4B NIMITZ WAY - BUILDING INSPECTION milfumed lion
71) m
-� �Ao
: . >u4N1'P�c idjyo uohdirSsap��aag,
Pllrq"6PIPIxaJ0
17
A .
P?i�noua uol�eequs��oauo ru
isuoo
2 ?. Us) oou red eat ma�t oieullxOddy:
! � uonllowap
�N -
_. .. _ . os�y•ul gsuey�.
pe3enpuaa',`. •opoS:jo�agrnN, ,
tlogeA juaal
f3upglz3` uorilPPd
AlNO B`JNib�fl)9 EyNi1$ X3 Nf N»,OM~�IQNQU3& $IH18131d1710b;0'R
L5$ L «rai�le
Q L 10
:*um
Ps7 p-asilij.4�t
wh aka H, w� �r uopenwau?� e u!aai�!��i -
ot bAM iiop�;
c
OU
M�6g0�'41(6��!f6S6Stt^f�6'r41.
o�ato-sa:4'�fiA•.'P��7✓�i�AMvF�as�¢Nu.L7�nHsvl�oE�t
' gwaarfioci:,
1�.T2I'3�IRO�I'd �TISfl�j
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tcntataatsY natscotl.
MAYOR lMWA90IGTOMStr M a SALFN.MAUACtnnBM01970
Tel:9734745-9595 a FAX 9M740.9$"
Workers' Com nation Insurance Affidavit: B i Ik nIIden/Contractors/EteeMctant,/Plnm
A Specialties
bens
Name itit.ianar P.O. Box 53
�,
Address:
e;tyistawz;p: Phone V `Z$1 - 5- I
Are .a ens pbyerT Cheek tits appropriate best Type of vroJwt(required):
l.L�J d am a employer with q 4. 0 1 am a$nasal conteaetor and I
employe =(AM and/or part-time).• have hind the sub-coonaceees 6. ❑New construction
2,[31 am a wle proprietor ar putaeo- listed on the attached sheet t 7. p Remodeling
ship and have no employees. These subtonhacapR have 1 ❑Demolition
working for me is a�capacity. works=•comp.insurance. 9.
addition
[No workers'comp,insunau !. ❑ We are A corporation.and its Building
required.) o$icers have exercised their 10*0 Meetrlcal repairs or additions
3.❑ I am a homeowner doing all work- right of exmtptioa per MOL 11.13 PhuabiuB repairs or additions
myself. o workers?comp. Q. 152,41(4),and we have no 12 ❑ f
required.] CMPWYCM[No workers-
comp i
insurance 13.Ly l .t=
�• required•]
I
rAw•wv�ar docks box ri sane sbo an we the e.edoa bsioo sheady ttrtreats.! - . ... -
1tam,orrss vts wbeituir.mdvtr --
sWYWsh s.9.at a eeofdwsideeaeaaeeenmueTau6ieijaewrstQdwt
rCwasrm.e tar dak Ws twsr mace snwetsd sa eddttteest atwt err:`
�swamsofie.a�ben.tr.vaomadrer.rartnN
!awe an 0=110Ysr Arar6.providIns workers'eosepexwdow Aawraneajor ary sweployies Blow
In orw 6 Urn an j =tiers, /' podry . dJobsW
Insurance Company Name:
l�J
Poll M or Self-gas.Lie.�.•__W C � b(O 2 acr
F.xpituton naee•�
Job Site Address` _.City/State/73p• —
Attach a copy of tbi wortars'compensation Polley deehtratioa pap(showier the
Failure to secure covers S Po1Ir:7 number sad a:plratba dad}
Sae up to s1,um co armor required under Section 23A ofMOL a 152 can lead t0 the imposition oferimiaal t one-year imprisomnent,as wall u civil penalties is the f Pons o a
of u to form Of STOP W
5250.00 a ORK O der a ORD
ER F.R and a tine
Y !ice the vwLstor. Be advised that a c of this sta
tement tement May be forty Investigations of the D Y forwarded to the O lid U for insurance covers tHee of
p vsiticatioo.
!do Aersbr cs�_under a*p =red psnaldp ojpsrJary UraltAra/njorweadon provided avi ti trrra and comet
m ature:
ry� Dew j2k, t O (O ol
Phone te: �� ( fv �0 S
oJJfciaf use OAIA Do not write in tlGls area,to ba eowrpleted by cltp orroww oJyfcla,(
City or Town: Permit/Meuse H
Issuing Authority(clreie one):
1. Board of Health L Building Department 3.CltyRown Clerk 4. Electrical Inspector 3.PIumblag Inspector
6.Other
Contact Person: Phone N:
Crry OF SALRu
PUBLIC PR4PF.r1Y
DEPARTMENT
waa. IM , - ws�r .sr�x�.�oaw�msrd
ns74s+M•PAS VM?40 M
Construtbs Debrb 04ad AAWsvtt
(�egµicd ow d amoudas ad mwndoe won
is MMWW a wilt dw !o�bK Cody 780 CUR seedom 1113
pdmta,d dw pmvtdan
g�1dt i is�e w�d:s eeadtdea dot dr d�is:ewdtlos Aoal
:lde wee!*0 be d4owd of Is a Heed wrwo dhpmd fimU ty s ds&wd by MUL e
rse ddwia wiU be ftwVoMd byt
QXJ1S J4ibn 2c%OL 1
TA.ddWs wig be divosd o[in:
11 C ,b,n QII '� M���nn�q�v � cAe� 1�
(� MUIW
l(0CCI l earnon� �VlEArL)L .
�IW Wf dpremit a�ligat
� 1
10 - 1d ^�
due
�e >ooanoxo�euealN o�.it!<r�xrJz�ukG%.
card otl3uliding�tegul§Cons Snd�Steuderds.,
Constiuctlon'SupeiylsonLi�ense' ' �
iipene CS; 53899 '
B,�r3hil�te 512/1882
- - Bxplr tlon 5/2/2009 7r# J2959
ResTvrJ�{tpn 00 ,
TIMOTHYJ'EINN
tlUALOORADWPOBOX53. —4-- i .
$TONEHAM,MA02180
Commissioner
PROPOSAL
CONSTRUCTION SPECIALTIES UNLTA., INC.
P.O. BOX 53
STONEIIAM,MA 02180
Phone (781) 665-4410 Fax(781) 665-4411
L EN N OX BROAN-NUI'ONE
HEARTHPkoouc?s� A NORTEK COMPANY
c;l C-4" l`F ill 1 D—y — 07
�a ler�t
Homacuncit�-}o b� ; n�orm�b, b �or•cL �� odd+'+ionoJ r�cara �
We propose hereby to funri�h material and la complete in accordance with the above '
specifications for the sum or l ate.
AS ABOVE
Payment to be made as follows: For special orders a 50% deposit is required.
.
For centralvacuum and intercom installation,half is d on rough-in a due upon and half is due upon
Completion. For all other work,payment is due upon job completion, pQr cN 4.61 DO
Authorized Signature 1p 5-O t C-K.
J
NOTE : All plumbinghook-ups, carpentry work& uilding permits are the responsibility of the
job site general contractor or homeowner. Prices are effective for up to 3 months from
date of proposal.
Acceptance of Proposal
iTe Wow Pam,Wpm uW ommlimu an Yutllnery W whvWy+oppd Ya ua wtlotWA w do lho warlc u Nx'6.d. Prymmt wi110u ea0e u ceJinM Wow
Signature I.// ( It \, Date: 1
If acelepted please sign d return.
� o Ass,)c- -
0 A6 i)eX u0t r (may)
i I
What 1s the current use of the•Ru ding?
-AeK a�
Matenal <Building? . WOO If dwelling,how<:many units?
Will the Building Contgrtn to Law?;
Asbestos? .
Archited's Name
i Address and%Phons- (VL )
Mechank s;Name v �" 0 21
Address and Phone ekros
Conshuction Supervisors License# S3 g q HIC;Registtation#
p . ®� s Calculatloir
Estimated:Coat of pr�ed s1$.._—
Pertnit.Fe
_ . .. ..._ -Permit Fee i Estimated Cost X S71S71700-Residential
-----' - -- - 'Estimated7EostXSk4/S7QE1�.'_ _ -- --
An Additional S5:oo is added es an
AdmtnistratWe;charge.
Make-sure that all fields.are;propedy and legitiy.wd ten to:avold'delays=.Improcessing:
The undersigned does herebyappy-ror:a Building�Perrnit to`build°to=the above-stated,
specifications. Signed under penalty"of Psidury
Dat9" �0 � ���� '
P
-15
V
�� JJ
. . \ JotM• ..
Ali
o .
ar--
.a ALL-
_ -
i
L