2C SPRUANCE WAY - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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MAvoa i20 v,9mauratastasar a SAtxa,MAUACHVWM 01970
Tess M745-9595 a PAxr 97i740.9M
Workers' Compensation Insurance Atffdavit. BaBders/Contractor$MetbUians/pfumbers
Aonlfcant Information- Cnneetructioni Specialties- -- -- PI!•ew Ih4nY i•oihly
Name il)utlmU .: P.O. Box 53
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Address•
eityistatemp: Phone#. `Z$f - (� 5- 4 I C
A�re�°ass
•mpleyer?Cbeck the appropriate box: Type otprojeet(required):
1.0 I am a employer with q 4. ❑ 1 am a general contractor and I
employees(&H and/or part-time).• have hired the subconnutors 6. [3 Now construction
2.❑ I am a sole propdetee or partner. listed on the attached sheet t 7. ❑Remodeling
ship and have woddug for mein c apacity wworkaa'co have 8. ❑Demolition
(No workma'comp. irmaince 3. ❑ We are s corporation and its 9. C3 Building addition
required., officers have exercised their 10•0 Electrical repairs or addWm-
3.❑ I am•homeowner doing all work right otexet Wdouper MOL 11.[]Plumbing repairs or wddldoy
myself(No workers•comp. o. 132. 1(41 and we have no 12p
insurance required.]t employees.[No works:;'COMM WRM= 13.(
;Any wm p ant eheeb bes et mom stern snout the eeett•a wtowerm aawks eni�,,� .�,
Homenweemweea6mkdikanldsWh—A eaagadaksaswakedanMWOM &easoeabmmeet newamdmk tcoee.emm dwebak ales bm amet mueb.d m ddW*W And dmrtea ere erne otae mbe•atoaam nerd drk wwkem•comp to tlai.
I awe am empbryer AM Is provfdlns workers'eompeasodow Gurraaae jor soy ewpytsL Blow to tAri
firjormmfoR lo po&7 sad job die
Insurance Company Name•
Policy N or Self-ins,Lic.k W C�-I ki 0 2-(
O�O t7 U Expiration Date-
Job Site adarc a: a G SQrJanc� l t9ca i{ Cityistaremp:
Attach a Copy of the workers'comPansation policy declaration pap(siosrlag the pulley camber sect expiration date)6
Failure to am=coverage as required under Section 23A of MOL a. 152`can Ind to the imposfdou otcsimiaal penalties of L
tins up to S1,500.00 and/or ono-Year imprisonment,as wall se civil in the form of w STOP WORK ORDER sad a tine
of up to$230.00 a day aping the violates Be advised that a copy ofthia statement may be forwarded to the of
Investigations of the DIA for insurance Coverage verification
I do hereby cerdA-under A* endpenaMw ofpsrjrrry that due Injopmedom prov/dsd ov ll trot and tarred
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Phone M: 4().,
FE�Ioarrd
oa/Jt Do not write 4 this ore;to be eomp/eted by c4 or town ojrfe/4
s: Permlt/Lkense t1
hority(circle one):
Health L Building Department 3.City/Tows Clark 4.Electrical Inspector 3.Plumbing Inspector
Contact Person• Phone M.
CITY OF SALEm
PUBLIC PROPERTY
DEPAWM ENT
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Consttrnc&a Debris Disposal AfiNavtt
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1 i 00-35,000 cf enclosed space
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1 1A-Masonry only -
� . I 1G-1 &2 Family Homes
I Failure to possess a current edition of the
.) Massachusetts State Building Code
is cause for revocation of this license.
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r DIG SAFE CALL CENTER: (888).344-7233- '
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BOARD OF B I`DINREGULATIONS„„,�.
License: CONSTRUCTION;SUPERVISOR>
Number CS 053897, T r
r" Birthdate 05/02/1962�5 + ;
Elplres 05/02/200712�07 ; f
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TIMOTHY) FINN,
y 8 VALDORA DR/PO BOX'S3
STONEHAM, MA 02180 Commissl� 'I
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PROPOSAL r
CONSTRUCTION SPECIALTIES UNLTD., INC. y C( _' qq�S
P.O. BOX 53
STONEHAM,MA 02180
Phone (781) 665-4410 Fax (781) 665-4411
LE N N OX BROAN-NUTON E
HEARTH PRODUCTS A NORTEK COMPANY
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We propose hereby to furnish material and labor - complete in accordance with the above
cifica i spe tons 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 priom-Pm -pone etW 000dJu. utiafe to,, me bevy accepted You wo authorized to do the wo.k ea aped6ed. Peymaot will be made w oudieed above.
Signature Date: l0-2 O•- 0
accepted please sign and return.
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PUBLIC PROPF:R'I'Y`
DEPr1RT1V 1tT
Nwma i3o Vfr a,+.,iin�nirlo r•rum%:y�swoasis�is o1970
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APPLICATION F,QR THE:REFAIR RENOVATION CbN�TRUCTION
DErL LI[TI' N OR -1M"'N O
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1:0 SITE INE 71ON
Locatbn.Nart+r. ,. .: C GLf1 Cam' 9ulkltng
Prop"Address
Propiriyrh beafed-ln a:'CorisenvptlonAnai"YM _ tilstorio OtWrkt YM _ . ,:
'450 OWNERSHIP-INFCRM/1TION
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ZslOwnerolKand.
� Name: v11
Address aCj(vctnC e t �
� T,elephonr- : .
ffAdd
E;THI8 $ECfi1bN-Ft:"it W im$TivaZU'll bINGBaONLY
t_x
Number of Stories Renovated
change in "
New
Demolition'
ej �zisting-
Approximateryear o6 Area per floor(sf) Renovated
construction•or,renovation _
of existingbuiRding' New
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Mail Permit.to: : -
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Whatis-ths Current rlae Of the suildln unds2 v(1)
Material o(�guddinp4' t,�-- o� ... .Ir dwolang:how'many
wul:n±..euudu+a:conronn eo'I:avv?
•Asbeatoi
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S 01 3 N! HIC Rsyistratbn
Conswcticn SuPervisors'Licertss`f{ C
pwrw, s Calculation
Eatimatsd COst Of Projed S �
Permit Fs.:i —
Estimated Cost X-S7/$- 000'Residenthd
Estlrnatad:Cost;X'i11/i1000'Corntne[dak
An AddMonala5.do iiadded.ai an
Admlhlstrative.charp..
6Aake surs;ttiatall`flelds ars'prop"and'leyibly=writtain to avoid defags In°pn�eessind•
Ths'unaersWnsd°does°hereby apply fd°a:9uildinp=PerrnR to,buildxtOths above'stated
spec&fl tk)ns. Signed under;penally'of perjury X V `�"i"
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