4C NIMITZ WAY - BUILDING INSPECTION CITY OF SALEM
i (4
�. PUBLIC PROPRERTY
DEPARTMENT
t:orarataT tut�ou
MAYCA lW WASF@CIM STSEfT 9 S►t est,MAXACttt79eM 01970 .
Tzu 973-745.9595 a PAxr 972•740.9M
Workers' Compensation Insurance Affidavit: Boildens/Con&utot sMecMciandplumbers
Applicant Information Cane tmetioni Specialties PI ase Print Legibly
Name cewiend P.O. Box 53
Stoneham, MA: 02160
Address:
City/Stawmip. Phoned
Are a as empleyert Cheek the appropriate bets
1.LI 1 am a employes with�_ 4. a 1 am a general contractor and I Ty��P�1 (K4�e�:
employees(AA and/or,part-time).* have hired the�n0ad� 6. ❑New construction
2.❑ I sm a solo proprietor or parafeo- listed on the attached sheet. t 7. ❑Remodeling
ship and have no employees These sub.coneaacpors have S. p Demolition
working far we in any capacity. workers'comp.inmate=. 9, Building addition
[No workers'comp.Lusur•nce 3. ❑ We are a corporation and its
required] ofHcees has exerclud their 30.❑Electrical repairs or additions
3.❑ I sm a homeowner Joins all work right of u mptionper MOL 11.13 Plumbing repairs or additions
myself[No workers'comp. o. 152.f 1(4),and we have no
insurance required.]t employees.(No p'or1:er#' 13.�f tole Co �cF[1
�Y
+ comp6 insurance req et ]
' ePpukmt cbecta bete 01 mot on as cut ape name.bdow
HameovuwveoVAMkuremdrArB�ntleseuy,nedy.n.m d�eb�O&WNCIM=:oy .d.
tcoetrac' m&d cm*dds bmt now wmehwe se ddudwa rent+wwins as ewe Nike mb4com wale anddWkvortoea'temp,vas I.oeamttlew.
naorwatl= nrAatlspro bra ln
vtdWSW*r 'eowpoxeadoJserroweojo►q'orarployesa JrSJOW
f NivpollrygxdJoirlli
l
Insurance Company Name:
Policy a or Self-ins.Lip.ea UD C�( b 0 Zb d U
t 1 Expiration Date: v I� d'?M,(�
Job Site Add:= �T C W t%,V^c L CIty/Ststefltp ` t 1(� Q �Q'Z�
Attach s copy of sae workers'eompesuatioa policy deciarules page(showing the Polley number wW expiration dab)6
Failure to secure coverage as required under Section 25A ofMOL o. 1S2'can lead to the imposition ofmiminal penalties ofa
fine up to Sl•300.00 andfar ono-year impriwmaent,u well u civil penalties is the form of a STOP WORK ORDER and a fiat
la es to S250.hoops o a day against the violator. Be advised that s copy ofthis statement easy be forwarded to the Office of
Investigation of the DU for iasuraaca eoveregs verification.
f do hereby e�der the and pens/des ofper/rny that A*Inforatadom prov/ded eft era and tarred
Sienaturc: �
Dewy 0
Phone A� �Z�l S 4141.10
F6Other
Use only. Do not writ*hs IM area,to b*eveepkud by c1V ortoww oOC1a4
Town: PesTalt/IJeeate s
Authority(circle one):
of Health 2.Building Department 3.Cilyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
Contact Person: Phone N•
Crnt OP SALEM
PUBLIC PROPERTY
DEPARTMENT
MAVIS s�7.oaiaiorumra xs.�oawwssmsrk
caawtiedan Debris Mimat AfWavit
00"hr at dwAUdon mi mAws s vaft
is saa dmn wids,dhe s6uf alld a of do seo.DdIdias cod%ass carat soollom tti.!
pa u%d dwp ovistom or3iGL s 406 2 Sk
a,madba rwdt r i.hasd�Wt dr oasdieioss drat d�dsbsls nauWss Aar
dit work*0 be disposed otis a 10o0w1y'Soaad wsab dfpoad A dit as dodo"by MAL.
'I/ts�.dsbsis wi11 bs trsaspaod an g
(ans�d
The d&4 will be disposed of in: 1 a
(�d
cad »
�1i�+dpvsdt�pUts�
� 1
dw
it
�. i 00 35000 of enclosed space
(MGL C.112 S.60L)
Il 1A-"Masonry only
1G 1&2 Family Homes -
'i Failure to possess a current edition of the
;! Massachusetts State Building Code
•�� is cause for revocation oft&s license.
i
DIG'SAFE'CALL:CENTER: -(888)3447233
•y. ,z BOARD;OF I DING+REGUtAA'kl
+ •License CONSTRUCTION SUPERV}SAt -
,* Number CS 0688974 .,E , ` • i
Birthdate,q,5f'021196 `_
• ExPlrejs "OSl02j2002 Ti ijo�•12Ztt7 ,� .
TINjOTHYJ FINM P
' �, B.UALDORA D,f3/P-0 B0�353 '
STONEHAM, MA 021.$0-��. C�
�r ., _� CommisslonsY
' r
C(I 1 3a18-
PROPOSAL
CONSTRUCTION SPECIALTIES UNLTD., INC.
P.O. BOX 53
STONEHAM, MA 02180
Phone (781) 665-4410 Fax (781) 665-4411
LE N N OX BROAN-NUTONE
HEARTH PRODUCTS
A NORTEK COMPANY
mar'i Aas �P -- 1&-0-7
�2xv�J.r2 �6-- cQk���� o`r �,S���sL '1 ���r��c�ce. d� Ct,t'1���✓t'�(
15+0,�\ L.evinox 3� ` LA)OL& P'rv_ftac�e_� cJk'VnV,
Sct rC— G (fir CQ4)8 r5,
We propose hereby to furnish material and labor- complete in accordance with the above
specifications for the sum of:
AS ABOVE
Payment to be made as follows: For special orders a 50% deposit is required.
For central vacuum and intercom installation, half is due upon rough-in and half is due upon
completion. For all other work, payment is due upon job completion.
Authorized Signature
NOTE : All plumbing hook-ups, carpentry work & building 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
The above pncee,specifiotions end conditiona uc aatis4c1nry�hereby ecceytaq You ve eull �' .o do zhe work of s pxitiM. Payment will be made as outlined above
Signature Date: `�I� / 0 7
If a cepted.please sign and return.
C10. ��10 �o��ee{ ,� ^ ,S r-p�n5; e_
0�9'�zQe t�rk.
-- F
� PUBLIC PROPERTY
DEPr1R'I11�hF�►�1T
roa' 130VVuwrKsin��nE • '
s+u�w�ias�„doi9�o`
'Iti1:9?{,7i}9S4S�,FA1Ci47L71e:9{I�:
APPLICATION FOR Tlt� REFAIR RENOYA> AN cONSTRYICTION,
DEMOLITION."OR CHANCE OF USE OR OCCUP�xr-y FOR ANY EXISTING;
�TRU�'T[7RE;OR.Bi1II nrnt�. _ _
1:0 SITE=INFO TION
Location Nan+r. C 0.✓1 Building
Properly(s lontetl'in a:'Conservatlon Aree"YM" Hlstaic Dt�Ct YM
44 OWNERSHIPINFORM%1TIOfN
21"Ownerof Land
Name: pt," 1Q
AddraW ti' rvt i Z wa -t
3'A`COMPL'ETI! THIS SECTION.FQ-- WORK IN E�[iAT un BUILDINGSkONLY
Addition, Ex'iettng
Renovation' Number ofStoriBe Renovatedd "
Change-in Uss New
Demolition Existing"
App[oximateyear of :Area per floor(sf) Renovated
conitruction-or renovation-
of exuhng building New
BaeLrDe�s.r'ptidn o/`R Sed Work: 0L''6
1'yelS`�
--
Mail Permit to: .
idiJe Y1 �0.'
Wpatas"the eurteM u32 of"theyuildin�T
Material ofBu�Iding? fl If dwetYng. many"u?ds
.� Asbestos?
8u _
WiM`;ttw iWing, _
nrct+iieeks:Nart+� ~. :
Ad&6"WW Phone
�M .. , ,Y�A ,n
MecltanidsNart+� ^ e �
Addross-an oKons b b 1 rer�a
CorAuw:tioh Supsnrism licsnse•io CS®gyp MIC Regititration,�i
Es*mted-Cod-of.Projed-i � Psrtnit F«Caleutation
Permit`Fse i,
Estimated=Cost X,$7/it'OOo'ResidentW
An AdditionM.$5.eQb,is�addea as an
Atlrti(nisirstivi.Chatyi.
Wake sure'tliatrall'!Tlelds aro^pYopertYand=le9ibNiwrilten•to"avofildelays`in=processing.--
The undo slgned dom,hweby,ap*y ter a:Building,Pemilt to buil&W-the=abOO stated
spscftatlons. Signed und6t-pe6alty of pwjJ rY
Date S
v
N
a
— 04