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11D RUSSELL DR - BUILDING INSPECTION CITY OF SALEM PUBLIC PROPRERTY -- -- -- ,7�' ---- DEPARTMENT- ----- — ttnrmaataY taasoou. AUYM tX WA2M$W 10NS rear a 4A'vU s1AMACfiVWMOIW7o 7U.979-743-959S.PAx:97 4o-9M Workers' Compensation Insurance Affidavit: Bnlides/Contractorsmectridans/Ph tubers Aoolicaut Information Censtn't% inn to tgCIi140Yi Please Print i ey ly Name(8m1eaW0quLirst awRndividual): P.O. Box 53 am, Address: City/Statemp: Phone 44 I o An m as employer?Check the appropriate bees Type of project(required): 1.Q•I am a employer with � 4. Q I am a general contractor and I employees(W and/or past-time).• have hired the sub-consactom 6. ❑New construction 2.❑ I am a soh proprietor or pagaer. listed an the anached sheet t 7. Retaodeling ship and have no employees These Strb oontracmrs have S. 0 Demolition working for me in any capacity workers'comp,insurance. 11 (No workers'comp,insu ance 3. ❑ We am a cooperation sired its 13 Building addition -13 Electrical repairs or additions; 3.(] I s4m�a dkc®eowner doing all work right olmrampelon per MGL 1/.Q Pkrmbinp repairs or additions myself.[No workers'comp, o. 152,f l(4)6 and we have no 12 Q f tastssanee t ]t employees.(No workers' 13. t i camp6 insurance rev"Ll ;Aw"wHe m da dab boa et now Wm®an"secdas bdor shoving**work=: - Homeowm=%so ur*e@ AY nmd.v fi-A' es dwy s e ddas an-.ak w aim bin � Nice. adpk tCoetraaao ihr dad[fhb bat emae atuehed m ditwA stoat d orfea the rums ofda rah•eaoftch a ad dwk vedam'emw.pDay wh mmkaa . I ace ace employer that Irprovldnj workers'cowpenratlow bvaraneejormsy ewploy*aa Below/s tkepolky and Job site Injorwadois, Insurance Company Name.— G Policy Nor Self-ins,Lie.N__ [[ J Q.11 rr( (j& 2- b(D©() gxp a DatQe: ( tR d Job Site Address: L L PW��1 I �• City/StatrJ2ip: —`�1 \f} l Attach a copy of the worksn'compensation policy declaration pap(showing the puticy number and expired"dtte Failure to seem covers a a rN requirsd under Section 23A of a 132 can lead to the imposition of criminal penalties ola tine up to S 1,500.00 and/or ona-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$230.00 a day against the violator. Be advised that a copy of this Statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. /do hereby certi/y ender tier palm and psnaltlee ojpedary that the/njormaadon provided bovi tree and totted Signature• /l/\� /�/�—� Date 1� Z (`)'l Phone `7 �( ^ (0 S—t( CFI F d use onl)t Do not write le tk4 ore#,to be eotep/eted by chy or town o,Qk/aL r Town: Permltluceass Authority(circle one): d of Health2.Building Department 3.Cityfrown Clark 4.Electrical Inspector S.Plumbing Inspector r Contact Person: Phone#• ' CrrY OP SAtau - -- PUBLIC PROPERTY DEPARTMENT � 6 >vs� tsrAsa�atort�.sisa.>Grtsas�atsot�s 11siI1srl$11l�s0#AS9M?4►" constnaeao. Debrb DbpoW AIW&vu (kequ4vd bra daft mm sd t+■ mmus wtdt, is soestdseos with dw"son a[dts Suss adwks cod,,in c ma seedom III-S 0ebtls6 d dw prwAdc is od3/t3L s 44'1M SuildiN ftmo o is Ems/wb!tie eosdideo disc d e dti &msttb bg Ace LM@ wek*O bs&gout Otis s prRF b tle�sse wsrM dlgout Ae[ggt ss dsAsse by b6CJf.s T1ts debds wiD be trsnspoMd by The debris will be dlspmW otlin: C LO �Lcl � (MMWFMUIW Wl�-- dw ryta�.rsertieutM 02L� So � 1 moixOzrrynweal/ o�✓��rrur �rvp6i a§rdofBuFltlingR4RW�tioneanthStBgtlards��, Gonstrustlgn Supervlsorl i�ense i" Ci erase CS 53697 Bittli� ts_=517J1952 pF.�jcpiraHon 51�/2009 Tt1E-12955 C R$strict)p TIMOTHYJ:FINN 8 VAI.DORA DR/PO BOX 53, - STONSHAM,tviq 0218U ObMmissioner n SEP-21-2007 05 :26 PM SURDAM 978 499 8789 P. 01 PROPOSAL CONSTRUCTION SPECIALTIES UNLTD-t INC. P.O. SOX 53 STONEHAM,MA 02180 Phone(781) 6654410 Fax(781) 665-4411 LE OX BROAN-NUTONE HEARTH PR DUCTS A NORTEK COMPANY u N�ss"m ��a11 l.i✓v�nr7o� 4�2� -3 (ast, QJW\AN+t r�e Ns P6 c me �R� -�r� '� rr►rle ©CCAJ✓ 1 V'e%-t.�' O We propose hereby to fiirnish 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 iT..b..Mpy,pedlentloo„otl mnCltleN.n..nNKCeryud w M1nby Vavkd Yau YewWoi4.d W dV Ib wa!r ry,dLd. po'vpy w01 be m,h u eul�dbaa Signature as Date: Ifs accepted plee sign and retlum, soc- oA&e� wtfk. \ What is the current uskof the•BU ding? _ Materialzf Building? p0 If`dwelling,how:many units? Wip the suilding-ConformJo Law?. Asbestos? Amhiteas°Name - Address and'Phone ( ) Mechanics Name Address and"Phone Construction Supervisors License#'CS HiC;Registration# '¢©O- PerrntE"EeeCalculation Estimated Costof Proled SJ9�— - - PerrnR Fee i Estimated Coat XrS7/51000`Reaidentlal fotrimerc'•:' -------___ An Additional $5 00 to addad�as,an- A rninistra"chergp: .I " ib written to avoid'delays In,processing: roe .and eg IY Make"sure hat all fields are,p p nY The-undemigned does hereby:apply-for'a Building Permf6to.":build to the above stated, speciflcaUons. Signed underipenatiy of€perjury X G� `. Date " b I ^� el ; q� N PuBIIC PuRQPER`TY DEPAR'Y NIF.,`vT ��" 136 w�ffurK,-i[W:b`It�Yr•s—��.�ytis of9;tb 44 . 7A 9'!s�3sss9s�*�t±ue�i'L°'Ls6K; - APP.LI�A r 'ON FOR TH'E 1tEPr�R1 RENOV7+1Tt � N G7D�tSTR4iT �� OO N DEriOLITIOI!1.OR CAANCyE OF USE OR Cy x®ltI3IG; 1:Ot;ITt:INFOR TIO,N' Location warm - V, ,c 4VI du(idtng , t�opeiry�Wares�- e t42D. _ ProplYlebcsad-trf.a:" onaervatloftArsilM Historl�Dte`biciY%N._. 4 OWIJERSHIi�INFOIttv�lAT10N . � ` _ Adtlrensf i ss _ Telephorae (o77 3 0"COMPLET 71341$-3ECTIbN FCSR WORK IN det�sT�uea BUIL $ ONLY Addittarti E�ftstii�� Renovation Number of Sforiee . :Renovafe� Change-in!PSO New DedtoliHon I. � Esosti�g". Approximate year"of ,Areaper ttoor-:(sf) Rertouatelt censtCU.d ,or;renovation ' LL «. _. of exiabn buildin t3aef Des "'piton of1Pr- setl WorK: � l��G�� � lltin�x 8 t "b t`et AAaiI Remit to: ��