375 LAFAYETTE ST - BUILDING INSPECTION � ' ������ PUBLIC PROPERTY
- ,. DEPr1RTviE.�TT
KIMBERLEY DRISCULL
MAYOR 120 WASHINCTM S7REEr S"LEK MASSACHLSMS 01970
Tm-,97&73S-959S♦F=97&740.98"
APPLICATION FOR THE REPAIR, RENOVATION. CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY Y EXISTLNG
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
3` G J Ia YE fI Y
Property is located in a; Conservation Area Y/N A J Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address:
'375 L F� Y�fs sue, SAGE.,
Teiephone: /- 97 3 3 5 dE/40
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 (so Renovated
construction or renovation
of existing building I I
New
Brief Description of Proposed Work: (3VLC �kZS tI�C� !�'�t7 ✓�
srL)E No05,�-
-- -- - -Mail Permit to: X 1-)c90.A HaA to9.5 Zve, 12r q 13ouY w�,9 . o S76 0 -- -
i
What is the current use of the Building? 3 r n 1/5�/ -1-'C7" S,i
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name�51� � ('���.s >ituc.7`�v'c �•�[ `
Address and Phone..?/ l,o�- ,'r���As I 1110a3 L),9 /�-24 . y7� .2(0 939�
Construction Supervisors License# r S o $3 9>(bHIC Registration# 7(0
Estimated Cost of Project$ 3 C- -Q'V-Oo Permit Fee Calculation
Permit Fee$ 1 5.�� Estimated Cost X$7/$1000 Residential
Estimated Cost X$111$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 perjury
Date /-
i
i
J
` � N
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0
N CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xmnsstttr txttscou
Mnroa
12o v�smvGTars�„rgT•��.>,1w�►atuatrs 01970
Workers' Compensation Insurance Adfdavit: Badewc ntraetora/El
eirwaawnumbere
Applicant Informadoarint* aly
Name i )�c9 P71^7 —.
Address:
cityisb>wrp: i� ,z�� n Phone
Are you an employer?Clbsek the appropriate boss
1.P I am a employer with 4. ❑ I am a general coii
and I Typo of pMeet(rag2.❑ I am aemPla aml sole(!Wl and/or part-time).• have hired the rs 6. ❑New coustr ctio■
ship and�av� won the amteet t 7. RemodeifoBworking for me in any capacity, workers•comp. Once, 8. ❑Demolitlen[No workers comp,inammop S. ❑ We are a corporat its 9. �i action
rt4ubad.l otHcera bave exereir 10.0 Bkctrical repsks or additions
3.❑ Inaam bomeowoer doing all work right of exermptimOL 1 I.C]plumbing repair or addidomsY [No workem•comp, a 152.41(41 and e no 12.C]Roufmingim
insurance ]tMPioYW.(Nc wcam ore ) 13.C]Other��Y�eeaser err sharks bag dl mar lino m1 ae me actlr blotHampwera win submit Ws sfikk"ErdtnWy mar rt dais v redo*mar Idml ieaamrlaatcomaasom err cbaak mis boa nor rtrrhad r nwt a*"hew sddWaed sites showing dr msr of dr mbeanaaran And msir warlrm•amp.Policy kobmtlaa
!aw aw ewp/oydr that!rN"Mbrj workers•comptuador heraraaei or r
in/ormatloa / cry tap/oyrea Bekrw br tlbdpa&7 and fob abe
Iruureoca Company Name 'rt
Policy#or Self-ins.Lie.
Expiration Date:
Job Site Addreae '� of t./q��.�yzc Sf
Attack a copy of tha worksn•con ttsatb■ Ciry/Seatellip
Pe policy declare W ge(s —s the Polley number sad expiration wins}
Failure to secure coverage a required under Sailor 25A of MGL a 132 can lead to the imposition of oriraimal
fore up to 11,500.00 and/or one-year imprisonment,as well as civil penalties in tits form of a STOP WORK ORDER lies a tine
of up to 3230.00 a day spinet the vioLmr. Be advised that a copy of this statement may be forwarded to the Oglw oandf
lnvcsng"Wm of the D A for ineuraoce coverage veritication
I do hereby torsi/? anArr the pains ore/penaldes o/Per/roy that the/n
/ormadow(19 provi4d abow 4 raw and correm
=0a
CU At C}2 "5 V, q—_9 395�
offle4 f use onlit Do not write be Ah dreA to be eompkWby c/o or town oQk/a(
City or Town: Peratlt/Idreme N
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Clty/row■perk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person:
Phone N•
I
Information and Instructions
_ IM&M fa their entploYed.
to provide,
%,yshuscta Gcoer l Laws chapter �f32 peon to the savieo of anotherY CO° of hie0.
Pursuant to this statatte,an eeellere
used as".-AvaY
express or wed,and or wrtttan"
a other legal entity or any pxo or moen
is Uflood s"an iio avidud.pumasb*9ffO OO'COLp°Lanon va of a deeeasad empleyor•or the
An aatpf°Ysin nptod in aioidt antapriae• ioehdmi the legal representatives �PWOM Howover the
ref the receiver�e�e of an individual.Wens,,assouties at other Ind entity. these>e.a the occupant of the
owner of a dwelliog house bsvnV not trait thsan three aperaneDes or 1ep�week an such dwelling been
f soothor who employs persons to do maiotoo D be deemed m b an employer•"
drew� at building apptttenam Ito shall not because of such employment withhold ou bstanat or
u.pDounds a awl
that awry start of wraith far aaq
S �(�also stun y,�,p V tM nearsen "
1 2.4 se te eeasorut
MGLahapnr •buaWs r hired.
coverage M
retuwtl of•tla``__.-s_sse eJt ps��y�kceed �M*of eospras"w_hb the of is politica eubdividow�aU
W.P!- M weakh no my
apptltase, 152.$23CCn ammt NeWm tb common OvidEnee of compliance with the insurance
Addidomft•MGL chapter �w�m work until acceptable
Cntor of lhss chtPts�O�� m th0 contracting av Y M
APP b • affidavit cou&ftlY by cheolnng the tunbor(G)along with their apply
sx o your
t ts�and'if
pigs" fifi M thOppv 064cntraven(e)nama(s).add and phOOe nPatmaships(LLp)with no amploYen other than the
° Dp; L gnieed Liability C,�ntn(LLQ or Limited Liabtity does how
Wand m carry workers'comp=edon ineurenee• If an i.LC to of Wastriel
ntanbers at 911110"al ate not i is r� Be advised that this afiidevk may be submitted to the Department
and dam too afffdsviL Tb affidavit$'cold
of insurance Ante b sere to sip of
�i�far wDBtmatioo � � far the permit ar license is bait+g taiDeued.not the
to the city or town that aPP rya yra,at if you are required to obtain•
be returned idnys Should Ya►have any gtteattone regarding should enter their
Industrial poll'•p at tb Member Barad belowcompensation . Self-insured eoimpanitt
self-iterate Resew number an due Bee
City or?own Offielsb has provided a speCe at the bottom
Please be sure that the affidavit is complete and printed legibly. The Del M eOLontact you regarding the appBcant
of the affidavit for yet to fill out in the event the Office of Investigations yt addition.an applicana
Pleas be surs to fill in the pnrmtit/liceDa°number which will be trace s a ref t�one affidavit indieadDg cDrsa°L
le Pceetitnicents applications in any given Year.need only
that tnuat submit if nomu'y under"Job Site Addres"the applicant shou
ld write all locators m�—(city or
inflortnAtimG
a marked by the city a town may be provided to the
tom)policy.A copy of the affids dirt has been officially stantpad or license& A now af"udrvis mtut be filled out each
applicant as proof that a valid affidavit is on file far finite Permits ant releta to any butinaa a corsmaeul venoms
y� Whore a house owner ar cozenis obtaining•hews or puma to comply this of idsvit.
Bt:
(i.e. a dog ns at Permit to bum leaves eto.)said Person is NOT required
The Office of Invesdgatione would like to thank You in advance for your cooperation and should you have any queaaDneo
pleas do not haitam to giw us•
Z he pepartment•a address.telephone and
'Phis Conin nwe"of Masgpbusett
DepuMem otPmfiWmd Accident
oft*of wadpnons
600 WAISAMPS Sftd
BtYdm MA 02111
TeL K 617-727F90 e d 0 c1 9n-MASWE
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