3B FLETCHER WAY - BUILDING INSPECTION f
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CrrY of SALEM
PUBLIC PROPRERTY
DEPARTMENT
MAYoa tZ WAS* M=NSWW a SAIFM.MAS&""Jsarss0t970
TIL 976745-959S a PAx'9W449416
Workers' Compensation Insurance Atlldavit: Bnilders/ContraetorgMecMctanx/Plnmbera
ADDlicant Information please Print r,e bty
Name Its ). Construction Specialties
X 00
Address: Sfnnsh' l pw 02180
City/StatdZip. Iftne/! 'Z S �^(e�— �(l{ Q
Am yo■as empbye ?Cheek Me appropriate bon
I.Q 1 am s employes with 4. Q I am a goveal contractor and 1 6.Pe process(required):
employea(!Wl and/or past.time).• have hired the subconttactora 6. 0 N New cooshtsctTon
2.❑ I am a sole proprietor or patmm6 lisped an the attached sheet.t 7. ❑Remodeling
ship and have no employees These wbcmnacmea have 8. Q Demougon,
woridng far me in any capacity workers'comp•insurance.[No wodws'comp.insurance 5. Q We are a eogxnttm 9.. and its 0 Building addition
re4uivdd l oMCM bsve exercised their 10.0 Electrical repahs or additIms
3.Q 1 Am Is hcnmwnw doing all work risht of exemption per MOL 11.13 Plumbing repair or addhone
myself:(No work=$comp. a.15Z 41(4}and we have no 12.0 Roof repairs
insurance rcvdre&j t CmPloyca.[No workers' 13.Q Other
* o w�dw ahaob bee at do r eta n nut the sedan sb�i ihdrm.b.alns�eompo..tl,e vo++ey f q�y�
xouNSMdochemumrdnJ.rit6rdedea dry dahq •pt,.aro.rrbaaWdtaaebaapumesanersawat>ldovtt
icme.oea.dra.a�dd.t�m[®rt.dace.e,e.amdmJ.b.a showing drmeeafewxo&Cueueawe.nadru.c.r..•eomv. iesam�do�..
djW an `wrAwt L.provfdlns worker•COIwIW xW d0A&;unsaCejor sq sssploysa Blow Is dks pogry sad fob slat
Insurance Company Name: V
POUCy M at self-ins.Lie.W_ I J G g0 (0 6 0110 6 OZ7 piration Date no
Job Site Adorers:_ i�(P.� �(Lf i Ciry/Stata2lp 't 21 1� , 0 (Cf 7
Attach s copy of the worker'eompeasadoa potley declaration page(showing the poBey number and esplratloa dab}
fait u Failure 10 am=coverage as to S ,51 00.00 and/orrequited under Section 25A of MOL a 152 can lead to the impositions of criminal penalties oft
of a to$250.00 a der a One-Yea >onoumR es well as civil penalties is the form of s STOP WORK ORDER gad a(iae
P y gains*the anteviol or. ra advised that a copy of this Statement may be forwarded to the Of&@ of
Investigations of the DIA for t��•A��-coverage veritfcadoo,
/do bsrsbr esrdb eadsi Nte poAsr pad peaeldsr ojpsr/ary tAW&*Atjeroadon provided above to tree cad correct
Skmature•
Datw
Phone M
FBOard
oal�t Do apt writ*In a4ls ere;Is be completed by dy or Iowa of eleL
s: Permit/Lleema N
hority(circle one);
I. Health 2.Building Department 3.City/fown Clark 4.Electrical Inspector S.Plumbing Inspecbr
Coatact Person•
Phone M:
Crty OP SALEm
PUBLIC PROPERLY
DEPAW ENT
MOVE ta.hoolod2ruff. W. CMmmat n.
11ns t►f�tbse...�,e+vs'aNste
Coosttrnct�oe Debris D1s�aat At'Ad�►vtt -
(eegitind!br ett emo0do.tatd naetr�dea�
Is ecoothe with do"WNW attbe Steve sttgdtos Coda 7W CIO seedam IIIJ
0"j.ad tttepeovWkmo ofUlMa+4 s sy
satiates Mamie fe bm d VD&the eoedtdw to dw dedte mad&g&a
LMg wad dag be d wand at In a Popsly 14 mud WNW&q d Aft an d.Aned by tdctt.e
Thq&ftlsvile be tramp Md byt
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rw ddde wig be ddispowd of in:
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What is the current,use-�o�fpthe B-ilding? r
Material of Building?
If dwelling,how many units? -
WIU the Butldirj,Conform'tolaw?
Asbestos? .-
Architad's Name
Address.and'iPhons
Mecharilc'arName
Address andPhons
ConsbucWn,Supeniisom Ucense# HIC Ftegistratton.#
Estimated:Cdit ofProjea i 4000.°�Pennit Fe.Cala,latton
Q Estimated Coat X i71$.l OW Residential
- --
-- -- -- - EstimetertGcst)E 101$-10 - ---An Additional &6 ts.added."an
Admtnistrative ata5ger
Make sure-that all flelds are property and'-legibly'wditen Wavoid del tis,ln processing;
The undersigned does hereby apply fora,Building.P/ennit to build to the above stated
spediflcatldns. Signed under penatty.of;pedury
date 1-a2- oZ:
O � y
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