450 LAFAYETTE ST - BUILDING INSPECTION IPPROVED BY T44E
IIaLS,j? 1 IDiRA TD;�1 lPE T B,EWG GRANTED
CITY OFSALEM
&�L—_2x Date
Is Properly Located In Location of /�� / p_ L�
the Historic District? Yes_No 1` Building 4 �)4 l4 9w
Is Property Located In ^�
the Conservation Area? Yea_No- I
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof PlerooLInstall Siding, Construct Deck, Shed, Pool,
epair/Replace, Other-
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
Address & Phone / 7 L 7(/(— 3 L
Architect's Name
Address & Phone
Mechanics Name
Address & Phone C0 n� 7YG1
What Is the purpose of building? ; L e 5�
Material of building? I Mpy—&" If a dwelling,for how many families?
Will building conform to law? Asbestos? —7
Estimated cost 3 00 0 city Ucense k N A state Ucense N 0 Z 1"
tra Hom Improv f (wnt
/ JIS �
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE .
Norte
MAIL PERMIT TO:
d
r,
No.
APPLICATION FOR
PERMIT TO
_z
LOCATIiil
PERMIT GRANTED
APPROVED
-
INSPE%-TOR OF BUILDINGS
co ^ ' OF SALEM. MASSACHUSETTS
v6 PUBLIC PROPERTY DEPARTMENT -
a ° 120 WASHINGTON STREET, 3RD FLOOR
}, 7p SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
Z �q FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR -
DISPOSAL OF DEBRIS AFFMAVIT
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,S150Ar.,I The debris will be disposed of at: LQr7 0
Location of Facility
lo -3
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
a ref f t,11,1 ft11,"2-1 !R�
Name of Permit Applicant
Firm Name,if any
T_�k W lc_(3 6
r �
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•w rn fornmonwaahk 0/ / w4ackwietL
f�oann 600Wm�irylon.3lreel
.lames J.Camooe6 loa, W .aaaehuaslla 02 i i i
comtrussaorw
Workers' Compensation Insurance Affidavit
with.a principal place of business at:
Lk W 1 a 13 - S r 5�4� 1✓ivl , lyi�+ 01 9Y 7 b
ioarra.ar.raai
do hereby certify under the pains and penalties of perjury, that:
I am an employer providing workers' compensation coverage for my employees working on
this job.
CbA-U0, 113
Insurance Company Policy Number
1 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/Policy Number
Contractor Insurance Company/Polity Number
I
Contractor Insurance Company/Policy Number
0 1 am a homeowner performing all the work myself.
I unotrsano that a coot of this anteroent"I be iorwaroeo w the Office of Irrwdtaoons of the DIA for to•eratt+vik3dm atta that Wort b taeatre
coveratt AS reoutea under Section 25A of MGL 152 can Icao to the imooution of crsnina oermsks cor aunt of a fine of tto w4I.50000 Motor one
Years irwwrnKnt as-A at dvi ocnaldts in the loan of a STOP WORK ORDER an0o�a fine of s foo.00 a an atairttt me.
Signed this �/ day of , �iw _ Z-d U
Lic see/Permittee Building Department r�
Licensing Board
Seleamens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617.727-4900 X403, 404, 405, 409, 375