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363 LAFAYETTE ST - BUILDING INSPECTION What is the current use of the Building? w Material of Building? �'� if dwelling,how many units? Will the Building Conform to Law? Asbestos? ' Arohited's Name Address and Phone l ) Mechanids Name Address and Phone -7 Constriction Supervisors License# OALI? 2: HIC Registration# / O®2 0 d Estimated Cost of Project= Perml Fee Calculation / Permit Fee i d U- Estimated Cost X$7I311000 Residential Estimated Cost X$ili$l000 fomrner fat-------- --- - - -- An Additional$5.00 is added as an Administrative charge. 7 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 st d specifications. Signed under penalty of perjury X Date�Z N O � W I � a a � CITY OF SALEM -- PUBLIC PROPRERTY - DEPARTIAEM al��•s t.tC ti.�¢Ax::Jd;SaraT�iu:f1.�LAvtlt::w.ta.1s::+t Ttit:tGiJ�aS1!•f.�9thJ�plars r- Construction Debris Disponsf Affidavit (reytaimd fa all denolitim and eanovatim worst) In aaonlanee with die dxdt edition ddw State BWWinf Code.7SO CAfR section It l.S oc ria.and dw provisions of vtGL s 40s,S Sk gWiding;fowdl A _ is issued with dw condition drat the debris r ethos fY m this wort shall be disposed of in a properly licertse0 wasse dispoW facility as defined by MOO c ll1.sis" The debria will be transported by: rhodcbds will be disposed of in r (aa w t 1 lustily) _ . f7 ...L:r,rsa ul Cax:Lty� •.Ald t CITY OF SALEM - -PUBLIC PROPRERTY - - — -- - DEPARTMENT wavaaatsr wetxsu 1I srtaa 12C WA*&%sraMSfltRT a Satsas,lfnsaa e.srrlx 0197d 'rho MAS-9595 a F.sx:9W4o.9s4& Worken' Compensation Insurance Affidavit: Builder/Contractora/ElecMdana/PMmben .Annlleast Information /1 Please P tt. rier .ati. N2MC IOuai /O neatgmiratiaWflmbvuhnq /r/S : 42 r eAL S Addreu ?Q 11�f&kJ Gfh/GI yer> city/state zip: etw:�_� 1'hooe a:�S_=�S Ara you as aesple k-ft appropriate bows •spa of project(►aq�J. 1. a cmpbyar witb 4. ❑ 1 am a 11 contractor and 1 d. ❑*��cortaarlreti� dawkwom(full snd/ut part-time).• have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner. lined on the attached sheet t 7. ❑ Remodeling ship and have an employees These wb.eonnseten have a. ❑ Demolition working far mein arty capacity. workers'comp insurance. 9. ❑ �arlditian f Na workers'comp. insurance S. ❑ We area corporation srtd its 10. Electrical nquirod.) oAteMs have exercised their ❑ repairs or additions 3.❑ 1 am a homeowner doing all wont right of exemption per MOL 11.❑Plumbing repairs or additions myself. (No workers'comp. e. 152,j1(4).and we have no 12.0 Roof repairs insurance required.] r cmployeas.Leo workers• 13.0 Other comp insurance rcquireal.J 11.A,o+aplisam ho I-- boa aI sap oho fill w law was"belmw ih"ahsa sunless'pamprtwtam pWwy inaaeantim` 'IIQWW Warm wow whmir rlw MadprY iadkpwb 6"an Jwyl aY wMt and ohm•hie wrhb eammaaem mw.uhmk a urw amAbvil inJtaina wh. {C mram s One chat Mw bat mar anadwd an aaaaaaho l ohm dmwins of raw of dw aad thaw wathara'mq.paliap iae nW o W /oar an a nployer that b prot4d/ng woibars'rosperrradon livafanee jar my etnploydoz Below is the paHsy and/ob s11q.. _ .,.,.....a....»_.._ir,{/arrwfMul►M.,w,.�,.-.�-.a..,�,..�,..d.-..�.....,.�.�„�,...� ..�...*.,...•,..v....<......:.....,�....�....._,..«.».,.....,.._..,....a....•._ Insurance Company Name,_ Policy tl Or Salf-ins. Lie.a: !`J' 3S'0 Z' Eapuuuon Date: - Job Site Address:_ f CityrJutuZip:llT� � ���(�D attack a copy of tho workers'compensation policy declarrtloa page(showing the policy number and expiration date). I-'uilure ad Wcum covemge as required under Section 25A of.IGL c. 152 can lead to the imposition ofcriminal penalties ors fine up as SI.S00.00 and/or ona-year ianpriaonancnt,as well as civil penalties in the form of a STOP WORK ORDER and a fee of up to$250.00 a Jay against III*violator. Ile sdvLscd that a copy of this statszoacm may be torwarded io the Utlice of I,'%.ahyauons oi'dIc DIA for vcriFicatiun. /do hereby esrtijy ,der the poi n per/cry Met the wyeranar/on provided as~is lraar and correC& Cis•:ranarc' D. — U/Jlriaf mse onIA Ast ndr wr/ti IN this area6 to da rosap/ehd by city or town a/jlcM City or 'rowoe Pcrmit/1 lecase l► Issuing Aulburity (circle one): —— I. Duurd of Ilcaith 2. Iludding Department J. City/foao Clerk 4. Electrical Inspector S. Plumbing Inspector G. Other Gmluct Persma: _ Phone p: Information and Instructions -- - - vtassrchuscthi General Laws chapter l52 requites all employen to provide workers compensation for their empby"s. pursuant to this atatuts,an tybl'et is defined as'...svery person is the service of another under any contract of hire. eapresa or implied.oral or writtet' An MRphUw.is Mines 0-as iatfit WWL parateM11* �toeiat"corporation or other 1*89 entity.err any two it more of at the the foregoing engaged in a joint swerprrse.and inclFodittt the legal reprcsastatives of a deceased employer.ever .ssooi-doo ac other legal ewijy.employing employee the tecetiver or trasue of as individual,pacmetithw' a�w�resides tht tear.or eht otxupara of the owner of a dwelling hours having not more than three aperleteat t «r work on such dwelling house dwetlint bouss of another who employs Mtsons to do maintenance.cunstrunion ePsic or on she groun ds or building appartasaK j dad not berates stanch emploinaealt be deeroted to be as employer. MGL chapter 152.¢2SC(6)also sates dad"e""7 stag or toed Messtdat shinty shagtM eossuaeawsa W withheld the ebissuancefee n rM er reaawui of a Una"or parole a operate a badness er to construct buildings la ay apporgiatwwits W net proded ac acceptable wades"Of coorONSIM with the insurance eovsrsgs requird» Additiuoalty,MGL chapter 132,123C(7)states'Neither the eonsrtonayealeh���telsornphliroee wnanrsnca tical subttivisions enter into any contract for the Performance of Public work until acceptable requirements of this chapt er have bias presented to the conaaecot authority.' AppHeasa Please till out the arorkees' compen:aden affidavit completely.by checking the boxes that apply toyour situation and-it sub•camractor(s)man adrkess(es)and Phone nusubst(s)along with their tsertif fam(s)of necessary,Supply companies LC)or Limited Liability PartnershiPe(LLP)with no employees other than the insurance Limited Liability (L tit member or partners,an ant nequited to carry workers'QORtPeOainsurance. It an LLC or does have employees,s policy is requited. late advised that this affidavit may be submitted to the Departmeentnt of Industrial Awidena for coaffttnation of insurance covengs. Also be sure to sip and date the sff!"AL 11te affidavit should be returned to the city or town that the application for the permit or license is being requested not the Department of be retu n Accidents. Should you have any questions regarding the low or if you are required to obtain a workers' corpensation policy.pies"call the Department at the number listed below. Self-insured companies should enter their self.insurance license number on thep Iine. City or Town Ofllciah Department has provided a space at the.bodos9.. Please bt.sure that the affidavit is complete and'pririted ILbibly: The lhprutrn P� of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the appl tyleass be sure to till is the purmitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple Permit/licenas applications in any given year,need only submit one affidavit indicatint ouneor policy information(if necessary)and under"lob Site Address"the applicant should write"all locations in (airy or town)."A copy of the affidaially stamped or marked by the city or town may be provided to the vit that has been Officially for future permits or licenses. A now affidavit must be tilled out cub applicant as proof that a valid affidavit is oa file year. Where a home owner or citizen is obtsiniag a license or permit not related to any business or commercial venture i i.e.a dog license air permit to bum leaves ate.)said person is NOT required to complete this affidavit. I'hc Oft ice of Investigations would fire to thank you in advance for your cooperation and should you have any questions, lease du not hesitate to give us•a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Dapactment of loahistrial Accidents OAkt of Inwtitlptlew 6W Washington Street Boston, MA 02111 Tel. 11617-727-4900 ext 406 or 1-977-MASSAFE Fax M 617-727-7749 .tcviscd i-26-05 www.ano.gov/dia • Sy '.R`r`6 „o.:l�ita�i�WkT�?�35��'.r`�•Z��jGi •�� 4�,,..'( r3'$�fi i N k y . y� ,s T�1.�c s •J�yz :+C�. �yy t m�F t > .c S� `E 5 ^x..6l1 T S �rsvS�34i1f�o�1Li�d*..� . 1 ,4 'S. 1 � � T;i�zc '('tF '}4 y S�^•rNf";k,{�,'P'ii�".`SSZ� "F.� r,•.1^.i..tt1'.�13�'iT.�Q�rY'34Cr.M�N•�+3•lT,,,s�..i/.a.�. � . ' • cn . POODUCM 1111 State Street • . . a sill Poston MA 1 •. e• • ;4 • 1- / ARROWHEAD FARM ROAD • •t -V�jN r �• r; a cr--a• 1'1 G i hs£4'45t•AS a?<ma.C`•'.Y''¢•f}F. :$ I x'UNht{r, ..s. x. �. 4, . !• ;<s-1Y.t^a• °�1 .i .c?4.N.: r cc1_u_c'R-L�rl 'ot t, k . • © � . . . ES •�. me•. µ .. , . , El © ` • . . . . Ej Ui . ai 7 L 7 ' ;: S'r t T•. r'r r�LgK>',\�"+l' r r.11 `.,., is- .. s�a� ¢ .j3i:s: :H :! •• n'N; %�^` ')1 -`".I>,rS �• _ ze' 2^'a; k: a:. jw MIMMETON �__. J „t, ^,•.,.;...a : ,, - g :.,v^M �'.>,Fr ?e: S S,c e'c I4�"'.x�s,dt-.u^.,x u r,a' ''d F`b' ., s?.,.;:s..:.. 'r.__.a•tx.m.o sral" . ..__—.. . .•e:�i�i.• P`;yr111+:..>fU:i'd:i Eli tt.^++'�Cl.:.i.'�'11 ufCiJ�4 -�==' 13aarY4 nP kuii4iny; }ttyul�Piona s+s++1 �.Ittatdneetc i .} r r . Hoff}: iMPPOVEMErrrcr�i�srz<,CTosz ,? Rc;'l iglr:3.1 e7Oi SQ(f;'JJ ...�•� GXP7.rar Z't,v.r�r I`il�s...`N;:J'V J lyPe Pt ;,/A,P cr:rpOr:a?ni; ;ra t(m Rd. firu.�cuG. t.}.4�e��i !)a011ll+ h1�1II.IS1fl�':��n)f s f e/frlr tUtjltlJlwlRlw'Wee 0/, 114?Aft't'/t1i BOARD OF BUILDING REGULAT1 i i License: CONSTRUCTION SUPERVIS # :Number: CS 068139 4 ' Birthdate: 01114/1956 Expires: 011141.?,008 Tr, no: 1; 'Construction - CS Restricted: 00 KENNETH R CARNES 8 DORIS ST GROVEt.AND. MA 01834 M Commissioner -CITY , V` PUBLIC PROPERTY DEPARTMENT KI> MU"o.aCt,. N.raa 130 WARUN W b n-r�• "MXK Ww>anatts1.rrs Ot970 141.978-745-9M•Fex;w&740.gW 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: Building: ---- .. _ P►opertyAddress:-- - 5�7_- ------ - - - -- Property Is located In a; Conservation Area Y/N / Historic Dlshk;t Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address. .746 .3 XA16gy&7re f- Tekiphone: '7 _y 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING G BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor NO Renovated construction or renovation of existing building New aripr Description of Proposed Work: ,�z P 7- Mail Permit to: y t --- - --