22 BUTLER ST - BPA-2004-341 y•H
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lliISPJ:L�AFiPFiWR TD A.PZWT:AJEWG GRANTED
; CITY OF�„ A►L M
q
Date
No.:
Wald
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Is Properly U7oared In Looatioa of
the F dwt District? Yak—No— Ifu11din6 d c�
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the Cori-w wino Awa? Yen No
BUILDING PERMIT APPLICATION FOR:
I Permit to:
I (Circle whichever apply) Roof, eroof Install Siding, Construct Deck, Shed, Pc
Repair/Replace, Other. "
i
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSII
TO THE INSPECTOR OF BUILDINGS:
lThe underiligned hereby applies for a permit to build according to the follow
specifications:
1
Owner's Name
Address & Phone eu i 1-..e a i 851 o
Amhkect's Name L _e e�) C t 6- 1_Y Cc)ti' i
Address & Phone ( 'A Ak�OS I t oabJoV(V S31
Mechanics Name
Address`& Phone Q
What Ii Qn DurP'040 of tarudlrrp? /`t y �e �
Mat«W Of bLik rp? - if a dweWnp,for how many families? _
WW W idihp conform to law? Asbestos?
Eaumaled cost e 9 s 0 �= city ucense. �. 3 Z state ucenae r 0 S 9 LI 8
Permit Fee 6-3 0 V some Uwrovement
Lic. ! O o 811 Signature-of Applid t
SIGNED UNDER THE PENAI
OF`PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
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.larnesJ Carnooeu /,oalon. //lauacnua.lb 02111
Commtsstoner
Workers' Compensation insurance Affidavit.
I, L
with a principal place of business at:
l C/ 9 MA S-17 b,, t 9 �20
Icu,i»�w
do hereby certify,under the pains and penalties of pzriury, that: :
1 am an employer providing workers' compensation coverage for my employees working on
this iob.
Insurance Company Policy,:Number
O I am a sole proprietor and have no one wor.in,, for me in any capacity. .
O 1 am a soie.propriecor, general contractor or homeowner'(circie•one) and have hired cite
I contractors..lisced below who have the followin workers' compensation policies:
Contra
cwr Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Nutnbw
O 1 am a homeowner performing all the work myself.
I Ur4ftW na we a COPY of dun acuerttem wiY be fo,wmaeo to the Ofrxe Of Lrmopax:ant of the 01A for coverage wnhemon a"Nri(An eo.WIN*
coyenee at reaAm under Secuon 2SA of MGL 152 can Rao to the enaosrwn 0 amma oenatus eor=ww of a rm of uP m f I.S00.00 anafer an
Mean' morvam e t as wen as t va oenatuu to the tom of a STOP WORK ORDER ana a ruu of s 100.00 a Pay alum tm.
Signed this day of
Licensee/Permiccee Building Depariffinent
Licensing Board
Selectmen Office
Huith Deparrmeac
TO VERIFY COVERAGE INFORMATION CALL 6 !7.727.4900 X403, 404, 40S, 409, 373
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publit Vrnpsriy 33rpnrimtrit
Euilbing Urpnrltnrul
(oat tn1tm 6tstn
50a-7i5=9595 Fri. 36D
DI5POSAL OF DEBRIS AFFIDAVIT
In accordance vith the provisions of MGL c 40 , 554 , I acknowledge that as a
condition of Building Permit 0 , all debris resulting from the
construction activity governed by this Building Perm:t shall be disposed of in
a properly licensed solid waste disposal facility, as defined by MGL c 1-1,
S 150A.
The debris will be disposed of at: _�
location of frulity
I
Signature of Permir pplicant Date
Fully complete the following information:
(Please print clearly)
Name of /Permit Applicant
7- l J L V: C AN 1 a- C-711V G
Firm Name, if any
I 9 1`�'1a � � ST— MA O 1 ,7 E
Address; city d State
The above statute requires that debris from the demolition.. renovation, rebnb
or other alteration; of building or structure be disposed of in a properly
licensed solid waste disposAl facility as defined by MGL clll,' S150A and that
building permits or licenses are to indicate the location of tht facility at