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JdSAECIL�H IARRD;4 P. .RE NO GRANTED
1 CITY OF SPLEM
Date 1/3/05
f Hatoda�Y�in Location
bailt�dinng of
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On CawrvadM Arm? ris_No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply)( Roof Rerot Install Siding, Construct Deck, Shed, Pee►I,
Repaire, Other,
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCIIIIII WO
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Ownees Name Jeff Mold
Address & Phone 18 Beckett Street P78 ) 744-8731
Architect's Name n/a
Address & Phone I
Mechanics Name Frank E. Obey ,K
81 Centre Street 7
Address & Phone Lynn, MA 01905 L81 1599-1353
residential What is to purpae W WNW
MdWW or buNdUg4 wood I a dwoftq,for how many hmles? 2 bow
WE b kWQ ow9oml to law? Yes AsbwtoeT no !r
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$4,000.00
Edmated coal. CRY UON"e N P` &ate Clomp e CS 027156
Lie. 103699
0� V Signature of Applicant i
y.
wit
SIGNED UNDER THE
OF PERJURY I I�
DESCRIPTION OF WORK TO BE DONE
Remove existing roof shingles.
Supply and install new 30-year roof shingles, '� I
i�
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,a p
Frank E. Obey, General Contractor "
MAIL PERMIT TO 4ru
�i ; 81 Centre Street
I� !�� Lynn, MA 01905
NEtI r " N ..I
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APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
APP OVFD
INSPECTOR OF BUILDINGS
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Workers' Compensation Insurance Affidavit
11 Frank E. Obey
with.a principal place of business at:
81 Centre Street,-Lynn, MA 01905
do hereby certify under the pains and penalties of pe4my, that:
QC I am an employer providing workers' compensation covera`e for my employees working on
this job.
VWC 600461001 2002 000
A.S.M. Mutual Insurance Co.
'
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me in any capacity-
0 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation pofiei=
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
() I am a homeowner performing all the work myself.
i uneen "wt a coot of rho wun+ent wiN oe ion voto m Ox Ofice of Imvctaoons of the DIA :« corerate teeSRcation sne otx laire to wan
covenant y reorrreo urwer Section 2SA of HGL 15 2 on kao so the inooution of crreiani oen ot$corsarint of a free of w so41.500A0 ardor taste
r<an' irxuonn+rnt n vrI y civi rxivluef i� th< loan of 5-TOP WORK ORDER ano a fr of 5 100=a or ap:tst me.
3rd January 2005
Signed this • day of
ccr,seeiFcr,ittet T cuilding Department
�rruing E-care
Selecxmens Office
Gep:r7mitn .
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL (976)745-9595 ExT. 380
FAX (97e) 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: 225 Commercial Street, Lynn, MA
Location of Facility
0 1/3/05
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Frank E. Obey
Name of Permit Applicant
Firm Name, if any
81 Centre Street, Lynn, MA 01905
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 cIll, S 150A, and the building permits or licenses are to
indicate the location of the facility.