387 LAFAYETTE ST - BUILDING INSPECTION v
what is the current use of the Building? �
Material of Building? If dwelling. how many units?
will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone 3 6 lm&o 1 sz&d, L.¢/1in 2>7 fox/d✓��
Construction Supervisors License# D/Prl HIC Registration# 047 33
Estimated Cost of Project S 1�� O6 Permit Fee Calculation
Permit Fee$ d Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/51000 C nuT'ercial -
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 stat /
specifications. Signed under penalty of perjury X
of
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EI-TY-OF-g r
PUBLIC PROPERTY
DEPARTMENT
KIMIM Y DRWXX1
MAYOR 130 wtivua GrON ST E 0 SALkJ4 WASUUI{:St'1'R 01970
Tfi 976-749-959S•PAX 976.740.96N
APPLICATION FOR THE REPAIR. RENOVATION% CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTIN
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: AA12YLMf IT Building:
Property Address:
Property Is located in a; Consewatlon Area YM--ZVL Historic District YM .1�Q_
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: 6a. aLrPA-1U ST
Telephone: - ZZ
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Z New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brie[Description of Proposed Work:
-- -- Mail Permit to: -- —
Haan! or Building W-guladom foul Sla(1dnrM
FfOtA.Ei!Y1PF2(?i'EfAFNT CONI'^nACTCli2
F. r�e�istra:irn !g073S
ExImot all
type rj:raa'eC .r;),v:jtinr
v� camas
f.fmtme.ac ,am)Pd.
4'01c. rz1.S 0,� A\IM aiwu for
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+' BOARD OF BUILDING REGULA
Licenso: CONSTRUCTION SUPERV
ki
-»y Number: CS 068139
` Birthdate: 0111411956
_ Expires: 01/14q008 Tr. no:
Construction -CS
Restricted: 00
KENNETH R CARNES
8 DORIS ST
GROVELAND, MA 01834 C
Commissioner
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MATTER OF•NLy • • .
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• DOES J#oT AIll State Street ALTER TW COVET.tAGE Aq�
3 . • c
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S• • ' . /• •ARROWHEAD FARM 11OAD •w .
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6 9 _ • ,v w cF"'U a 3 ' �'ry`Swd ,t•tQ�s"'sZ"a�{"r ,3.t rl.,, _"2 y '�.�a4.,�
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TOWN OF MIDDLETON
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CITY OF SALEM
PUBLIC PROPRERTY
DF.PARTM- EM
alp+•s t11'L�N::.y►i 7�LT�iu:�ftavtlrr.t11s::�
Tn.W 4645"•R.%a WW4& W
Construction Debris Dbp " Att[dsvit
(required fbr all dsnwwion and rwvatios wank)
fa aaonlsnce with the sixdt edidon earls Sew liluilding Coder 730 C1Ult soctios It 1.3
LkbcK WA the provisions of NGL c 40.S 34t
BWI&rd Pamil p _ _ is issued with the mmAdom that the debris resnldnS float
,his work shall be disposed of in a property Licensed wasse disposal fbcility as defined by WIL c
111.S INA.
The debris will be transported by:
_.r Inow.rf narbrt)
rho Jails will be disposed of in :
C/.Y rf& ,
(aartllr t'fxdlty)
17�r-
CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:wruaFaraY rrrti r,
xsrtte t2t:vras..,arotstisar.M tt>x hraaowe�nx01s70
Tit-9W45.""a P.u:gwiia va s
Workers' Compeasadon Imarsace AMdavue BrildenlCostrsctgsWEjC tridstulphmDen
Applicant Information ✓1�yt /� Wed vW t a be
Name(IbmaewOrsaairatidwIftlivKhrall: /(7 J yyy0/,I19�
CiWSmWzip: � /� lum N _
Are yw u a yec?C a�M apprepryte boat 'type orp► jow(rNuiresi1.1. as a ero*yw with 4. 0 1 no a gel eomraaor and t
2.a 1 mp (roll an eve putwime).• have hired the sols4 turun ta s' 13 Nowuaras
a sole proprietor or partner. listed on the aoaehad sheet t 7• 0 Remodeling
Ship and heirs no amployom Them wb•romakm to bevy k ❑DerWitim
working for aw in any capacity. worltan'eorrtp,inwn iaL 9.
f No walkers'camp.insurance S. 0 We am a corporation and itsadditim
required.) ogloms haw exorcised their, 10.0 Electriew repairs or additions
3.13 1 am a homeowner doing all work right of exampNpt par MGL 11.0 Plumbing repairs or additions
Myself No worker'comp. a 152,f 1(4)6 and we have no 12.0 Roof repairs
insurance required.)r :Mplayft*&llv'o workers'
comp insuraam Mquirrd•j l3•0 Ot m
'A'q apPlicmt tar ell-' tree at ran she iss"ew,raim lwiewsee"tk*wrtst a,uppaamtwticrioaeouniaa
'tl.nrw,wmm who sum*ran amdwi"Oft our am degas go wank W ram his oMWe saatunans awl.ueoni a new t'unrasnra tW ctwek era W nmt ar4dnd m addkMW ahan.iswins at nine Ado■h.earmaaes W rtwn w.vkns• ae,pwiniril iy a m roc..
mimr �•Perry ..
on irmitimb.,pw t/rrt yPNv�roy/d/wg worAars'roarPrwrwtlaw luwrawci or
my enrployrrs Bdotr Is the PaNi�
Insurance Company*48nw :2
Policy s ur Self-irb.Lie.M /V�S �y7/d Expiration Dam:
lob Site .4dktrcss: T 7� ��r Y�—//L' S T CitylStatu2,p:
Attach a cupy orthe workers•compeesatlun policy declaration page(showing the policy number and expiration date)
Failure to secure coverage as required under Section 25A of.1GL c. 152 can lead to the imposition oferiminal penaltiesora
ri ne up n)51.5410.00 wwor one-year imprismmnicat,is well as civil petu ejea in the form era STOP WORK O
a(up to S250.00 a day agtrioat the violator. Ile advixcd that a copy or this statcuum ORDER and a fine
may be furward to the RDE a
Im snganum ol•Lhe MA for rasuran•.ce awcraye sc ' ikon.
/Ja herr6y ecruify andei ill and nu/rlr�u/prr/wry rhor Nw 1n a►ww/low
/ prorated ahoy is trwt and correct
�i�•narir� , .
Ph,a•e a ,S-3S= r 3� �"Mile unQt /)O nut wrly 1w rhb arras,to r51 rawrpkrnd by elly r yew oA-14d
City or 'rown: PcrniN keess w
Issuing Autburity (circle one); ——
1. Board of►Icalth 2. Building Deparuncnt J. City/roho Clerk 4. Electrical luspcctor 5. Plumbing Inspector
G. Other
C.rrrlact person: Phone At:
Information- and Instructions
1 S2 requitrcs all employers to provide workers' compensation fat their wtpbYGOL
�tasaachusnma Gcneral Laws chapter of arwrher under any contract Of"
to this statute.an"VAW 'r is defined as .evaY person is the temce
Putsulaw .
e%prass or itnpliod. ral o at writes
tl ddlnd m-la 1 0 ►Lsoetene�. a ors o �enited many two arm"
of he r aJ"M m a Job Seaatlt "&and inehrWg k�tepeauntttavea of a dcemple employer.However
the
Oi the r or tri sa s of a ad &Sweastioa of other lq*G* t.40PIC t. r the O ep
receiver a&va of s o ba,Ang M nWO'/d and robs r I " - thtateiR et the otxttpertt of the
owner 4 dwistlLg banes bwieg sat ream Ihtr them maintenance.
construed"or repair work on such dwelling house
dwea tg house of another who employs P f"es to tie maintenance• be dinow to bean empbye.
Or on tilt gran ads or building apptnetstaae �iheV Oct banns at rash seplmytmmat
�lGt chapter 132.423C(6)also smsa that-is"-acab W feed tleenrdq ag say shaft wit kbMd tM btsrttstea I
retained of a tletw S pet it b St bad..er to towearttet bid~b tba npatweaMl fat aqr
a operawWistta of cerepratisa wW the fnstvaa ce coverage re4ob
appllenat wba ben a=-prdme/a the cmOOmweal*err mY Of its political wrbeWnebat shill
Additianaih.bIOL chapter 152.;23Ct ) w,�until acceptable*video"ofcomoisow with this insurance
eases into an)r contract liver the performance Of:contracting aubwity
requinmenrs of tbis chapter have him presentsd
Applfeots tO our situation and.if
plean tnl out the isterkaa'compensation affidavit oompeaab.hY checking the bog that Air c r
necessary.tttpply ems)nan*s),address(es)and P�awtrhae(a)along with their emti employees
a)of
Cimino Liability Compsmlea(LLQ of Limited Liability paMftlbiP$(LLp)with ro employes other than dais
insurance beturance. if an LLC or LLP dons have
members or pasttran,an act reeptin�sed that this@W cea subatiaed to the Department of Industrial
Accidents.•Poker is tisq 0 coverage Ababa sun to sip sod date the aRWavM. The attldavit should
Accidents for cmAnnationapplication for the permit at license is being requested.OW the Deparbmisat of
be returned to the city a tOwn that the app obtain
a worker'
Industrial Accidents. Should you have any gttastioa the lawu regarding t should ears their
compensation Policy.plow call the Department at
t numbs listed b or if you an required to obt
claw. Self.inN+nd companies
self-inaurmta ffeena numbs oo the
City of Tows Offlelda
u ,. ._.._... . -. fete and printed legibly: The Dspme to t ha providsd a rpttos at the.bo000L-.. .
Plcau be wre that the affidavit is comp InvestigationsYou
of the affidavit for you to fill out in did 9 ltcenaevnttmberent the Officis owi ba used as as r�efinence nu to mber. In In uldition �
lahm" be aura to till in the pc submit one affidavit indicating corneal
that taunt submit multiple PermiNlieaase applications A any given yeer. should write"all locations in_.ici4'or
policy information(if necessary)and under"Job Site Address this applicant
town)"A cope of the affidavit that has been officially stamped or marked by the city a town may be provided to the
ut sub
applicant as proof that a valid affidavit is on file for li+ettrc permits mbar related to any businasa it orcommercialbe lled venture
year. Where a hams Owner a citizen is obtaining a license or pan
mit(i.e.a Jug Iken"or pertrtit to burn leaves ea.)acid pawn is NOT required to complete this affidavit.
i hu Oftiac of lnvestigatiumt would like to thank y-u in aJvance for your cooperation and should you have any questions.
please Ju not hesitate to give us a%A.
The Department's address, telephone and fax nurthee
The Commonwealth of MassaChusetts
Dep&CMW t of IndwaW Accidents
Oak*of in"dipide"
we Wasdti SM S>>led
Bodo^MA 02111
TeL N 617-727-4900"1406 or 1-977-MASSAFE
Fax M 617-727-7749
;taw iaaJ ;-26-05 www.mm.gov/dis