419R LAFAYETTE ST - BUILDING INSPECTION 'PL�N6�AtlST!!EfRA94ND APPROVED BY 741E
JeWZC=-PFlwlpil TV A PERMIT BEING GRANTkD
CITY OF_SALEM
No(�Sa- DabWWd
bld"
ft a OIk9d'i„ Yms No X oa of
Is PIMMY Loomm in
ft ConsuvownMrl
Permit to.- BUILDING PERMIT APPLICATION POR:
(Circ lee whichever apply) Roof, Rer)of, In�I id ft Construct Deck, Shed, Pool,
F4apair/RoD{ . Oth 1A )i nI�1
PLEASE RLL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSM
TO THE INSPECTOR OF BUILDINGS: '
The undersignod hereby applies for a permit to build aocorWq to the,
/
//'� e to
Owner's Name (�Ti2.9P �2FN/V�/� M
Address A Phone S'q CIS' lq�7,6 7W— /3 �3 r
Architect's Name
Address d Phone
Mechanics Name ,AJ ( /HRVA 4/
Address 6 Phone
whn Is to prpo of
mduW of NNW ��iN v L M a dwslNrp,for how m my fansm? /
wo fslldYq to kw?` ti a�S Asbeas?
EMioNed oft �v`city uc. • amr uo r
2 e Lie. I�ltwt
Signature of Applicant
$NOW UNDER THE PENALTY,
OR PERJURY
DESCRIPTION OF WORK TO BE DONE '
t
1 �A
A
i tl
MAIL PERMIT TO:_ BUNROEUN CHHOUY i
HOME DEPOT _
4 COBURN RD.
TYNGSBORO,MN. 01879
i
APPLICATION FOR
PERMW TO
/nP 1 IaeeAle,�
(,L/ M :s
LOCATION
PERMIT GRANTED
APP OVFD
IP69PWTOR OF 13L11 NGS
L '
r CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
IZO WASHINGTON STREET, 3Ro FLOOR
SALEM, MA O 1970
TEL. (978)745-9595 ExT. 380
tOO FAX (978) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge 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, S150A.
The debris will be disposed of at: 45 I{S GOCE(V W OUb , V1702 CP��r 2
Location of Facility
Signature of Permi App cant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
orrtg-
Firm Name,if any e
� u5 C-ar(2E&n,wbol� s , Ul)02CfSff�
Address,City& 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 cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
1—
i t - ,I r,nF Ct nnl.tlo �,
U --Ju,''b ,.�i �r• fnC A('
600 Was'hint ton Street
�i Boston, MaEs. OZI'l
Workers' Com ensation Insurance Affidavit: Buildin Pdumbin Electrical Contractor,
NO
14
Herne: I I ltN
CH HOLM l
`7 --
address: C o&,4 1 tj '\b
city iJ Gsboko (/p state: ti : I K7� phone# 1 7p --574(y
work site location(frill addressl: 7( ( /`4 r/—z T
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction[ ltg odel
❑ I am a sole o rietor and have no one workin rn an ca act WMW
❑BuildingAddition
INEW
&UMI am an employer providing workers' compensation for my employees working on this job.
count; name: OJtIFi eol-yl(Ce S
hone
In.ut n¢e eo. j P. 5•: CO•. 'fTC s K A S ✓av
I am a sole proprietor,general contractorf or homeowner(circle one) and have hued the contractors listed below who
havo the following workers'compensation p6lices:
como'tny name:
address:
city ` clone a:
lnsiurairee Co. Roliez a
comu�fovname•-. '
address: _ .
phone a•
insunoee sio. tic a
Failure to secure coverage as required under Section Mot MGL 152 can lead to the imposluoa of crimhul penalties a a fine up to SI X0.00 and/or
one years'Imprisonment as well ss civil penalties in the form of a STOP WORK ORDER tads two orsl00.0o a day against me. I uadenhnd that s
copy of this statement may be fornarded to the Office of lovestiptions of the DIA for coverage verification.
!do hereby certify under thepains and penakies ofperjury that the information provided above
is
true and correct
Sig,Latute Date 7 t�. U�
Prat nameo-1# 9]1r. L/e G 62
M -1 kvi+'.`.1�.?i:�6K �'Y.ca". T.i e? R"A-c ..- si:r^a-3'.7V�A�.-
omeial use only do not write in this area to be completed by city or towo ofticlal
city or town: permlt/iccu"eq ❑Building Deer rtmeut
❑Licensing Boird
❑check if immediate response is required ❑Selectmeu`s 01rice
❑Realth Deparla,eal g'
contact person: phone q; ❑Other t"
• (Rv6W Sept 2QQ3) t-
�Y..t �..-,.�
Apr 21 05 09: 00a Michael Bedard 1 -401-246-2068 p. 4
HOME IkIPROI}:h11BN'T CON9'RAC f
'.iakl,kantiah.a mul,",I"I
.. iU Abll unu5rn n<n.l l:
r �
d.A, Ih kl D 1 V II c :
)15A'11111 tdSlvlAh hbV 1'I
Branch Number:<<� Jnbq: -- L�GI loll Fnv lgdl)(A iF U -I i .hill
('f Incc sF�1.:^: :x1 A fh,mn hap.,enno;n<',il,ponl.Y 14,y a I.roANl
�/� �{(I/1q f
Instalwtion Address: _r-1 /^x'_�_.__ "t /n/f_!.'...
Unc
l l 'Ut rd f.yk lla't .. 1'- Wort;ll x _ u,ll
h
Horne utdraN: ¢.I..1". .. _.�!�^•.(...'-//z �J�G1j t'J
((f ddlrnnt front i nlallatlon Addres� Cin' %1;Tr Z,I,
PealedlofDrrvoaliar,: liWc:You{"Po;mhnsrr'l,d;rmu'ucrx v.'lhc prnnery Inullwentthe ahaweirem ....address,ollbr
contract with H.met Depot U.S.A..Inc.t"II DoPni'I to out ish,denier and.vnmgr to,the iar:afatmn of all Il,:,lc.i:J.u.
dilicnIN an de attached Spa.She..N: .Inc.ryo:meN herein F.y rcferen:e;mil bade II Pan 6arof.
ul/)fa'l s ,)l,--/3 s
/ 2 Hon.Ocput,twervc»the right to anneel Ibis conIL upon re-inxpeetian of the job,Home Ihpm flotomhtb law it
mlmI perform it.obligati...due to w Ill......on problem with e�t,hunlr or because work req Ulred to cnmplcic cic job
,•\Vlf xes not Nciuded In the cnntmi.
OY POtii'f I A\Mf M OPl IIII
<+ ei I odo. I, u
���-��� i' O h m SI Ilti M rnc YOIxn
CONTRACS AMOUNT' S /0t�TY ht I'1 lia III )
i 'LESS DEPOSIT S �7�— 1. t'win('ud'a,vi,ahenulrn:m III unnx-('trill One keW.
Vill NNNW..11nl rammtr A;n.re lyn Lalrr.x
7��Z h.unn.uen'InI:::'ION(IN C Imnrnoc,..x+1I
(1N%.F.'i
AlAIWC:olich I lltl .0 illrt'arRTfl
/
xd1fnlcom3S°/nufC:oarrutt Alnnuni Jar upon.scc:lliun �Ny37-0Gx 2LzN(,P
Y his coatrncl, Ir. �VV�� W�/'�s V.n u r y
I VI'C.IC IC. �sYQ N/¢41'1
IIIAIL'NIl'f tlxanl'llf]I e1hMi for ' -it vim' F V { Illy ll D I r Farp. -
RALANCEIONCOMPLETION:
14 I,\ I,�
-------------
/} --- HII or HUCC.Amthnnyallnn(Udes -
f .......,......
_._..__....___—_—_d.._____... ..
Pu clinci agrech fiat.inlnsdii upoll xalislliI e'nolkdon Ill the work.PurclaI will CXU'Ulp a<'nnn11di0IT On tW:,[c
:fortpayany Cxdanecdoe. Purchase.n1ilL1 Ucrecs In be h auntp and severalty('.bligmed and lianlc hereunder.
EMI r 'ru me Ih'. trrentcnle,ld it, a :1 II 1 tit L''In, ' L It '1 e_s"h'!INLI
,vfi whin llep .,I ran 1..I hea •,did ... olco,I,,wn1i,l,it, ,n-porn. pn•nin.s'pn t by ho f,p.lriie,
NOTI I:I I LI PURCHA.SI:IZ
II lhb tamtroet hefrrer or„d it. tow ora.alilh'dIn,—lin'letelh'fdrd in rupl ul'Ihrc mlr,ol ,1 the llo,.. i, N..,,
1 to Pr.nvl xnur I III I),I nni limit so,("ol Plelinn Curl f-oc nr uarcenanl xtalinµ thin can:uc-Iolmd a'na R,o,lie. ,.:i...
II Ihn 111',Ilt'x't iNvotilddrl•. IAW gY01111ln IUolle 1'Vlllh:'Imlriostom Iran N gvirtinll llr Olt'.t'.Ilt ntia('.nllnPli111,I't•'IiII-n,,,,.no4
Lc the nwnen'prior la the xeDu!completion of Ilse work In Incites formula lmdur Iho C.ntrion.
Port vitae euneei this transacdmler any rim.Prior to nddnnal of the lh!rtl business day after the datc of tills votirvet. `,N Nonce of
ClenctuillUn nor an eAidaaAilnn Ur dds right. 'I'III all,Ile a xerxete ehlinge a lod to 211,4 of,he clu tno l amnmu I:the Jnh Va
Cnleelved by Purdlu o.AITEA an,Third Uuunevdm'.
BY MY'01;1(SHINNI I MiLI IW.h W'1:AGII IIt111%InluA1)Il!"O I I.'RAMS 01'11 ITS C Ill RAC 1. 1N11 rdTNOMII ;Id
F h(hIF I UP A C'UI's OP'I H U,('ON I T II'ANtiIWO C'UNWLI fH)C:kill FS ill'I HL:NO I t v:if CANC i:LL it itrv.
BY MY,OLIII Sl(IN'A Ill nth. ill%[OW. LWf LINDLIt SI'AN0 TIIA'I"I 10: AGRNAI f.V'I IS St;RI I:(-) 10 ILI VI W' ,n. Vt Ili
C'R1 HISTORY An01 Wf AL.'l 11 lit/I H IMi.l l 01 Alll'.F)RI/IJ)COcl'R C IIR 0 VFFI FI AND RI\I1 W h'r'')1ITT
n(I �7"rl� NUI N 4 tl:fJ RI FOR 1C I N(Y .1�p Ik�l 1 4\I, T01:M WtUtd III I.L.IAIIII;TY
SUdelllI Is HY; tIILC`C1/11 7'tlNi\ It r( -INt IIFFI Il IpOM IVAD i In N
CRI ill I F . 1
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