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2A FLETCHER WAY - BUILDING INSPECTION (2) CITY OF SALEM PUBLIC PROPRERTY e DEPARTMENT xntat:suaY tsuscou. MAYM - -!so W,wtnacMSn=a S=M4 MMACtR)s8T 0lW0 Toe:M745A59S o FAM 978.740.9446 Workers" Compensation Insurance APQdavlt: BuUders/ContractorsMechidan>t/Plnmbm ADollcant Informatton . Cnne t ectinn Specialties Printi .Please Print dhM Name its ` P.O. Box 53 - �•- ' aa�—nae nn Address: Stoneham, City/statemp. Phone# 5— A_re�■as employer?Check the appropriate best E roject(required): 1.0 I am a empbyer with 4. (] I am a gaffal contactor and I employee(fbll and/or part=time).• have hired the subconuactarsw eeastruction 2.0 I am a sole proprietor or partner• listed an the attached sheet todeling A*and have no emplayeea Titess sub COntracmra have olition working for we in any capacity. walkers'comp.insrrnnae. lding addIticn (No worker'COMP.insurance 5. 0 We as a corporation and its required.) officers have exercised their ctrical repairs or additions 3.[31 am a homeowner doing all work dot orwMaptioopar MM bing repairs or additions Myself:(No workers comp. a. 152,§1(4)6 and we have nop insurance requited)t cocup.insurancereq� l *ANY wt�d.t dmb bn of muss deo ea out qr asettoa hdow�a"wQd or OOmP PAY�+rgrpoa xamocim*.k.ddtdik bm nv muec d d m s eur.n ddsa.9.mk mt mnrdwcuutdi eoaseot' muse dmih a new&MdM*tCoatraeewa tree eAreb Fhb bn meet atdeld r ddieoed AM shmbs r area of da and dwk vA dome comp �mWjM l arnatfo p+hdot lsprosdd7wj worlds'eowpexratlos►aaaraaeefor ary easployeaA Below is the potley ast/Job sEte R! Insurance Company Name: G rr�Policy#or self-ins,Lis w. W 0 ,I 6(O 2(Q t d D Expiration Date- Job Site A City/staterLip• \ Attach s copy of tht Workerat COmPeasatioa policy declaration pap(showing the policy number and expiration dab)6 Fadute to secure coverage as requi:edunder Section 25A of MOL a. 152 can Ind b the imposition of criminal penalties ofa tine up to S 1,300.00 and/or one-year impdsoammt,as well as civil penalties in the form of a STOP WORK ORDER and a fiat f o up to$250.00 a day against the violator. Be advised that a copy of"statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veSd &WIL -do hdrrby ee�=der the p l and penalded ojper/ary that the injonaraafow provided ve 4W and coned T/ 1.17 _ b 1 ` Dare Phone M: `�� lV S 4 LP j.,p oJJleiaf are ON66 Do not write Is thin area,to beeoafphiad ycAV or maw ofyleI4 City or Town: Perm)NLieetw N Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 3.Plumbin Ire for 6.Other 8 Pa Contact Person: Phone 0. CrrY OF SALEM ' PUBLIC PR+OPEFay DEPAXrUMWr Once 12l stets•susi%Nsasoaw m*tm 1+a�n►:+s-mot.�.,.s�a+►�w Coas&uctiois Debrb Dbposd MWavit us""dl ax ds wn=ad t.eoadas woo La soaatdom with dw dz&@dittos otdts Stets SWUing Codsy 780 CM2 soedm 1113 oabdsti ad dtspsoviatans at31Gt a 44•Us gundbolrndt is taoad witl dw aosdidas diet du darts eawdtiy sots do wads adds be&Vaal Otis a tab!teasel wa M&%NW bd ta?,i/as 4odw d by SM• 1t1.S1M& Tha dadis win bs itaapoatd bys Co C7 1" aeao e� & Inc-, (wu d i The ddeis will be dispow d otin: L DfIS `�cJ�CI�► 2e��t11��� 10 al f " j (am d M Ib (o 7Ir2wAo< f j• VVLe VVA. (tea � 1 �21107 dw 00-35,000 of enclosed space , (MGL C.112 S.UP IA-Masonry only � . I 1G--1 &2 Family Homes - Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. I ;I � I."- DIG SAFE CALL CENTER: (888).344-7233 li aat9n6,1 ,BOARD,OF IC�DINREGUL/TIO,y,S` License: CONSTRUCTIONSUPE0... 2r F_ I Number CS 053897,. z} s of Birthdate 05/02/796 ` � _ Expires 05/02I2007 Tr.no. 12Zf)7 - ' ` Restiicted 00 ;+ TIMOTiliYJ FINN " r i c- ' ,y 8 VALDORA OR/FO BOX 53 9 STONEHAM, MA-02i80 Commissioner F '� III -- PROPOSAL CONSTRUCTION SPECIALTIES UNLTD., INC. P.O. BOX 53 STONEHAM, MA 02180 Phone (781) 665-4410 Fax (781) 665-4411 LEN NOX BROAN-NUTONE HEARTH PRODUCTS - A NOR E K COMPANY an Fl Co" q � 6rA, M 01q�'1 o �l- C�1 ccc3orr0V,,1J U fL� Sac ® �P� �i f cs — l� I�, /1 It , We her propose eby to famish material and labor- complete in accordance with the above speciMations 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 ake,c pnw,<p<cifimiem<n0 cooal1 Mpr vti<r mon.na v< p•_',(`( <Y ec40t W You vc<mM1o.iz<d io de iM work u apaci eb, peymem will be nuG<u omlin W<bum Signature cc Date. if accepted.pl ase sign and return. I __ �� v``��st°�ci c��'i�n �'erS,Pun • � (�, 3?a .S C .- , n * kL IT "� ' e;'" •"� Efya�"`�4rs F' , ..;� 'ro•^ M k s S; t•� w Rn An. i 1 3j � f i�g��u. C ! m l o a .y 1 • r 4i m s K e w � L v a� V 4zr WhSt.itthO-CurreM 48 of tFie'Buli�ldirg7 units? un . Material-ot-9uiWing2 fl fit — H" ding.tlb many' toa? WfYthe"Buildtirp;Car'f°rr'n"to law? ,7\sties ArchiteeC e'N arrtii ann&PhonP` Address _. ies-Nae+e C Mechan q� io;�C l o C CL Address-an&PhoM S©tip Supen isM:Li : 1 MIC F2 " fsltratbn:S Construct(a+ Censs,*.� _ . eg1 Es*nated Cost of ProJset.S.3D . ! P4Wn Fee:Cakx+letfon Permk Fee"S fall Estimated CddtX,$7/51000Residential Estimated°GoatX'=j omFna[cia4---_ AnAddittpnal:S�6:0, addbdca*an _ Adrtiinuiratfve cl+a�• Wake wro that ailtleids are-pfcperly artdeieBiblf!> ^ `avoid delaysib„processing., The understyned dbes hereby apply,for a Building Pamiit.to build tosthe.atwvs stated specftaflons. Signed under pbnaft pG4uiy Date . . III I d,,. . It V: . N LA r 0 I, a