12C RUSSELL DR - BUILDING INSPECTION (2) CITY OF SAL$M
PUBLIC PROPRERTY
DEPARTMENT
AfAYoa 120 WA5HMV r3NST=r a S►r9M MASSACHLW 301970
TEL M745-9595 a PAxa 978-740-99"
Workers' Compensation Insurance Atltdav[t; ByIIderslCoatraetorSMOeMclans/Ptnmbers
Aoolicant Info_rmados Cnnc}motion Specialties Please hint UAW
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Name tllati--A/ ) ; P.O. Box 53
Address:
City/Statemp. Phone# g — (c, (c S—'-(4
Are u employer?Cheek the appropriate best Type of project(required):
1.Q I am a amployor with 4. i] I am a general contractor and I 6, Q New construction
2,01 am sole(tLB and/or part=time).• have hired the aub-couftcww
Proprietor or partner. listed on the attached sheet t 7. ❑Remodeling
ship and have no employees The»mb canuactas have 8. 0 Danolirian
working for me In any capacity. workers'comp,insurance. 9. 0 Building
(No wadies'comp,insurance S. Owe are a corporation and its
required) ofters have exercised their 10.0 Electrical�or additions
3.0 1 am a homeowner doing all work' right of exemption per MOL 11.0 Plumbing repairs or additions
myself(No wodkas'comp. a. 132.j1(4).and we have no
insurance mwhv&j f employees.(No workers' 13 Oth=
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Insurance Company Nam:
Policy s or self insZ Lie.N: (Or 2(p(p f7C� p Date:
Job Site Address_L (�
C �552.E� De-, CIty/State/71p: ` l i 1 i 7 (� �Q Z t�
Attack a espy of tbs workers,Cam
peanadon Polley declaration page(showing the polky number surd expiration data).
Faihue to a==coveragi as required under Section 23A of MOL a. 132'can feed to the imposition of Criminal penalties ofa
fine up to 51,500.00 and/or one-year imprisonment,as of up to 3230.00 a day against the violator. Be adviud wallae a u co civpyil peofnalties in the form ofa STOP WORK ORDER and a fine
th may forwarded to the Office of Investigations of the DIA for insurance coverage vaidesdon this sate ment be
l do hereby card&under the and pmaWw ojparfary that the lnjoraradow prov/dtd above i<trwe and correct
Signature:
Phone No �Z fo 6 S 4 q l o
of/lekiuse en6% Do not write IN this axes;t0 be eoaplsfd byc4 ortowv ofrlCla(
City or Town: Permit/I.leense fi
Issuing Authority(circle one):
1. Board of Health L Building Department 3.CltyRown Clark 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Pence:
Phone>Y:
Crry OP &umm
PUBLIC PROPEzff
DEPARTMENT
xra. tas�oiaron>ens a.raexus.oa.sarsmYre
Consumcdom Debrb Disposal AAWavit
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:his wads AM be&Vaud of a 1 !loom"weds dtepoed dtdit as dedaad by 1(M a
1t1.�1lOA. '
Tha debris Mill be transpoOd ban
The debris wig be disposed*(in:
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i. 00 35,000 cf enclosed space 11
I I (MGL C.112 S60L)
iI 1 A-Masonry only
1 1 G-1&2 Family Homes
Failure to possess a current edition of the
Massachusetts-State Building Code
9 is cause for revocation of this license.
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DIGSAF.E CALLiCENTER: (888)344-7213
0 BOAR D''QF UJIN floe
: REGu 7f
License CONSTtRLCTION SUEE'i� Is'-,
tY i' i
r ,g 'Number CS 0538�7� .�
Blrthdat�Q5f02ia�982�s � ,
ExRlr.,ns 95702f2007 Tr nog' J2�7 -
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Restrie(ed 00
TIMOTHY J
8 VAiDOR `b6w646X 33� -
,ir STONEHAM;`KA 021p0
Coinnmissio�. f
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07:1.3/2007 07:53 FAX 7812247559 VNA MIDDLESEX EAST L6W OO4,UU,
" PROPOSAL
CONSTRUCTION SPECIALTIES UNLTD., INC.
P.O. BOX 53
STONEHAK MA 02180
Phone (781) 665-4410 Fa= (781) "S-4411
LENNOX BROAN-NUTONE
NEAR A NORTEK COMPANY
4i.i -1 b" C
1 a c ep'54'; el �
C�1i r��� <S�Si-�� • �sn3�.�( L-.e��+ox Q�2-s -3 b
�nC,�JF30� � PC � 'S-DJft GY
We propose hereby to fumtsh znatelial and labor- complete in accordance with the above
specifications for the sum of-
AS ABOVE:
Pa}anent 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 book-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
r. bowvim. wwbv yw=pW Y..whwi=4Wd*LW. bYP6A-& P.y�rGlWd wmg,.dW . )I
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Signature Date: 13 1
If acre ted please sign and return. ,
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Matedai at.°&iildin�? L� 'ma�Y
H.dwelUng.hovi!
V11iNiM BuiWi ,t:oriforrn to Lavr't Asbestos?
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grehited's fJatit� ;
Address"and'Pha+e�,
ltAechsnk�sNarr� nOz
Ad&m and'Phom
is
Cone6udt suce"is«s ucsns,,sr Cs o� 7 Hlc ftegtiauort.fl
Estimated Cost of"Pro1ec3-i -a?Jc}� .6D Permtt FeeCaleuletlon
Eaymated`Gost XFS7/st0o0 ResidenWl
PertnitFee:
_ g cost X=i11/Sft100 GomFndrelal -- - - -
An.Addiflonsl i5.00 fs added•as an
Adnilnistrativs dharg•:>
Rake sure'that all<flelds are Pro p'erV aM lefiib w~AO:avoid dela 84hIpmessing.
The,underslyned doee hereby apPWfora°E ilidirp Pertnit`to bulltl°to:-ths.atiove-stated'
speailicatkm slyned under:pen'alty'of,poury.
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PUBLIC PROPER'I`Y
DEPAR�=TI4IF:i:NT
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APPLICATION FOR 1<'AE,,REFAIR -RENOYA� ---Art.,CONSTRiTCTiON
DEMOLITION. (QR CHANGE OF USE OR OCC'[JP NCY rFQR ANY=FF.IttII TING
�RU�TUI�EOR BUH:DIN ,:
1:0 SITE INFOR • TION
location Name 'C 0.wi c9� Builtling;
�letw• (rn A-- o la-r fl
Propuly=Ts located`In a:ConservationArea YM talstorto®ti61d YM . _.. .
g=Q OWNERSti1P:JNFORMATION
2s1 OweM of Land Jccc Pi RoM,_T `
Name:
Adtlreae:
l2 C, koese-(I f•
ffAdd
ETB.TH 9 SECTIONf WWORK IN E�(182INp B 0 811IGS.OI�LY
Number of Stories Renovated:=
Change in vss New
Demolitlon � Existing•
Approximate:year of a.per(]oor (sf) Renovated
eonsirucdon-onrenovation
Are
of existing-tiuiitling New
&ief DeW pfion of`Pi setlJ:lA/ork: olt� s�
Mail P.errriit to