6A RUSSELL DR - BUILDING INSPECTION - 440L
PUBUC PROPERzy
DEPAR'I31IF;i'�IT
wvaEu.avoiuxax4
taovvwurKznw�nsyz�' yr, iMoi9io
6666 m 4'irs9ssS r,Fw�c 9,7iT�8.96 ,
. ;LICATI FOR TAE REPAIR. malt Os sim, t^TION
DEMOLITION. QR CHANGE OF USE QR Oc , vc�r AOR ANY EXISTL}�1G.
STRIfCTURE OI�,,B = lNG
.1.01 S17EA"FOR .:: T10N_ .
Locatian;NarrwR: 'G 0.f? , cy.J' f3uildingt
Proprty4=An a:'Cerisstvatlon Area Y1N tiisiorlC Cttstrlot YtN
'Z.0 pWNERSHIPtNFORM/1T10`N
�Z.1 OMrmrr oY Lan�f
Nam: VtCR Ser
Addre '
Ot TO
3 0GOA1Pt.ETR T111S SEC7tON°FOR WORK-tN EXtS St1tf:OtNGi8;ONLY
Addition EzisUng
_
Renovation' Number of Storiae Renovated
Changs-I use Never
Dernoftiort xisting
Approximate year of Areaper floor(sf) Renovated.
cortstructton or renovation_
w. r.
a axisting'sbuildin
g
addiOes ption of'Prr sed Work:,
Cx 6 x,(�\)( �-c'.re 6-( i; (* � Vre�� S rc�rvl { + c ase'
Ir^r.^'.`IYW X
Mail Permit to: y"Lw«s�
Met
. �C�S f (0
CrrY of SALEM
PUBLIC PROPRERTY
DEPARTMENT
,cadaartnr tatscroti
ytarat
IM WAS11M=WSf2W 0 SMJW.MAWACtwsaM01M
TM 9WO9595 a Fexr VS-740-9M
Workers' Compensation Insurance AHidavlf: BaUders/Contractersmetbidansmiumbers
ApatkilutInfnrrnatlase Cnnstnict}on Specialties Plating Print Leidbly
Name ttnstinow P.O. Box 53
Stanelfamf M* 02180
Address:
City/ststemp: phone# `Z� i - tc fc S-� 1 C
Are yea to ampbysr?Check the appropriate boss Type otprojeet(required):
i.51 am a employer with 4. 13 I on a general coutractoe and I
=plays=(AA and/or pas • have hind the wb�xonactora 6. Now construction
2.0 1 am a tale proprietor or partner, listed on the aaached sheet t 7. 13 Remodeling
ship and have no employees Thew sub4oatractors have S. 13 DMWHdast,
wodkiag for me in any capacity. watims,CMP•Insurance. 9. 0 Building addition
Rb yam•gyp,insurance s. 13 We am a corporation and its
rem) o$lcros have aserdsed their 10.13 Elacaical repain or additions
3.13 I am a bomeowaat doing aB wontdg6t Par MOL 11.13 Plumbing repairs or additions
myself(No workers'camp. o. is2.�l{4),sadwe kava no 12.13 n si
iaaunncarequired.)t ectPWYN&Die wc"o 13.C�70t1 C,' 1'ift; IcR
compo lesu:atoe regrlired}
;AW W Maardo4abboa0lmatWeaewetiene"bdoW* h*d*bwa*us- tforYolw
lkmoo+seoaadrs aubaait ddoalad�vlrkaaWk a deep am dokyae wadraad deabisaomatdsoamaesora oast ssl"a oowaCldade 6adSwtaasnra
tCoawaeraro tbo stink ride bra man awebod as*14dood nonan dowks ew awas of dw sob4couscom and dwk workma'comp,poatq bass=" .
I mw an esephyer that Japrwvldfwf woridrs'eowpdwsatlow kssmmwcifor cry eawpfoyeam 1reJow L rhe policy owd job sNe
information
Insurance Company Name: 7TI
r f�
Policy N or Self less. a w. (��LibU a T 3 7 Expiration Dow—
Job
ate Job Site Address: CltylStatel2:ip
Attach s copy of Ilan workers'compensation policy declaration page(showing the policy Number and expiration date).
Failure to secure coverage as required nyder Section 25A of MOL a is2 east had 10 tba imposition of criminal penald"of a
Rae up to S 1,300.00 and/or one-year imprisonment.as wall as civil penalties in the form of a STOP WORK ORDER and a ihxe
of up w 5230.00 o day:smut tbo violator. Be advised that a can ofthia statement may be forwarded to the Oiltce of
Investigations of the DIA for insurance cavenge vesiRcuioa.
I do hereby cerst&under sho pais sad pdwaWn ofpe#wry&a a*Infornatlaw proWd, u and correct
Sianarure ✓t^�r ✓�'� -^ — Dale i
Phone t"
FBo*rd
t As not wdW b tbir area,to becomptdW by coy orIsaw of e14
Town: PermlNldeeme M
y(cinto ane):
lth 2.Building Department 3.Cityfrowo Clark 4.Electrical Inspector S.Plumbing Inspector
Contact Person: Phone il:
What is.the current use oft the-BO ding?
MateriahoP Building? . �Ddl 9dwelling.how many units?
wilt the BuildirgConform to Caw?:
A$be'stos? - -
Archited's Name
Address and Phone
Address and Rhone=-
� (o
Construction Supervisors Ucense l 65
HIC.Registratbn# �
Estimated Costof Project$_c Pertni[.Fee.Cakailattom.
- Kermit Fee S Estimated Cost X`41000" 6oldentlal
—_— -- --- — - - - Estimated Cost=)E'$t fSloElg ommeodlal; ---
An Addt6dnaLS5:00=ld�added�as,an
Atlministrattve�char9e
Make-sure thatall fields are properly and>Iegibly writtemto avoid delays insprocessing:
The undersigned does hereby apply for a Building
�P/ termito'build to the above stated
pec
sifications. Signed under penalty of perjury /�- -
s s
fl �'
—
i
i
Crry OF SALEM
PUBLIC PROPpxf
DEPARTMENT
?41A ISWA «omm2now 0 Symy 1101W6
111I:11s.T�LfSif�R11tl7�i�ilNt
C4*"&UtdG* Dehrb DbP4W AMS'Vit
0"6 au&mum and mwva"Waft
1s aoeadalw wide the"am=otdcs ft"Dwwbi Co4 INCUR lead"111.1
oamkmddwpmvW*ua(UGL*4@sSS41
suaft rumb s is fm d t dd1 dw ooldidos dW dw ddah►rovAbS Das
chin wast"bs dspowd otts s popub►if wmd wu"&Vm d haft as do&md by a6M s
tilests .
Th@ ddm%.wis b•aanapod @d bytl t
G�sssa d
The dcWs wiU be disposed*tin:(
Q044r
t�� f�ws of 1�lttty)
VY t��sP.c ��• a'Zt`t b
LPOW*(o+ms vpuuw
� 1
>✓ ALr.�aclw.rit. - Uclau't ntcnt ..I' YubUc �alin
�� k3u:u'tl til 6ttiltli+rp Hr^�tdatiun,+ and Tt:md:nd.
Construction Supervisor License
License: CS 53887
Restricted to: 00
TIMOTHY J FINN
8 VALDORA DR/PO BOX 53
STONEHAM, MA 02180
Expiration: 512/2011 .
tuud..L m,-r Tr:-': 15400
II
I
i
Ln UK)
CONSTRUCTION SPECIIA1 TIES UNLTD., INC.
P.O. BOX 53 e\�,
STONEHAM, MA 42180 �
Phone (781) 665-4410 Fax (781) 665-4411
LENNOX BROAN-NUTONE
HEARTH PRO UCTS A NORTEK COMPANY
C1� ! vv� `
1
z
Ji
6.Carr ��� .� t ,� C del} V e,�" c
i. 'S �'.x.�S�t''�` �`/'✓ (CICS ��'?u�(y Cz l CY(XO'i��� Ci ( ����'�,'�
J
We propose hereby to furnish material and labor - complete in accordance with the above
specifications for the sum of:
AS ABOVE ^'�—"�
Pavrnent to be made to i'ollows For Spec;sl orders a � )% depose �s require
For central vacuum and intercom installation, half is due upon rough-in and half is due upon
completion. For ull other work, payment is due upon job completion.
Authorized Signature
I
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,
Acceptan of Proposal
I:+ .ra.e C^W�,pnin � um conNuom u.r.J.(.e¢iry.. ua aeoY wuPw Yuu ua wWovaE m do Nt.aet a ayn'if W Y.rmau ritl M rzsue u o�umm vn..
Signature _ V_�"'----_ Date:
N accepted ple e sign and return.
< e%
rte` �1 `CCYi� �k t , � , s Cf✓1�ti .\