
❑Licensing Board
mmediate response Is required ❑Selectmen's Onice
❑flealth Department
on: phone a; ❑Other
nt