329 JEFFERSON AVE - BUILDING INSPECTION � 4
i i l6i"f3Ef L `{ I PPROVEO BY T44E
11IrGTA>B , FTILtR TP '.pF17 BEING GRANTED
CITY OF SAIL EM
No. Date,
Ward
^ti
{ ± f\e Zoning District
Is Property Located In Location of
the Historic Diatriot? Yes_No_ Building
Is Property Located In
the:Conservation Area? Yes,_,_No_
c
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof Install Siding, Construct Deck, Shed, Pool,
Repair/ eplace, 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
Address & Phone �2 9 �F F�2 s o . Avg (97K) 7 q S- 9 y
Architect's Name
Address & Phone j 1
Mechanics Name
Address & Phone j 1
What is the purpose of building?
Material of building? If a dwelling,for how many families?
Will building conform to law? Asbestos?
Estimated cost 9, 8 0 0 ( c) City Ucense# State License a DID I /
Home Improvement
Lie. I OJr 19 L e�
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE (�
a CI
MAIL PERMIT TO: G L 6.9 L_Y C'owI 2 g
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600 VVa hinq r,—iIree(
James J.camooen l�odLon. /rl u LG 02111
. Commissioner
Workers' Compemariorl hisurance Affidavit.
LV
with a principal place of business at:
S-r o k
do hereby certify under the pains and penalties of rcrit,ry, that:
I am an employer providing workers' cor:pcns r on coverage for my,empioyees working on
this lob.
Q ~. :. 7-b
Inuurance Compatry Policy,:,Number, --
O 1 am a sole proprietor and have no CM for me in arty capacity.
O I.am a sole proprietor, general contractor or he ieowner (circle one) and.have hired the
contractors,iisted below who have the fo!!o•air:c; %%,orkers' compensation policies:
Contractor Insurance Compar(y/Policy Nutsbttr
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number.
O I am a homeowner performing all the wort: mysc!t.
I undeivand Wt a coon of thu wtement w,W be torvvarocd to me Oflice of ;n. _:::o.v of the DIA for.cmmrate vtM1(KX"an0 out IA"to woae
. coverm at r"xnm unov Swoon 2SA of MGL 152 can;tao to the nmovs.n c!o mina;otnaiues coma✓"of a(wN of uo to 31.560..00 a4ws,r tae
yext' irn u xnrt'a's�wtw at chm oena;uu :n me roan of a STOP WORK C)'DER ano a (we of f I00.00.a:wv agAtu nu.
Signed, this (Uy of
Licensee/Permitter _ !ding Department
c:nsing Board .
Sticametis afore'
(ch Deparrrnent
TO VERIFY COVERAGE INFORMATION CALL: 6 : -27.4900 X403, 404, 405, 409, 37S
Lo—
D15POS,�L OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 4.0 , 554 , I acknowledge that as a
condition of Building Permit 0 1 1 all debris resulting from t;he
construction activity governed by this Building Permit shall be disposed of :n
a properly licensed solid waste disposal facility, as defined by MGL c 1"
5 150A.
The debris Will be disposed of act .
location of facility
Signacure of Permit Appiicamt Date
Fully complete the folloving information;
(Please print clearly)
Name of Permit Appiicant
Lam �' 1J �nN 1 12 4c7' w(
Firm Name, if any
Address : City d 5tate
The above statute requires that debris from the demolition, renovation, rthat
or ocher alterar.ion. of building or structure be disposed of in a prept- ly
licensed solid Waste disposal facility as defined by. MGL cIII ,' 5150, u:d that
building permits or license's are to indicate the location of the facility it