410 LAFAYETTE - BUILDING INSPECTION a
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What is the current use of the Building?
J1
Material of Building?ZZL-� If dwelling.how many units?
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WIN the Building Conform to Law? Asbestos?
Architects Name
Address and Phone ( )
hJ d N U'Q'
Mechanids Name J rCa
Address and Phone 76C �`'-A "`
Construction Supervisors License# HIC Registration lr D
Estimated Cost t o t'ID Permit Fee Calcination
Permit Fee: Estimated Cost X$7/$1000 Residential
Estimated Cost X$41/$1000 Canmerclal---
An Additional $6.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury x
AA^
Date
N
CITY-OF-
PUBLIC PROPERTY
DEPARTMENT
KnaFxrz r Dsucou.
.%"VM 130 WwurrCLt�N�`nE[,T '
141.M745-9S"•FAx 970.74&gW
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY VaSTING
STRUCTURE OR BUILDIl (:
1.0 SITE INFORMATION
Location Name: 4/6 ZA A Vle-t Building:
--- -
Prop"Address+-------- - -- —- ---- _ ---- - -- ----
I )
Property is bested in a;Consarvatlon Ares Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: S
Address: 410 441-Z)hC7-
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use pw
Demolition Existing
Approximate year of Area per!l )or (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: o r vq t- 4�4) fd r- ,.O r G Te
Mail Permit to: O C FSStX j J'l�J--.Np 60T
CrrY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.lusr'ntxr ttatoxxru
?rLtwte in was csit rott*eair a UUML Nasttacie. 7ixOHTJ
Tu:9W4&"" 9 F.sx:9W4o.9a4e
Worker's• Compenat)oa Issuran"AfMfdavlt: Britlien)Coa&actaWEleetrldsna/Phmben
A
Name tausiaoWorbaa/:,rierlwrvrh.11:
Add 61 Gib
City/Staglozip. e lL. — . t'ttotte N: 2d—.2
'troy an emplayert Cheek the appropriate h
1. ost
awe empbyor with �_ 4. Q 1 ant a Senegal caolroetor and I KkAunmWO&
o1�(►guilevo.
2.[31 amoma sae(rull Anwar part-time).• have hired the sub-cuntru-tora caradructionptoprieonr or partnes- listed a the attached sheet 1 modelingsip and have no employoaa Then haw molitionwanting for am in any capacity. workers'carp,inwrattaailftiag addition(no workers•coalp. ittnuraacd S. Q We am a corporation end itasquired.) otfleers haw examined their ctrical repairs or adduiona3.Q 1 am a homeowner doing all work right ofexamptian per MGL mbing repairs or additionsmyself.(No works'cmnp. c. 152,f I(4).and we have no f repeiceinsurance required.) t cmploy�NO workers• er
comp, insuraaus Mquirod.l
n+ppaar fir elfsels ear al nup aYe as c.a a■aaeuaa twfaw row q flit srarlw•wngeaawifa pWk9'aarnmWO&
•I l.newfwfafs vita elamY flit alllawY say an daft'all wwY W dw Nta aaftlsa evffmaofsn neat auema a now amdave idldina uwi;C'ualratlln 40 anal ells es afar a14eaN an adeklmal AM 11dowins as nose sees aheenaacspa ad flair)sallow dtolwgd�ftntk7'i
/as us eadAl"Or that b prevldtag wonbrs'roa0entraden lnsarancefor fey eaploydres Below Is tAt Bc ant/
Insuratttx Company Vamr.���i ' �i�S�YyOY�C �,, ,f tl .
sft
Policy s at Salt--ins. Lek/. p: ._ .. Eapiratfon Date: r� �T 6
JOo Site Adchss: TI Z. J N G I F Z City/SutuZip: l �
Attach a COPY of the workers'compensation pulley declaration page(showing the Polley number and espiradun date}
Ifailurc w xcum coverage as required uadcr Scctioo23A of.%IGL c. 152 can lead to am imposition of criminal penalties fine up m S1.S1W.00 rnd/ar one-year imprisamncnt,as wolf as civil pritallican in the form of a STOP WORK ORDER and a flat
-If up to S250.00 a Jay agaimt the violator. lie adviscd thug a copy Of this slaWanum may be forwarded to the office Of,t�o�sn�aumul OI'the DIA for scriffcation.
/do hereby cerri as ♦ ias unJ prrreU4r o/per/nq lbw rift la/eratsden pr ow ded o trot euJ rorrret
Ci••:r.fur•. } O �
d)Qiiriel eft ow/p no ear wda/a thk arrat to he roapkle d by d)p or Iowa op lid
City or rows: PermiNUecaa M
Isautng Authority (circle aloe):
1. Board of Ilralth 2. Building nepartmesl J. City,'foao Clerk 4. Electrical lusp.ctor S. Plumbing Inspector
b. Of her
GnUael Person: _ 11hona p:
Information and Instructions -- - -
.%tars tchu"'Us General Laws chaPgsr 152 tequinrs all employers to provide workers' canpensation for their employees.
is defiosd"",.svet7 person is the service of another under any contract of hike.
i�.rsuartt to this st:tnrte.as esyl�'�ie+
c.press at impli oral or wrhtM
_ naoeiataoa.o wporad"or other kph etatiry.or say two ir more
.A the fbresoints easopd i° �� �th kpl r���vcs of a deceased a .nor�
reviver es reveres of a iadtvi&"parmershy,assoaat"or Oder keel entity,empbyi $anPby� of the
betas bevies act roars than den apowt"as sad who twirler dentin.W the Occupant
owner Of OfkO11ee who employs Petsntt o do maieseaa OM c.�tim or repair work on such dwelling hotw
err other is a these»spas rt"beeeses of WAcb ese "Moot be doomed to be an empbyer.
Or on the smunda s
htGL chapter t 52.42SC(6)also stoke that"aver!essts M be d Mosedut army shd wduMY the Iseesece Or
toOPerab a belies"or to eonswest btti~In CMeese saner"fee tray
reaswed d•aeeels w M�leietsd *VMS=@ of compliance Wulf the lawraace coverap requir
appocant subs baa set cared nor any of its poli atbdivisieaa dell
Add d"011y.MGL draper t 52,125CM states tical work umil accept- Is evidence of cwnpliaace with the insurance
enter into any contract for this periormaece of oa
rcths contracting attthoeity"
quirell cots of this chaplet have bee presentee
Applicants
Please All out the workeea.compensation affidavit completely.by cnumbes the boos thawith
spiry rt your(s)Of
ae4 if
naves my.supply s)oasse(s),address(es)and pboas munbar(a)shoos with their employe"
Other
abilit. Companies(LLC)or Limited Labt7ity Partastdups(LLP)with no en+pbyesa other that the
utnu+a� Lmugsd are not required o catty warkan'ee°�006�anca' if an LLC or LLP does have
mein)y or ppolicy. uirsd. !le advised that ibis affidavit may be submitted o the Deparhnmtt of industrial
employtsts.a policy le req o f insuratxe covMlp Ass be sure to vise sad dogs the amdavft. Tlw afll&vit should
Accidesgs for caalitahsaett that the application for the permit at license is being requested, ant the Depsetmeot of
be returned o the city or sown the low or if you an required o obtain a workers'
laduaaial Accidess. Should you have any questionsnu bee lid below. Self-insured comfeems should enter their
compensation policy.Ones call the 134FRUMM` a number
self ittsuraaea license numbercos the
aPPMELME City er?owa OQldsk .
— - to ib The Depareelar has ptovdded a spot+at the horrors _..
Picamsc be sure that the affidavit is complete and pr'utted a ly
of the affidavit for you o full out in the event the Office of Investigations has o con test you reprdins the apPileattt
t'lea" be sure to till in the p,trmitllicensa number which will be used ana reference bmit one atYtd t t addition,
ndicatins current
that must submit multiple pertniviicense applications in any given year,need only
policy information(if necessary)and under"job Site Addrc""the applicant should wrier"all may b p id (oily or
town)."A copy of the affidavit that has been officially stamped or marked by the city or own may be provided to each
the
Applicant a proof that s valid Aldsvit is on fro far tours permiicense of ts licenses.related o any business w Cwmnercisl be filled lvvennue
year. Where a hone owner r citizen is oa sate.)saidlperwa is NOT rcgtrued o complete this affidavit.
t i.e.a dos license Or Permit 10 bum
t he OI liae of 111"Itigatiuns would like to thank y.w in advance for your cooperation and should you have any questions,
lcaae du not hesitate to give us a ill.
The Departmrnt's address. telepbone and faa numbW.
The Commonwealth of Massachusetts
Depatmteat of IndugaW Accidents
OMM slinwdpdod
600 Warhio6011111 Street
Raton,MA 02111
TeL 0 617-7274900 cut 406 at 1-977-MASSAFE
Fax N 617-727-7749
2evi>cd 5-26-05 www.mass.gov/dia
CrrY OF SALEM
PUBLIC PROPRERTY
DEPARTM- ENT
aL��•s l�'r.�9N::JNS 7aaT•fAt:fit.uAvt�ta.t�1f::9
ttit:YO►7af9lrs•f.�tt:9nJ961W
Construed*& Debrb Disposat'.i►tiiidsvit
(required lbr an denwtidon and tmovadon wont)
In aecar imm with the whit edition of the Stets Building Code.7W CN11 soctim t l l.S
Debi*and the provisions of M- GL.a IQ S Sk
suildinS Pamb N _ is issued with the condition thou tit debris resuldng ftm
this wet shall be disposed of in a properly licensed wags disposal facility as dented by WIL a
I11.3 is"
The debris will be transported by:
_ W
tna=ofhSWd )
rho debris will be disposed of in :
t awne of rxd�ty)
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