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4A NIMITZ WAY - BUILDING INSPECTION o2�,1/— CITY OF SALEM r PUBLIC PROPRERTY DEPARTMENT KNZ UZYDanoou. MAYOR - tW WASF@1:WSr W a SAU04 MAUACM7WM01970 Toss M745-9595 a FAx 978.7/0-9W Workers' Compensation Insurance Affidavit: Builders/Contactorsmeetricians/ptnmbers Aoalicant Taformatton f_nne:truction Specialties please Prtnf Legibly Name j TadividuW' P.O. Box 53 stonahamr Address: City/State/Zip. Phone ll g( - (0 tc S-H 4 � C An a as employer?Check the appropriate bolt 1.0 i am a employer with Ct 4. ❑ I sm a gemr d contractor and I Type�I J (ro4 d1: employe"M11 and/or part-time).• have hired the wb cantracoota 6• ❑New construct 2.❑ I ane a sob proprietor .or patmar• listed an the attached sheet. t 7. [3 Remodeling ship and have no employees Those subeonhacmrs have 8. ❑Demolition wocktng fe tta in any capacity worker" comp.inatraace. 9. addition workers S. We �°g[PTo comp.irtntranee ❑ area tad its i erporatlon required.) o$lears have exercised 10.0 Eecectricat or addition their �� 3.❑ I am a homeowner do all work' right of M 11.b8 dL exemptionpes Plumbic ❑ a repairs or additions myself o re workers comp. o. 1S2.ces.( and we have no 12.k')Wm airs innn"nes requited]t empbyeos.(No worJree;' LRy✓ _ / comp.humane nq��`d•) 13. Oth 6Z 'Aw'wv"M dm dmb bma at moat da A0 ere dw saedas bdmw rhom hra tadrenrkarE Hmmtoeete who mhmkdkkaetdw*�,u dwyan dots"aa- ad dt.ab+ieaaedai mnK,aber a ow aA4drvtt hrdieafLaa tCoatraaara dw chaek*is bat mare saaebed m addhimd shoo alma orL er mess otthe ab.eataaaae anddrk..orke.a•oomPtryiofbtmatlaa l Qarmatl an sr ANbprovldlrj warhera'cowpsnsatlow brrar efor A amPloy"a' Bdow 4 the po/fry and/ob rW Insuratrce Company Name: 6 Policy#of Self-ins.Lie.# W C- (0 2-{0 Expiration Date: (� Job SiteAddtesa� J)iJ►,��7.- WOE i Ciry/StaterLs "U�'-�ip: � ' t,ars 1fT' Q �97.0 Attach a copy of the workers•compensation polley declsnyw pap 4howing the pulley number and expiration data). Failure to secure ccveage as requite under Section 25A of M(IL o. 132'can lead to the imposition of criminal tine up to S1.S00.00 and/or one-year imprisgmaeaS as well as civil penalties in the form of a STOP WORK ORDER and a ties of of up to S250.00 a day against the violator. Be advised that a copy of this ststan may be forwarded to the Otltee of Investigationsof the DU for insurance covemse veritfeation /do hsrrby cam under NYs POLU and pswaldss ojpsi/cry that dFo lnjorAtatlow provided abo Ar and correct,Signature _ rfy/�y"v /l�� Da a � Z1�7 Phone* 4(1./ FROardo(Health oa66 Do not wrfte b Nib area to be rompkied by cffp or town o,Qfe/a�4 n: Pertelt/I.Icense N hority(circle one)- of 2.Building Department 3.Clty/rowa Clerk 4.Electrical Inspector S.Plumbing Inspector Contact Person: Phone N: Crry OF SALEM PUBLIC PILOPEWN DEPASTMF.m alma �a��waia�or>ns4•ssa�as�aa�sot!'fd �rn�.a•�at•t�usrn�+►+w Constmdon Debrrb DbWal AAwavu (e""dt s>t 4awm s sd Mo m"wadi td seoa�ds000 wide sis�•dt M o[&s St"HuildtOM Cod4=CUR 6"M 111-5 ii pabri�d dr p�vvistan al3i!>L s A S11 suim%l ftua r to 1as►4 wilt dw eaoMm dW dw darts mubbf dart a&wads dM bo 460- d otis s ye4Fw rle="ww dlWOM Adft as dWi d by MM is T�s dells will bo transpoetd byt TM da&wip be dispowd o[in. cWhkow of&two :•�. yes dw i 00-35,000 of enclosed space - I - (MGL CA 12 S.60L) � 1A+Masonry only - - I I-'1&2 Family Homes :I .} Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. i . I :.I i I DIG SAFE CALL CENTER: (888).344.7233 �Jairamotiumwi ✓t'Larkn rr � BOARD OF;BUILDING REGULATIbN$' License CONSTRUCTION SUPERVISOR'S Number `CS (i53897 7, t, Birtfgdate Expires 05/02(2007, Tr no.•'�12Y07 i "^ �Resfricted 00" ( I y TIMOTHY J FINN e 8 VALDORA DRIP_A BOX 53 _ 1 STONEHAK hAA 021`B0 - Commissioner � � I • PROPOSAL CONSTRUCTION SPECIALTIES UNLTD., INC. P.O. BOX 53 STONEHAM, MA 02180 Phone (781) 665-4410 Fax (781) 665-4411 LE N N OX O _" GROAN-NUTONE �HEARTH PRODUCT A NORTEK COMPANY � R2Xno re q- IXCSVOsc- cv Plk��S�i`ns P�C4c� 46- CVl m(�eA C�nS ti�� �e�r�r7x 1�12 1 - 3/o + u1 �o Pcef(ce- tL S�4(e� Bar:�c�rns L i f I G We propose hereby to furnish material and labor- complete in accordance with the above . specifications for the sum of.- AS ABOVE j Payment to be made as follows: For special orders a 50% deposit is required. For central vacuums and-intercom'instdflaflon,'tidif*is aue upon rough-m anh'ndd*is hue upon completion. For alIl other work, payment is due upon job completion. I Authorized Signature 1�9xidin%�zxwn't-ege the-r w-ar i hi Ut.y of_the job site general contractor or homeowner. Prices are effective for up to 3 months from date of proposal. Acceptance of Proposal The above p[ia sped fiom ar v b ns ere Sa(rStu-rory gob ue neraoY acceG[M'tw ete eu4mi 8mto-tnewvfam3{ntifin4 Raynw-wWLcaVwvWivaLMw.c Signature Date: /S accepted please sign and return. �— iC1���tQ yVhat:�s:the eurterit uss p u�ldi—= `N:dwelling.hovs`ma'Y'units? Material of°Bum? Asbestos?. . . .. N11M tM 8uildirq Co^forta to`Lavr7 grch,teeCs'Nart►i Address,"Vhonli' Mectiank's tJame , , lb� Addrese "andit �.(!c c«►etructlort Supervisors can, C ©Cp 31' 7 kltC'FTagitratwn:fi Estimated Cost of"ect i g� a , ' Permit,F.ee.CalwlaUon PertnitFeri Estimated=Cost X,$7J$4000'RosidentW Estimated coat-x-sy t!it000 Commecia�-- . _.. - An Additionsl,$5-00 isaidded,as an Administretive.aharpe. INake;sure=that+all?flelde ars properly and leylbly.:wr(ttbn>to%avoid`deisye lif processing• . The underalghed dose hereby a pply'fora°Building Parrnit.wb-bW W--the•atiove-stated apeciNcatbne. S,ipned:UMdf-'pen`allY°of.°Par_ury /t._-V Date nl0 o � N At a •� P a a ,B ' • t �.#P'�. .. #v � •y . .'1 '', 4�h��j Ste,,` !� ':L°+ r 1 s : �J -b t 1, e . i.. �•v a , r