2B FLETCHER WAY - BUILDING INSPECTION .1 CITY OF SALEM
�. PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensation Insurance Affidavit: Builders/Contraetora/EtecMctaus/plumbers
Applicant Information Cnnc+ructiott $peCiaitie8 _
Please Print i •ets.taa
Name ., . P.O. Box 53
vay..ai..w.u' .o.v VL
Address:
City/Statiump: now M — (C Cc
A"vow o ampkyar?Check the appropriate boss
1.O I am a employer with q_ 4. O I am a general conusaw and I [,;3.
TYPOIpr°l�(ro4>had):
amployees(Sail and/or part=dma).a have hired the sub-mmetosallow construction
2.01 am a sohe proprietor or pasmeo- !feted o the attached sheet tRemodeling
ship and have no amployam Thm arb-contnoho s have amolitio
working for me in any capacity, workers'comp.iasuranec
(No worker'comp, insurance 5. ❑ We are a corporation and its uilding
requimd) o8icets have Ew5gerhiave'no
their lectrical repairs or additions
3.❑ I am a homeowner doing all work' right of m:temMOL lumbing repairs or addidods
mYaehL(No workers'comp. a. 152,f 1(4), pp /
insurance requbvd,)t emploYem(No worker#' f l�l 14G1
�R Insurance required)
1AW app�ot tW chocks box al mo also tip one dw online bdor.hoades aahrraodtwo.eomgerstlae policy ..
Honnoovm sib submit"&dS&vkhdfo rhryau doing*2vo*and drtMiramideomaaaaona
man sub"a now,atIId.via
tCoatracom doo cha.k 06 boa anon.am.ehd as oddfdowod d"Showing*4 anon of ar erbaoauaetaa sad db k coo boa• .
I aw as awptoya tlhar La.Prosddbj woman'cawpaxratfon Lararance of
rnjorwarlow, / j try awployaa Blow 4 tAr0P00 wow ob rfq
Insurance Company Nam:
PolicyNorSelf.ina.LioaY: _�� ki� 2�i f�Lj
Bspiradon Daft. 5 v os _
Job Site Address Clty/Shtcaip.--X m /� . d Ng7,0
Attach a copy of thb workers,comp*Medea polky declaration paje(s�� tht IT
FaAure to secure covarsga as g 00W number sari dapdration data).
find up to accum.00 and/or under Section 23A of MOL o. 132'can lead to the imposidoo of criminal pesiaitka eta
of u to 3250.00 a des a Y Aso nt' a wall as civil penalties in the form of a STOP WORK ORDER and a flue
P Y 8 the violator. 8s advised that a copy of this statement may
Investigations of the DIA for insurance coverage vuifiegdoo. be forwarded to the ORke of
I do harrbr ear=dal rho pe"psnafdaa o jprrjnry that t/rt fajoiwadom provldid eve Is gird orrad
Sianature
Dates I
Phone k:_ L �q S - •�.�
O.Q7eid'us onfjt Do not wrffe in u4lr are;ro beeveepkied br ciq or own o,Q7efa(
City or Town: Permlt/Llcease N
Issuing Authority(circle one):
L Board of Halth 2.Building Department 3.Clty/rowe Clerk 6.Other 4.Electrical Inspector S. Plumbing Impectoe
Contact Person: Phone S:
N a
Crry OF SALEM
PUBLIC PROPERLY
DEPARTMENT
Canwmtfam Debrb Dfgm t AWavit
(tog#"ON sa dsstoWiom sod removal"wad*
Is soos�dsooe wide the editim of ft Sbft DID&OSCadft lad CUR secdost tlt.S
Dabd4 d tirpsovisieets cfMGL o�'SIt
a gs�a to tssoed with ttr eeodiete.tisat tbo d bdo +s Bost
:lsd woet sbN1 b•disposed oust o t��Itesmsd wswo disposd Adgq s.ds�ad try 1(Qf.o
Tlw ddWA wiU bo&zmpcott_e-d b54
Y/Je�CA' d-i\c
iAmms
1'tw debris win be disposed of in:
��erpeemit�ooue>as
su.
i 00-35,000 cf enclosed space -S.60L -
(MGL C.t 12 )
1A-Masonry only
-i 1G-4 &2 Family Homes
i '{ Failure to possess a current edition of the .
Massachusetts State Building Code
i is cause for revocation of this license.
e
IL DIG SAFE CALL CENTER: (888).344-7233-
I !'
"" ✓ate Znpoiamai "I✓ O"k
,aat<u
h� BOARD OFF6UILIDIN GULATIONSa �.
UC?fION SUPER�VSORx
L{cense. CONSTR
Number CS 053897
n
Blrthdate 06I0271962'x��� _
Expires 05/02Y2007 Tr.no: 12107 Y,
- -''- Resf�ic[ed00 ,-�
6 TIMOTHY J FINN "
8 VALgORA DR/PO BOX'53
- a STONEHAM; MA:02180 - Commisslo"01 '
t
PROPOSAL
CONSTRUCTION SPECIALTIES UNLTD., INC.
P.O. BOX 53
STONEHAM, MA 02180
Phone (781) 665-441.0 Fax (781) 665-4411
LENNO
HEARTH PRODUC73
BROAN-NUTONE
A .NORTEK COMPANY
V -c-a� - off
pewyIeVe-
4�
i�ns�jCt,�l (._ennvx !� Ili 3� �jc� roo�9 (q, ec C��mne.A.(
nexo C) 1QcSVt i r1� 0 )a T o
cSJrrouicd
Ff e-efro d c ��� l,� ( i 1.ec.e5-5ar�
We propose hereby to furnish 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 ' due upon job completion:
Authorized Signature
NOTE : All plumbing hook-ups, carpentry work& building
job site general contractor or homeowner. Prices are effec ive or up to 3 months frome
date of proposal.
Acceptance of Proposal
rigor wee.,,w«Iwaw..� w.Mbhao ffbY�'�'aplb Yae,re wiMllae!lo'do IM wort u.p JIIaO. Peymeni rill pe�e u ouUineU.pove Signature Date: _ Z Z/ 27
If accepted.p sign and return
�QQ l Ckp- (.cerL on 1r1s4e ton
Q i _
what is the current use of,the�n ildingT
Material of Building? - `^ If dwailing,how many unitaT--LL�
No the Buildipg Conform to,L4,0 -
AsbestosT:
Archited'sName
Address and Ptwne f
Mechank's Nams- ^ n r\
Addfass arW,Phons.
Constriction•Supervisore t icense# C5
,05 HIC.-Registration#
lcstimatedCost of Project SO(p PermR:Fee Calciiletiort
PermR Feed Estimated Cost (S7/3t000'Residential'
An AddiHono 5;00 is,adde&as an
Administrative charge,.
Make sure that all fields are properly and'legibly written to avoid dek",Iq;Pr"sinQ-
The undersigned does-hereby apply fora Building Permit to build to the above stated
specifications. Signed underpenalty-of: dduty
x -
Date
0
s %)
NIX
ad
3 .
i
EI'I' O.�r. --
PUBLIC PROPERTY
DEPr1R'I'11�IF.►�1T
Nwrat 13owwyuwc,-i�sr>�ar•
. T4a_9'!LT�S'-9S9S�,FA1C 97f-7�4b1f r _
AP.PLICAT[ON.FOR THE:REPAIR. RENOYATI � N � ONSTRUCTiON ,
DEMOI:MN. OR CAANGE OF USE OR` 'FORA1�1Y EXISTIN
STRUCTURE OR,BUILDIlII(:
1.O SITE:INFO !EON
a ocatlomowne:... L 0.Vl . c •
Prop'rty AddresIF
0I`I"leG
�`-� Propartlrle located,Ut a:'Condervatton Aroa YM HistorlC:QlBtrict�Y/N'
Z.0 OWNERSHIPINFORM/1T10N
9-0,Owasucit Lamed _.
Name: Chrl. OJ
Address'
hlP+ ola�0
Telephone• - : .
3SO.COMPLETH THI9 SECTION.FOR WORKIN Ex18711l1r3 OU—M-1NGB,ONLY
. .F
Addition Exiatlng
Renovation Number. of Stories . I Rerovated >
Change in New
FAApPr,,Ox!Mate
molitiod Exi"sting
ear of
Y Area per door;(0) ;Renovated
structiomor renovation:
atiisting-tiutldmg r New
t3aet Description of Prom°sed Work:
`S�F c toil `•E- ` ems
\ C�
Cv1�M �-`�J `3� 1'e i t/ &; ,o C�trlCSILA,
Mail Permlt O.