410 LAFAYETTE ST - BUILDING INSPECTION - - -- .. -- I he l ,uun,ln,lsCalth ld \La,saalu sc•n,
c -- --
l
O e Ii1t.IrJ .,I IfutlJhle Ileeulaw,n, .utJ SI tnJ.uJs
l -r \L:IssuLIRINCIts State 13uildine ('Odd. SI) ( \IR. Jnttal
l3uilJing 1lennil :\I,{ licatilm Tu (l)j,sirucl. Repair. Rinl,\.Ile (h I)C!,u,li.h .I
--- t - r,r f,l o-l'erulh 01,rllin� --�--- - 1--- -
!� h Se,I Nit I or t)ffictal !\e Onlv
1
RuJJu1g Pennit Noter. _ _ ... . — —i D•tle :1�.plttJ' 74_"�b'
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1 Ilu tF ('nnuttl.� ntcr ilyccb nl 9u11dlnc. fl.tla
SEl PION I Sl hF I\FI1H\I \ I ION
I ' ha,e,+nrS Map A, ParvVI \ur .hers
I _a I> this .111 AtaCPWJ ,OCO ,C,
f .'. Zoning inforntution: 14 .r , 'v ty s I
Z.,trty Ci Iml !'rupowd 1'se LN r.... ,sq lit
.`> Roll linr< Setbacks Jill
Ra yu.:.d �.. PnuldeJ RcyuurJ ?—Pr•,a ltJcJ R:yul-rJ Pti."uIcd
i,G ri ,ta 1acN3y: I b,.G L c. 10. §511 1.7 F..14Qod Zone irfornt.^i3un: —tl.f3 J1',4.1PY Dt,pt cai Svcttm:
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Pr!•:Lite❑ } I untatra;�Q On "IC
Cheek it 'eo❑ __--_...____
-- SECTION ?: PROPERTY Oil;;MEr'SH1P'
n t t r kr,•pr4: �^
�Srs.S_�t�'�L_ . �L LS�•� S4IC 5 - -S4�Crt !
-N 11;; Print Address 'o.
! irr.:wrc CC!cphcne !
r__--- SF:CTtON 3: DESCRIPTION OF PROPOSED NVORK2 (check all that l;ppiy)
N . v t_ m-�uctiun t�-F1-Z ing Building, ❑ O•_aner-Occupied ❑_LR a>; :r„tt ) L.i T \ U ❑ j
it v ❑ t Aecessury Bldg. ❑ Number of Units_--- T ..)rher Q do clay.
�.:: : .:t1. ,I .:. ,.1JJ•-.,pl,xdW„rl:•:�C�(_ Q�__�9_. �1 -letC�k Cmrr���r E./W CxCA.4�- ;
SECTION 1. ES HMATED COirSTRUC T!ON COS'_'S
-----..__ .._. _
E-snmmed i'„sts.
Item Official Use Only
I tl ahtrt and Naienulsl '
! Building ) t{I 00, CJU j I. Building Permit Fee: 'S Indicate It:-aa fee n JitCutlni J:
r-- ❑ Standard Cirv%loran .\ppttcatum Fee
__ ---i O Tidal Pn,iect C'„sl I Imm GI a multiplier ____-__ ,
t Plunlhmg S 1. CAher Pees: 'S-
aka hunlcul !f`ire --
lu + ursslnnt ti 1,d.tl :\II Fees
-1L--- --I--
('heck No _ ('heal. .\mlnrnr
h rota! Project Cnel Stf,640.cu 0 PaIJ m l=:d1 ._— 0 (hn>r.tnJ;a;., If.t!.tn.e I;ue
SECTION 5: CONS7'RUC LION SERVICES ---- --_-
5.1 Licensed Cunatructtun Supery tsor I C'51.1 ► O�
cvC/1�t�7`1\�'
VkAildd"�_/_ 1.1,1 ,iS1, 1\pc ,cc h0mu I
Ri,iomid M _' f'.innit
1icn.LLqwiL I \Li„mn Ihd,
Rt
� f.•Irphn n,• \1 S—rH id:nlial \\ i J� „ .0 J 1 I u _ _ _
�il 4 H iJ.iw.�l S L.11 iii li in n`\LL ui In_i I .in_'i' _
5.2�,Negiste Home ro lmpsement Contractor 1111Ci —-- — --- ___-_ -
_ _I35 S6'pL. 1- I
HI ('tin m N me or f Rr¢i,tranl tie Registration N'unihcl
Fyiian m Date
sipwture 1'e1cphune
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506)1
Workers Compensation Insurance affidavit must be completed and ,ubmnted with this apphcarion. Failure to pro,ide this affidavit will result in the denial of the Issuance of the building permit.
Signed Al idavit Attached" Yes ......... No . .. .. .. ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
-__— as Owner of the subject property hereby
., I ❑uthontr _LAG to act on m_v hehult. m all ni.incro
reauve to w-.n k authnnzed h, !his hod1tg permit nppliratiun. d.
— --
Siena u c of O t •r Dale
r SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION --�
I,, �\lCr,, — ,r\PC. , as Owner or Authorized Agent hereby Jec tare
that the statements and information on the foregoing application are true and accurate, to the best of my kno Medee and
het.
`(t'
Signature nl Owner or:Nuthonze :1gv Dale -- ----
(Si med under the am,and enalucs of e(ur))
NOTES: _
1. An Owner who obtains a budding permit to Jo his/her own work, ur an owner who hire, ao unieLi,leied t-oiura, fol
(nut registered in the Home Improvement Contractor (H1C1 Program), will nnf ha,e acre„ to the .uhi Vation
program or guaraniv fund under M GA, c. 117A. Other important inhormatton on the III(' Program and
Construction Supervisor Licensing WSLI can he found in 780('MR Regulations 110 R6 and 110 R5. re,p" 1
' When ,uhscmtial work is planned. pro,ode the infircmauun below�
Total Iluurs area t Sy. Ft.t — nncluding garage. lini,hed ha,emenUatucs, decks or P,,reh,
Gros fivtne area tSq. Ft.l Habmtble rourn coum
j Number of Itrrplaces —.— Ntnnher of hedro,,in, _-
! Number or hathwom, _ NUrnhCt of IeJlih,uh, ... _.--_ -- .- _-
\pe Numhcr id Jr.k„ p,n,he,
� I sloe of s�n�lm¢ ,,stem ___..—__ IInJu,i,l upon
7. . 1',-tal Project Square Fno(age" may he ,uh,tiluied for "fntal Pngcct
CITY OF SALEM
3
r •
PUBLIC PROPRERTY
1 .
DEPARTMENT
� '.I i;P!tlfl' UNlif �,I I
Vl.0 1K 1-'Z Al\,I!IN-;I,,N S 1KI�.t.l' • $sf l-a. �t.�••.t� I I� •P l 1. �l`I'7
ll.1: 9'g-'1j'69; ♦ Fsx: '1;SJd;-')3�b
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
r tlicant Informetinn Please Print Legibly
Name (I III,mcss.()rg:uuZaII,m.lndis i duall:
.\CldFC5S: Q o Goy- VQo
City/state/zip Phone #: �003 ' Y 1 s— 1 (407
Are you an employer? Check the appropriate box: 'Cype of project(required):
1.❑ I am a employer with 4. ❑ 1 :un a general contractor and 1 6 ❑ New construction
employees (full and/or art-time).` have hired the sub-contractors
p listed on the attached sheet. t 7.. ❑ Remodeling
?.❑ I am a sole proprietor or partner-
ship and have no employees 'These sub-contractors have 3. ❑ Demolition
working for me in any capacity. workers' comp. insurance. y, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.0 Electrical repairs or additions
required.] II.❑ Plumbing repairs airs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. C. 152, S 1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers 13.4 Other�LC�
comp. insurance required.]
*Any applicant that checks box HI must also till out the section below showing their workers'compensation policy information.
t I fomcuwners who submit this affidavit indicating they ore doing all work and then hire outside contractors most submit a new affidavit indicating such.
:CaNrmtors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I ant an employer that is providing workers'compensation insurance for troy employees. Below is the policy and job site
infuriation.
Insurance Company Name:
Policy k or Self-ins. Lic. 0: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a Copy of this statement may be forwarded to the Office of
Investi,ations of the DIA for insurance coverage verification.
1 hoherehy certi i' s antt� dpenalties ofperjury that the infrtn nutionprovided above is true and correct
Date
Phone
01ficial use only. Do not it-rite in this area, to be completed by city or town officiaL
City or Town: _— __-- Permit/License
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
b. Other
Contact Person:___--- Phone p:._
Information and Instructions
Massachusetts Gcneral Laws chapter 1 52 requires all enlployel:s to provide workers' compensation tier their emplloyces.
I'ursuant to this stalute, an etnpfgree is dctined as"...eccry person in the service of another under any contract of hire.
e\press or implied. oral or lvrittetl."
.\n enrp/ujer is defined as "an individual. partnership• association,corporation or other legal entity, or any two or more
of the fiuegoing engaged in a joint enterprise. and Including the legal representati%es of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
ow net of a dwclling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do ilia intenance• construction or repair work on such dwelling house
or the.giyunds or building appurtenatu theret-o shall Clot because of such enp5loy nlent he dcenlyd n, he an employer.'*
SIGL chapter 152. §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for-any
applicant who has not produced acceptable Ps of compliance with the insurance coverage required."
.\dditionally, MOL chapter 152,"si25C(7) states"Neither the conunonwee fth�nor any shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractorls) name(s). address(es) and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the•city or town-that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address'the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you hate any questions,
I le;tse dU slot hesitate to gi%C LIN a Call.
I ee Dep;uvnent's address, telephone and fax number:
i he Commonwealth of Massachusetts r
Department of Industrial Accidents _
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
;_ny�_Vi PUBLIC PROPRERTY
DEPARTMENT
NI 120 WAM H N(;!0-\S I REET # SAI FM MASNAL:I I I ,] I iSol')/'
f'EL:978-745-9595 4 FAX;978 74&9S46
Construction Debris Disposal Affidavit
(required fior all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CN1R section 111.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit ft— 7 is issued with the condition that the debris resulting from
�
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debt-is will be transported by:
_YS��imnie o`th�aulerlc
The debris will be disposed of in
7 aM—Cry!
(address of facility)
sigpiatuie of perout applicarif��
(late
,M)'i'affdoc
e
:r
,.'' °` R''-'gi`Ji* Board of Building r gguit om a
Construction S HOME IMPROVEMENT CONt"Pervisor License- 3
License: CS i1 Re9istraBon; 135559
Birthdetei,.6H411970 0 ,t -
Expiration 4im2010
ExP ra0 n i Type Individual
R 6F'i42009 Tr& 16110 x RostrioUon 00, - EVAN DEWIRE
EVANA DEWIRE EVAN DEWIRE
40 40 BOULDER DR >NH 03819 BOULDER DR
DENVILLE s ANVILLE,NH 03819
- Adm
-- Commis-nc��' ty.5
PLOT PLAN OF LAND IN SALEM, MA.,
DATE: 6-30-08
SCALE: 1" = 20'
OFFSETS SHOWN ARE APPROXIMATE BY TAPE SURVEY
BAY STATE SURVEYING ASSOCIATES INC.
100 CUMMINGS CENTER,SUITE#316J
BEVERLY, MA., 01915
�N OF Af
p ROBERT GNP
g JAMES }
SOTIROS
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