13 WOODSIDE - BUILDING INSPECTION i
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OVER BY T44E
�, IJAC? „Ii310RfP P T BEING GRANTED
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I iTY OF S, EM
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Date
-Zt7 0 ; ; '� 7 J U • 0-3No.
a'' Ward
j \Asivm' Zoning District
Is Property Located In Location of
the Historic District? Yes_No_ Buildings-
Is Property Located in
the Conservatlon Area? Yes No_
BUILDING PERMIT APPLICATIO FOR:
Permit to:
(Circle whichever apply) Roof, Reroof Install Siding, Construct Deck, Shed, Pool,
Repair/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 S Ati o rL/a (Aj P& w Ja
Address & Phone 13 Wo ej to c r b- S-r- ) 4 L1 SS(,
Architect's Name
Address & Phone ( )
Mechanics Name
Address & Phone ( )
What Is the purpose of building?
Material of building? If a dwelling,for how many families?
Will building conform to law? Asbestos?
Estimated cosA 7 8 D 0 �� city Licenser 7 3 L state License r O 5.2 xi R 7
O a Home Improvement l
Lic. 150&11 Signature of Applicant
oc 0)i(o'A SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE t�
MAIL PERMIT TO: L 6. LV C o.vS�
! 49 Mara (!a-
T.. gb0of( M/q O f 160
A;15f1 t,6
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1108 i7d qwt<, .. ,�..y ,. Ls,, r !r.td+.ww; -
!tar3iiit^ t s n,i wi«�I,.ra _ f ry "^.<5. rY. 1 ft .. - vt,i sd:.� j ,4..� _•
.,{,yr,,.( 'y q J y L Y �p py y }� y { ;}
♦Oi uiY'fib° 9'-iVf�{ �C.. 4 d..@.d� 9A+. ii Is Sr)jm°dY�bi ;$a.u1i I" A .A?. W 1OP� (.�4"4- Ala Cv
n.. r ,. $:»S 3kf�C) t .,a} t�Ii3::3 �.a, {'J'1 � �.tf. .:; r!>•.)h?i� + A'vi(,b�, I
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it 600 VV adn n ��rae[
Jame3 J.CamtIDell - /,oa(on. M o.:,�>. lle 0211 1
Commissioner
Workers. enrti:rr1 insurance Affidav
� Com P li
,M1
with a principal place of business at:
do hereby certify under the pains and penaiuts of P' ;.::y, that:
I am an employer providing workers' co tp ,overage for. my,empfoyees working on
this job..
-
Insurance Company Polrcy,,Number — -
O i am a sole propriccor and have no on me In any capacity, .
O Lam a sole.proprietor, general contractor or I: .:..enwner (circle one) and hive hired tfsn '
contraccom,.lined below who have the !o!!o i irn; workers' compensazlon polfdez
Contractor Insurance Comparry/f olicy Number
Contractor Insurance Company/Policy Number
Contractor lruurance: Company/Policy Number,
O I am a homeowner performing all the wori:
I unduAarta"M"a caoY of tea wurrKm w14 ba forwxata to the 0[r4z of of ene DIA for coverage vardictaoa++b out 41arn m.aftoa
coverage as rewrta unaer Sccmn 25A of MGL 1 52 tan,tao to uir rnvc::x.i of trcnmu oenatuta cortR u"of a Ma at,uo to S 1.500.00 Myer ens
Yeas' rmortwrmmt as wtx u'cmr oenaiuu mute Iom, of a STO P `NO }, i;.�..-i�ER- ano a fmt of S I OOM a oay atxw Ma.
Signed this ��/j�i _Ly o F . __. 1 u L'f a tl o o
Licensee/
PennitMe � — _ !'!^ing Department
:-i:sing Board
..,,L!ctmeris Office
th Deparrment . .
TO VERIFY COVERAGE INFORMATION CALL d ' -'.'2'7-4900 X403, 404, 409, 409, 373
'.T-pr rtmrnt '
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�uilDinL� ?Jt{tz!-mrrtt
ti
DISPOSAL OF DEBP? A: F_: YIT
In accordance 'vith �the provisions of ?i L c 40 , S54 , I acknovledge that as a
condition of` BuiIding Permit p.____ _ e11 debris resulting from t-he
c045truetion; activity governed Gy : u= 3-'.. '!ding Permit shall be disposed'of in
a :p.roperIy licensed solid vaste dispo: l 'r.cility, as defined by MGL c 1 _
S 150A.
The debris Lill be disposed of at : 'al `� f • O. i_lh � l 10 ��� (=�«:G
1tcL. on of f cility
ft �
Se Date
igaacure of= Permit plicant
4
t
Fully complete t ':e ± ^l .. > ing informations j t
(Please pr'_^t _!early) #{
fir_-------
' Name of Permit Applicant
— 3
Firm Name, if any e
S _
Address : City L, Scate 1
tl
8
f
The obove 'statute requires that dcbs : <_ iro the demolition, renovztion , rebut
or other alteration, of building or r :c::ure ' be disposed of .in a proptsly
licensed solid vaste disposal fiei.l_ t}' ass defined 'by KGL cll1 ,' 515W� I. thst
building permits or license's are to :cc +_r t
xte the location of fxc 'lity x