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189 LAFAYETTE - BUILDING INSPECTION ftldl61M ST-BE fILf� APPROVEO BY THE JdSPF..CT'L1H PWR TD A_PERMIT DING GRANTED CITY OF SALEM N07M V� '� Date MARa, I 2065 s' r � •� r Is Property Located In Location of the Historic District? Yes No iu8 I K 1 &�4£rr 9 Is Property Located In aw Co mervatlon Area? Yes No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Replace, Other: K�PR 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 A + .T /1 Address & Phone 14 A V t7-£ (yl$ ) 7y5 7 y y F ' Architect's Name Address & Phone It ) Mechanics Name Address & Phone ( ) Whet Is the purpose of hulkling? &j£ L c t v 9 MeterlN of buklI q? f.jno D r-Rlim f R a dwell tg,for how many families? WIg hrrlldhg conform to law? s Asbestos?? r r'b, o )/ iir nr y ) Es*Wed cost // 7 oo CUy t.ice"r N A Siate Licarme K CS D �Z 6 54 Some Improvsant LLc- J Sl6ftfure of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE :# T� P,C. 4 MAIL PERMIT TO: t` _ _ i APPLICATION FOR PERMIT TO LOCATION-• Sy�te �r � y PERMIT GRANTED .` 3� 310,5-- 2.0 AP ;OV D INSPECT. OF BUILDINGS i The Commonwealth of Massachusetts Department of Industrial Accidents a office elimi dow - 600 Washington Street, 7rh Floor 1 Boston,Mass. 02111 tuz Workers'Com ensation Insurance Affidavit: Buildin Mumbin lectrical Contractors address: C 7 / '1 6k-, 1 DN fk V C ? city AA 4' ZA U 4N state: zim G) phone# work site location(full address): ! ,Fy 14 i C A €V-f Cr SA(_ tlm /Y_A ❑ I am a homeowner performing all work myseif. Project Type: ❑New Construction Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition (CY I am an employer providing workers' compensation for my employees working on this job t e vg : . ems+ f4,,ai�,afd.sit -N add city: " y, r*'t �" § P �s\ s✓s�.,�u r•.,.rTM a"' t �Sa naUrana.Cn. nn11CY %S ❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following er workers' compensation polices: company name... S -2 . CON S j OL L)CT r p N ram/[' address: apyTb t✓ R v5' c canlnBnV name: I s ra- s r 't'y= ' "' f .wa. e ka � r�' ^` de`'`..'€"e r: _ �,. .:"� c.. ,#;.a,,«a•„aiyrt''>�'a'r`�?4•�r`#.� t i .ti'${k +•sa."�?.F Failure to secure coverage u required under Section 25A of MGL 152 can lad to the Imposition of criminal pent in of a flue up to S1,5W.00 and/or one yam'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification. l do hereby certify under the eppa'ins and penalties of perjury that the information provided above is true and correct Signature ,��--'.^^2y' Date 3—�10 — )o026 ? / Print nlm P,r, j T r/`I i L ( £? Phone# ?1?9- official use only do not write in this area to be completed by city or town official city or town: permitillmnse# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Halth Department contact person: phone#; ❑Other IrcnuJ Se0l.Zlxgl - Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire,express or implied, oral or written. An employer is defined as an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity,employing employees. However the owner of a dwelling 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 maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 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 evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents OOtce of ImloSdIRtbml 600 Washington Street,7'"Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 �� GTk trianr9xnnwer>�l/r. od:!�aauu/uraefld Board of BuildingRegulations and Standards +l i'"aiy h License or registration valid for individul use only _ I. HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registrations 138581 g g Expiration: 4/15/2005 One Ashburton Place Ron 1301 'Type: Intlividual Boston,Ma.02108 - SCOTT MILLER SCOTT MILLER 57 THORN TON METHUEN,MA 01844 � � _�-• -- -- - - — ------- ------ Administrator Not valid without sig ature rt BOARD OF BtXt.D* Rii - �' ,,Lfeonse CONSTRUCTIOUSt Num4er"CB` tk$2650 ��,� . i 6Biidyda109416119Tfi �i ' 6fp '0�f118k2006 Tt no:.•.8209B� �! .,. ° • `.,. Resiridtad` 's i „ yi '� �� SCOTT,MRLER ��1� a (�wre.ak2�• .. �i k 5?THOE;N1'OH AkV� � METFtUEN, ktA: O'iFLf4 Ipls{tg x a l .�o CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM, MA 01 970 TEL. (978)745-9595 EXT. 380 FAX (978) 740-9846 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, S 150A. The debris will be disposed of at: A L L S W b rS P Pei 1.1 (. Location of Facility /lq.,l-Gi- L' -zoos ~ Sddhature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant S rM C n .. S f;F t,/C, r/ ov _r c. 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. Pl- 4Zr-g-y „-F sT V � N 40 V Z s Z � l l ,� ._._Z _ i t I t t 1 L GJ & GJ Whole House Remodeling & Restoration 978-387-9888 Agreement For : Astrit Mustafa 189 Lafayette Street (H)978-745-2488 (C)978-395-5192 Salem NH Work Description: Attic Finish Frame entire attic (43 ft.x 16 ft.) with 2 x 4. Insulate entire attic with-1043lnsulationv, () Install sheet rock to all attic walls Install Drywall to all attic walls Prime and paint all walls Install Carpet to entire floor Total Cost: $ 11 ,200.00 All Plumbing and Electrical work is owners responsibility ' Paint colors are ones picked by owner " Owner must supply cabinets and/or countertops