51 LAFAYETTE - BUILDING INSPECTION fli�M6t�EfD AppROVH)GRANTED
��Op pglpA 7p p.PEAMtT �tNG
CITY OF SALEM
Location of`/ l v
c / luildin8 JJ Lt�ATVC
is PropartY locd�InYam_—� x
ma Hwaie owifid?
ow carmierA99n NO
Al"?
Yes,
BUILDING PERMIT AP Shed,
FOR:
B W
Permit to: Roof, Reroof. Install SidingTr Construct Deck. Shed, Pool,
(Circle whichever apply) RepaidRepjacs, 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 tolbwinq
sPgIoaOons:
9 r lS L, 1. •�,
OwneesNeme )-7 AL00 ST Sv /c lDo
Address & Phone
Architect's Nam2o9� , l9?� 7jY 7379 -
Address & Phone S c oN ScR�e 100
D• -0 axs
Mechanics Name
Address & Phone
T, s• AKA,
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SIGNED UNDER THE P
�� OF PERJURY
U p CRIPTION OF WORK TO BE DONE
L .STOd 6VA 1 S 2
MAIL PERMIT
.a
1
NO.
APPLICATION FOR
PERWr TO
LOCATION
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ADDltexnt Int4rmatlo>t Pleas!bw L'o+hh
Name
CitYMdw7RQOL/2CX , *A C--164• Pbmla6/?. 71q - 76,ate
Are you a■est filter!CbO&the#ippeoorlats Eats' - k
1.❑ I am a eaeployer wvili! t. I am a penal casuaetor ad i
asployeq(LsB ssd/or Psri'dme}� Lave Eied ti�mltaearaalo�s 6' ❑New oomaunedoat
2.01 am a sob p Mpsietor or parmao- liDed on dwsttsrisd ska i 7. JR
73me sub multsmu bm &ship cad have m esnpbyea DemoHtioa
wad ft la cat is may , r. 'to 'con*issmapca p. ❑Bwlft addition
[No wodwal camp,inasaoce S. El we ate a aotppAdo'i'soq ib'
of O e: 10❑F.Iwwwrepaha or addition
3.❑ I am�homeown doing as was fi*Of � � �p mm 11.0 pha upsks ar addidm
my"m[No wodrane'.eomp �1(� ip�i�ieBsvei'no 12❑Roofsepan
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1learoraae wile alma ads now" an w 4 ft a WWI and ar�am�oeaaice�e eloksebu*a ens ealdrva his acts
>Cans.eace6etdrdetWtiea'�mseceeraed eddafaeelcuedbahatieeaaeerarwimeaWoemdDeiwObW coup po"h& nw&&
Isaea/twills).tAefbpnpptdns:wr4ars�eoasprasarliabssanauufi►sgdtrple)tIs DdewbdapellgassdJolalss
befwssadas
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Job Sine Addaearvy�l'sT.9L S? cstytrnip S�Gi- /1,',4 ®�470
AttaCh a cagy of the worbW muspeaando■poky dedaratba pap Gbow&g tbs poft m tuber and esplratlou date).
Mine to secaie coven s s regimed order Saedam 23A ofMGL a 152 cm kad to me imposition orahniad penaltta of a
floe up to f l'somoo and/or cawyear hopsiso®eeet,w weB as ciW paabia ie me fmm of a STOP WORK ORDER and a fine
of up in f250A0 a dry apical me vioWw. Be advised mat a copy ofmk shteaxat may be farwaeded to me OtHce of
Iavadptions of me DIA for masrsece eovenp vcd&mbs.
Ir Nan wedar pabsr an/pssalrYas ojpa/aq rAas rba 1afa+acellosOrovllrt above hr awl and earrr:rs
Phone* 6/7- 7/ 9 . 76 g.S
O,p?cld arc mib& D•no*Tft An A&any to k e*mWldt/by cadorfew*,Okla
CHy or Town Permk/Ileense N
fuming Audwrky(cirde ones
1.Board of Hakh 2.Buddlag Department 3.Ckylrows Ckrk 1.Mftwcal Inspector 3.Flund"g inspector
6.O&W
Contact rersont rhoete N:
s
Information and Instructions
cm=,a,� 152 nquaa an O100 & MY aonuad®fhire. `
naat
b this som an dwPbiw is Awned a"...every Da'�
of implied,oral of wri c
aospoo8oa err oma kid asiRy.or ssy tan of moth ,
asas eta dooa to aoPlaYa:or tL°
At�- b» atapsiss, the lepl reptaeata6va. As
>aocixdn or oma W ashy,emPlOymi�bl�0m aFq
reeerva err Ism ouse��t �oiea apa�m>�and TAS resides&CMK of�a�
owat of a dwelling MOfo employs persons b do ,oomuncdoa trot
adwelling��tppu www Saco than sot because of snd mploymcnibe darned b be as anPloya."
MG,cbVw 132,42SC(6)90 thus mat"sveq atata or toed dt4311119 A F"wftbhoid the bona."or
r"cwal d•deesas err Peps to ova a bad.ea or to eomdrud bld"V the"mssoawatlb for any
mamesm wbe has sea Produced'e�evidence of w�the laa r torerap POftdb6MON
�uy,Um chMjw 1a 42IM scats"Neiman ma aongewnwalm�Ooom Haeee ;loran"
cater into say cound fog the paimmae"ofpnblic wok Haul aoeepmble .
requ$eumsofthiscbVw ban boa Pun"b60cesi acbs=tb**.!
• affidavit comple*.by e1►�as boxes ant V*tayats s�9 A if
neoaarY.snPO��-�0ados(s 'l"dins:(")a►¢17>►"a au>lm % alai with amployeess)odw ass the
ios4� Limited LiabtlhY Cmepssdss(1u7 at Limmed Liabt1Wt ��IZ,C,of Lty dons bave
IDembaa of Patinas! b carry -
a��,�t�aed�Be advised ass this sffidtvjb nraY to b the DaParuoeat Of brdusMal
employees, of immtmee oovesaPs. Alm by�tO'ip'ad date the atndavL Mw affidavit should
Deparmacmil of
bAocidCWS e r d bcoa lbs ant the spphcxd a ere as permit or dame it being n4uase4 a wafkens'
�dmuialpccidests, Should you have any 4nadoas as taw err dyou are tegmsed Se sboald c"w*ek
p�sscanthsl)epllranca<stae"IDbaAbedbelow. l4imorod'eanepaoies
des on do lift
pq or Town Of lchm
lose and printed le&IY. The 1 gzft em has provided a spas at the bottom
please be ine that�'� 0d� tiom has b contact you reg ngn dw app&,L
of the affidavit far you b fin out ont io ere evem>ba C>E&a of Itvstipa � In additios4 at aPPlicaat
please be sine In do in the paraWkema number which win ne be ed n a refaeace member- indication""rent
au mist mbusk msltiple pan ne apphcadom is soy fiN"Yap. camneed only writ one affidavit
mformataa(if necamy)and under"Job Site Address"the applicant aboald write"aII k►adons is (ettY
of
Pot Y. ant bss boa ogjcb*harped abed byC g c*a boa me/be lao Ucd b m0
towns A copy dths al0dtvh a licenses. A mi af6davtt mmtbe Md out each
app]{Cam an proof ant a valid affidavq is"fik for Ams not Iebated b sty basis::err oomtaei>d vmbre
err.Whese a boms owaar or chines is obmmio� less Isis AM"
a doh sites:"oc Dams b hart leaves ere)said penot it NOT regaaed b ee®P
The O@]ce of Iavafttions
would lily to thank you in advance for you cooperation and should you bave any wesdOUS,
please do rot besAsts b f�ns a ea1L
'roe Dcpxta'cW$address6 tekpbooe and tit:m nber
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oda of favesttpdon t
600 Washington Street
Boston,MA 02111
TeL #617-727-4900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
05/01/2008 13: 19 FAX 8174789121 fa002/002
STPAUL
TRAVELERS WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GKUB-886X292-7-05)
RENEWAL OF (GKU9-866X292-7-04)
INSURER: THE TRAVELERS INDEMNITY COMPANY
1 NCCI CO CODE: 11347
INSURED: PRODUCER:
DESMOND ROLAND DUPONT INS AGCY INC
CONSTRUCTION, INC. 410 WILLARD ST
91 MAIN ST. , APT. 1 QUINCY MA 02169
QUINCY MA 02169
Insured is A CORPORATION
Other work places and Identification numbers are shown In the schedule($) attached.
2. The policy period Is from 05-22-05 to 05-22-o6 12:01 A.M. at the Insured's Melling address.
3, A. WORKERS COMPENSATION INSURANCE: Pan One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
m=
B. EMPLOYERS LIABILITY INSURANCE: Pan Two of the policy applies to work in each state listed in
Rem 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
- C. OTHER STATES INSURANCE: Pan Three of The policy applies to the states, If any, listed here:
SEE ENDORSEMENT WC 20 03 06
-e
D. This policy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
e�
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating
.� Plans. All required Information Is subject to verification and change by audit to be made ANNUALLY,
DATE OF ISSUE: 05-03-05 DS ST ASSIGN: MA
OFFICE: ORLANDO INDUS AFF i61
PRODUCER: DUPONT INS AGCY INC 75XGD
a000as
V
CITY OR SALUM9 MASSACHUSMTTS
PtJBUC PROPURTY 09PARTMUNT
120 W"M'NOTON SMAT, 3119 Fubom
SALEM, M"9Ae"S"" 01970
'ral"W0119: 97►,4 .90/s W. 390
FAR: 979-740.9949
��lli/�fyrel 1pw�.
Ia accordance with the provision of MGL c40 S 54
our
Building Permit is that the debris resulting from this work shall befdisposed
Of in a properly licensed solid waste disposal facility as defined by MGL
Chapter UL S 150 A.
Mm debris will be disposed of in:
(Location of Facility)
*patmZo-f=A=�ppWt
5 -3 D (0
Date
. t IA IJ n�Il rs, s ur.{ 1 e i d5 W
:.,
1oP F MPROVE MEN* U,i.RAETOR pp::
^ley i ratrbtY. 139112 Gi
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BOARD OF BOILDINa REGULATIONS +I.
License: CONSTRUCTION SUPERVISOR ,
i Number CS 084144 E
t Birthdate 0 8/1 211 9 7 1 •�,.
a g-i
Expves OB/12Y2006 Tr.no: 84144 t_
Restricted '00
DESMOND M ROLAND I'
91 MAIN ST
.,
�.:>,tOUINCy, MA 02169:. - Administrator