450 LAFAYETTE ST - BUILDING INSPECTION (2) dlIU T13E fIL ID APPFIOVED BY T*IE
II�S,
. PECTD.-R PFUDIR i[D A PERMIT B.FMG GRANTED
z
CITY OF SALEM
�S/off
No2-(o5 -2Op,� �.`� '�A, *�� Date
'ar <i�• i�t r_ �p
Is Property Located In Q/ Location of
the Historic District? Yes_No R Building
Is Property Located In
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: -Z4& fl-00Le 42V�' 1'dl-L
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name LI�140 F2(Cof,'f E121 ` 1P I A!V F
Address & Phone ^ y 5-6 44 9?dk — 7Y 3kJF-
Architect's Name
Address & Phone ( )
Mechanics Name M,4- full Co <n5 7�40 - 101JS 4
Address & Phone 6 ( 7 b
What Is the purpose of building? C
Material of building? A) (')I,) If a dwelling, for how many families?
Will building conform to law? Asbestos? N
Estimated cost*2r Q-V--b City License# N A State License # 0 2.S-J`o-7
1� a o �i Home Improvement V (/y// c0
�' r 7 — 8r�'f L{ Lic. i ,A1 'mil-t/Li� /ntt 0� C�
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
B S41lrwl� a S Aral ifGr ll�
0h Of 9a�a5 -e
MAIL PERMIT TO:
2�3
No. c)L�
APPLICATION FOR
PERMIT TO
LOCATION
Q PERMIT GRANTED
APPROVFD
y INSPECTOR OF BUILDINGS
i
OF SALEM. MASSACHU5ETT5
v° 3L PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3Ro FLOOR
2
SALEM,MA 01970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846 .
STA14LEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I aclmowledge 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:
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
rA GU 2( (2 VAS f ► C4 �' C1til
Name of Permit Applicant
Firm Name,if any
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.
Commonwaahk o/ 1 0.6.iac"tL
ris m, � � /l .l
� P l
Janus J.Camm" (�oslen, /asaae�ittss!!S 02111
Corrmrsstoaer
Workers' Compensation Insurance Affidavit
with.a principal place of business at:
. . - lta.rtsw✓strl
�do/hereby certify under the pains and penalties of periorya that:
I> 1 am an employer providing workers' compensation coverage for my employees working on
this job. ��i✓`J"n'L� ��, .
Insurance Company Polity
Number
I am a sole proprietor and have no one working for me in any capacity
O 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Polity Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
O I am a homeowner performing all the work myself.
I unoentane wt a cove of chit wtemcnt wo be ior.+aroeo to the Office Of Inrotitaraowu of the DIA low corerage•eriftcacen ane onat Lfiwt to Wcare
co. avt m reooreo unoer Section 2SA of HGL 15
2 on leao to the inch thjon of criwninai otnanln consisting of a fine of w m41.50000 MWW she
rear'imornonmrnt v W J "chi oenaltitt in the loan of a STOP WORK ORDER arse a face of S 100.00 a eat'aga+tst nx.
Signed this . day of S' h
/��� �/C�--mot � � I`" • ,Z �g�%<.a-� R
Lice/Fcrmittee —�— Building Department
Ucensing board
Seiectmens Office
}health Department
C COVE;-I,G;- CALL: 12% °00 X4C 404, 405, 40?, 375