45 R BROAD ST - BUILDING INSPECTION II poll MUST III E :>T, VED BY THE l' �
JdSAE:CJIIF7 Q Rt 21MWMQ GRANTED , ,:;.
CITY OF SkEM
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Is Ropaq Loosed in Location of
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BUILDING PERMIT APPLICATION FOR: r
Permit to:
(Circle whichever apply) Roof Reroof, Install Siding, Construct.Dock, Shed, Pool,
/Replace, Other.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROC
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
speciffcatlons:
Owners Name 6ec/�
Address & Phan
Architect's Name
Address & Phone
Mechanics Name
Address & Phone CX1 r, Y woos 07)kl
Whd Is so purpose Go h~
mdum ar k~ N a dwdlY g,for how many emm"?
WN bukOW oonemt to ew7 ? '•. �+ '
EMimafad core. , D6 CRY Lloaua• N p` see Lloaw M 6 » S
� �L� aaBraa Lpa'on..ne
t Signature of t
SIGNED UNDER THE P110110"'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
IV O 641 l c/L(J
�r
'`� MAIL PERMIT TO•
WWQ
APPLICATION FOR
PERWrTO
5±,
3
LOCATION
PERMIT GRANTED
APB° ,.
INSPECTOR OF BUILDINGS
s
r'
PUBLIC PROPERTY DEPARTMENT
,! 120 ViASHINGTON STREET, 3RD FLOOR
'Sir1EM, MA O1970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. LISOVICZ, 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, S150A. /
The debris will be disposed of at
Location of Facih
L
�a� o
MgnatuiCof Permit Applicant ate
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
�/ 5,4 41
Name of Permit Applicant
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, S150A, and the building permits or licenses are to
indicate the location of the facility.