14C RUSSELL DR - BUILDING INSPECTION CITY OF SALEM
�. PUBLIC PROPRERTY
DEPARTMENT
xataeatsv txttsoott
MAW* uo WAstm�W M ftMT a SALEK MASSAC}nrS M 0197o
TEL 97t-745-959S a FAX WS-740-946
Workers' Compensation Insurance Affidavit. BuUders/Contnetorimectrictant/pinmber s
AnoUeant Iatormation Cnngfruc4inn Specialties- -- Please Print Legibly
Name P.O. Box 53 Wift Mee
Address: '
City/Statezip PhonIV.
Area u empbyerT Cheek the appropriate bast Type of prgj (required):
1. I am a employer with�_ 4. ❑ I am a fmatal contractor sod I
employees(Dill and/or part-time).* have hired the aubconbactors 6. ❑Now cam m cdon
2.❑ I am a sole proprietor or parnum. listed an the attached sheet, t 7. ❑Remodeling
ship and have no employees These subconss a have S. (]Demolition
wotidng Dxr me in any capseity. worker•Comp.insurance.
[No worker•comp,inatrranee !. ❑ we area corporation.and its 9. 0 Building additiaa
required.] o$icera have exercised their 10•❑Electrical repair or additions
3.01 am a hameowmer doing all work right of uO mption per MOL 11.0 i
mbing repair or additionsmyseht[No worker•comp. a. 152.41(4),and we have noim suance requird.)t employee.(No workers• 1113
comp,insunmee required 13. lCt� t l�ti
Any WPHce mat dada boa at aawt 94e MGM dw tacks bdm dantke drk any!eempoadoa DdkY
k drd his boa Bare wad�Ntlaut h n wadtd dM ilks add"emtrae0ou mats wi6eb a am afIIdwk bdlapeegtb.
dawfna are aama otdr aibeoatraamta and*Ak.taatate'camp PONey bdb ma"
J ewe aw eatptoyer that is pravfdlag worAen'cowpemra&m bumrawcejo►mty e+wploystA Below 4 Nis 7wjorwotfow poffey andjob s/fe
Insurance Company Namur• �c�
Policy N or Self-ims.Luce. 0- �-rkj(O �p f)Cr) Exp os Date: > vey _
Job Site Address; l T C S'SC'�� �( . City/State23p: \ ', 1 E �970
Attack s ropy oribb workers'eompeauatlos policy declaration page(shunts the
Failure to recur cover as g Policy number and expiration dab),
g� required under Section 25A of a. 132`can lead to the imposition of criminal pesaltiee ofs
tine up to 31,500.00 and/or one-year imildla sent,as well as civil penalties in the form of a STOP WORK ORDER surd s fine
of up to 3230.00 a dry against the violator. Be advised that a copy of this statement may be forwarded to the Otliae of
Investigations of the DIA for insurance Coverage verification
f do hereby CVWA nnder the p aved pewalNea ojpsrJwry that the/n jorewdaw provided afore 4 and treat
Signature: �(/`—�. —1
112Z���
Phone At• l fat �9 Dew I
o leAd use oefy, Do not wdke IA t6fs are4 to be completed by clalr ortoww o,QTefaS
City or Town: Permit/Lieesse/
Issuing Authority(elrele one):
I. Board of lita tk L Building Department 3.Cityfrows Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person:
Phone M:
CITY OF SALFm
PUBLIC PROPERLY
DEPARTMENT
L
Constmdas Debrts mat /lAWsvil
(segf"ft sit amomon mod ereoasdes wad*
in mwds wide dw sbak a Mm of dw Sbss fpuUdIng C*4 730 CUR seeder 111.!
f)eb ft wd dwpsovldaw ofUGL a 4d6 S S s
SU Wty OMN f1 fs hood UM dw Waddles dW dw ddwk mmdtbg A**
NO wodt mitred be disposed offs s pwpwfyf Seemed wrM disposd dellfir an dsgmed by UOL e
1il.stio�.
Theddris*0 be&u wiled by:
CUM affbodbi
The ddais will be disposed of in:
cam•of FmUIW
r>mm"
� 1
10-7
dos
+,Ii 00-35 000 cf enclosed space -
.I (MGL C.112 S.60L)
1A-Masonry only
� .} 1G-I&2 Family Homes
+ Failure to possess a current edition of the -
Massachusetts State Building Code
is cause for revocation of this.license.
-IL DIG'SAFE`CALL CENTER: (888).344-7233-
BOARD OF� LD1�G�REG<nrICSN
Licegse. CONSTRUCTION SUPER
Yfi
Ndlmber CS
Btrcrt�ace ob[ozeasB t
Expires 0 /02/2PQ7 Tr,' no. 12Yb7
TIMOTIY J FINN , it
8 VALDORA DRlPA BOX 53 STONEHAM, N1A 0218D CortiinlssloneCt'
PROPOSAL
CONSTRUCTION SPECIALTIES UNLTD., INC.
P.O.BOX 53
STONEHAM, MA 02180
Phone (781).6654410 Fax(781) 664-4411
LENNOX BROAN-NUTONE
HEAR A NORTEK COMPANY
We hereby submit specifications and estimate for:
C4-- � �u Z ECRA
s�c vti
c�� i et�' �v�� ��zct��lE pe��c�z�n�-�C��.
We p po %e Ce`by to furaisTi maul aad labor co�plete m actor ce with the above
specifications for the slim of:
AS ABOVE
Payment to be made as follows: For special orders a 50%non-refundable 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 Yesponsibility of the
lob site general contractor or homeowner. Prices are effective for up to 3 months from
date ofproposal.
Acceptance of Proposal
,ea M-Wy�tl `wmm4e.lrtl Wto Yi,wa+ku
Signature 'o'""b P• w a.ow..+, ww.m.
Date: `I /
cepted ple a ign and return.
What is.Ihecurrent use of the Building? '� 5" �`rf
Natedatof Building? �t0 H dwelling,how:many units? -. T
Wintha Buildir�,Conform 01aw?: -
Asbestos?;
Arehited's•Nams
Address,andPhorte VI (p5 (�— fl p
Mechanic's Name '^ _ \�
Addtess and Phone P��r�S2 O ZI. 6
Consbuction Supervisors Ucense# ( 7 HIC Registration#
Estimated'Cost.of Prcject S as B� Permit Fes"Galwlation
P-ermit Fee-i Estimated Cost X.S7/S-1000,ResidentWj
- _ - — -
-- -- — -- .---- -- -- E9tknatedzGostk4fS
An AddMbnai &CiG--1a adds ad'
Administrative charge.
o
Make-sure that all fields are;propery and legibly written to avoid'delays in,prQpposing:
The undersigned does hereby apply fbr.a,Building Permit tb bbuild toahe above stated,
spedifloacins. Signed under pena ,Of.pOddury X I
date " Q
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APPI LLA'ITON FOR THE REFAIR.fRE1 d A V* NtjNSTRYI TION .
DEMOLITTIO G
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4.•
AN
tq"Sff, INFO —
lacatlon
Property address2M
Proputy fs bested tn:a;'Conservatbn Area YM H Chfrkt YM
1 Q QWNER'SHIP�tNFORM/1TICN` -
; Z.1 Owrlar�lrend ,:
Telephone:
3 0 COMPLETE.THI$ $ECTIdN„FRr WORK IN dtis±Ttura gtLb,INGS ONLY
Addition Extating;
RenovaUpn 'No
most Rar�avated.
Change-It1-Vse
[�emoliUontsUrrg
Approximate yearef Area per floor{(s Renovated
constrtictton or-renovation
oG exisGngbUitditt9 ,, 1VeW
Brief Oesrption of Fc sed Work: oU� `E
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