272 JEFFERSON AVE - BUILDING INSPECTION (2) 1:' L
fLlrfls �+ YEG BY T41E
+'l�QRi AIMING GRANTED
CITY OF SAO.EM
e ' or.on
� ti iea.eus�taisoana Of
�e
on llf"Wh Loodod ID
Oo swalloe NNT YZ_No`�
BUR DING PERMR AP PUCAtWN FOR:
' Pennk to
(Ckft whMwwr apply) wvwFe Roof Cwk .Do* Shad, Pool,
Ra�pal
PLEASE PILI.OUT LEGIBLY A COMPLETELY TO AVOID DELAYS W PROCE@NM
TO THE INSPECTOR OF BUILDINGS:
Tho undemeOW herby appft. for a partnk to buM am oft to fIM fft....
Owmes Name s bn S
AddrM B MOM 34 wGdJwd� l� rQ�d) d (J=-73J"/
Arohkect'e Name
Ad*M 6 Phone ( )
Meftnft Now —TO i•^' 1 W C 14 c ✓
AftM d Ph01M 39 Chire Ix 117 2Yrse 1
What Is to papaw qp} ldALt.o �UVeY.fid G j,+�''W.
lrww a ewldYgt wcoc r.dwMnv,for how winy aonMo4 y '
wo eraano aadomi b es M0
' �O._�00-0 phUnnwf N rwinuoowo CS o 8zz6z _ ON-ftw_6.
a-
/ (� U4. /
n o plloarif
J SKiN;;D UN®ER THE
OR PERJURY
DESCRIPTION OR WORK TO BE DW
C,c,,,fi —{b Ga- ;
MAIL PEflMIT TO•
I
In
1( E
i
pr n w.r. 6Y a. r. r.. s. •.M:•,b, o- tlns.3ii. 4C a ti
d
r'
S '
j. .
7
40
: 1
�1
Vs`
r — --
NUMBER DRIVER'S LICENSE Gr
S52578495
DATE OFBIRTH CLASS REST HEIGHT SIX 'M
11-04-1963 D 6-00 M g
WIRES-04-2008 "
HERSEY -P
JOHN T
39 CHASE ST -
LEFTSIDE iaa.:Bsa ea, s:
BEVERLY,MA
I. 01915-4338 /9 T " -
4� �
BOARD OF B3UILl ING RE Cl O S 1�
License: CONSTRUCTION SUPERVISOR
Number: CS 082262
Sint
hdate: 11/04/1963
r A i
�ExpTres; 11/04/2b05
Tr.no: 7826
Restncted:'00
JOHNT HERSEY: :.'`
39 CHASE ST
BEVERLY, MA 07915 � �
Aaminlstrator
i
I
PUBLIC PROPERTY DEPARTMENT
120 WAsMmmm STRE.ST, 9RD FLOOR
SALEM,MA 01670
TEL (970)74"595 EXT.360
FAX (Y76) 740-9046
STANLEY J.IUSOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I w3mowledge that as a condition
of Building Permit N .all debris resulting from the construction activity
governed by this Building Pe nut shall be disposed of in a properly licensed sorwwaste
disposal facility,as defined by MGL c III,S150A.
The debris will be diapowd of at:
Location of Facility
Signature of Pg#fApplicant Diu
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Tiw l • 14erjeL
Name of Pemnit Applicant
Firm Name,if any
IP 044sc -5--/
Address,City dt State
The above statute requires that debris from the demolition, renovation,rebab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGI,cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
� foeymmonuh:ah �Infn1o0� +,lal6aAG"atb'
6
U.Pa,lewf ./.J.�,isldt�rccia.�
600 W-1611m 31,ssf
02 1 ,1
Workers' Compensation Insurance MUM*
is
. . with.a principal place of business at:
. . Icavue.erurs
do hereby'cersify under the pains and penalties of perjury, thus
() I am an employer providing workers' compensation covcrate for my employees working on
this job.
Insurance Company Policy Number
V I am a sole proprietor and have no one working for me in any CapatiLy.
Q 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who-have the following workers' compensation polities:
Contractor Insurance Company/Polmy Number
Contractor insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I rno.ncane erne a cony of rhb wu+nene vM Da iom areee m the Orks el Lff,,k tom of ft DIA few CV. 29e .erirrtoden WA CM LAM 10 aeeere
co.erarr » reav+eo unow Section 2SA of MGL 1 S 1 cm kae w ene inoae.rien of Rv,.ror oeeuroa eorJoC el a hag of 0o mi I.S00A0 One
feire'inxoorrnenl>f sA u cini "vaiaa it rnr io m via STOP WORK ORDER ano a Arse of S 100=a ONat,nat tree.
,^a y _ �Y
Signed this • �� day of /l
:iccrseei F crriuet ouilding Departn crag
i.�ten;ing Eearc
Seiemmens Office
nc:lth Dep:r'men.