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4C FLETCHER WAY - BUILDING INSPECTION CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT awWAM tausoot t. N/YOR tM WA4mdGTOMSia W A S=Md,MAssACst WITS01W0 7h.9711•745.9S" a FAX:9W40.9a46 Workers' Compensation Insurance Affidavit: Builders/Contractora/EtecftkUns/Plumbers Applicant Information Cnnetrnction Specialties Please Print LeAbly Name(Businete/ P.O. Box 53 it Mee Address: City/statemp: Phone# An you as employer?Check the appropriate boss Anwar Q I am a Type o[proJect(cegnlewd): 1. employes with 4 ❑ I am a e the contactor and I 6. ❑New construction employees(iWl d/or pae6time).• have hired the sub•contadaa 2.❑ 1 am a sole peoprietas or patmet� listed on the attached sheet,t 7. ❑Remodeling ship and have no employees These mbcanhactam have 8. ❑Demand= working for me in any capacity. workers'comp.iaau mum 9. ❑ addttiaa [No workers'comp.insurance 3. ❑ We ors a corporation and its required.) o8lcan have exercised their 10•0 Electrical rep&rs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself.(No workers'comp, c. 152,11(4),and we have no 12.0 Roof repairs insurance required.)t employees.(No workers' COMP,inauaaee MT1hjQ 13.0Other ;MqWM=WensdoebbuelmaerdmtmfirtheswdozbYwAmina*Air wakew HamonAewbenibdtwrenkkk*b gdWmddolauwa mdmab+na pm �.�eer IXdrrir a a rComee sws t6Y cheek eds Gas mace uueb.d anwddideaet r6ert r6oa4�as m a<i6e abeeewaemrs sed 6e4 watwm'camp,v�Y(atb�metloa. 'r arararlod er that teprovldhq woF*"'eoarpearados huarsscijorAW ewptoyeat Below te Nee po/try andJob site Insurance Company Name•. ��p G O Policy#or SW-ins,Lie. L tWq C$l(o SO 2 bra 00 Exptradm Date: O ('�`7 Job Site Address: �K �e I� er 0C¢S-( Ci1y/SfateR3p SaL (c�0 Attach a copy of thi workers'compeaisatlon policy deeleeatien palls(showing the policy number and expirsdos date). Failure to me=coverage as required under Section 25A of MOL a. 152 can lead to the imposition olcriminal penalties of a fine up to 51,500.00 attd/ar one-year imprisonment,as wen as civil penaldes in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may forwarded to the Office of Investigations of the DIA for insurance coverage veri&uion f do hereby cerdj&q_�mrde���pohrt andpenema ojp dwdot the lnjormados provided a ve trw and coned 'I Signature: .3�( T�©-7 Phone M: 1C( (o (0 5 L(q ( O T Ofylclal nu onb6 Do cot write is this are;to be compkfad by c14'ortews oJyleW City or Town: Peralbueass s Issuing Authority(circle one): I. Board of Health L Building Department 3.Clty/rown Clerk 4.Electrical Inspector 5.Plumbin8 Inspector 6.Other Contact Person: Phone 0: CrrY of SALEM PUBLIC PROPERTY DEPAWrMENP �. us.aes�itses:.ista.YwoaaTts01+� TILrsf7+aasn•PAS9&7+Nw Com&ucdo. Debrb Dvpold AfiMavit (Req�ised 16r�dseolidest cost sessrradosl wedgy 1s smosdsssa wM dw sisuti WWM at&@ Sens BuUAV Cod,,780 CIO seedom 1113 weds,d erg a(IMe+a S sN „aft ftwa r i.land wed do eeedtdee&d dw I I mmiWag!toes wok"be disposed otist a psopaft dsannd wasb dhpnd ed*y as Mined by UGL a tl1.�13QA. 'tie deeds win be trsaspoetd byt The deeds will be disposed otin: (AMISOC �+wswr etOtAf�spgjwas � 1 dw 00-05,000 cf enclosed space 11 { (MGL C.112 S.60L) to-Masonry only ..; 1G-i&2 Family Homes Failure to possess a current edition of the I Massachusetts State Building Code i . is muse for revocation of this license. i}} kIIIp %1 1 $! DIG SAFE CALL CENTER: (888)344-7233 ✓,rye nryHbq/4 /{i(.[I�yyfldd/Q z-� BOARD OF BUILOIN REGULAVON3,, -License: CONSTRUCTION SUPER VISOR,x+- Number CS 053887 r- Birthdate 05/02/1962�'�; ¢ - Expires 05/02/2007 Tr.no: 12307 Restricted. 00' TIMOTHY J FINN & ). { 8 VALDORA DRlPO BOX,53 .' G--- - STONEHAM, MA 02186 +� Commissioner }t MAR-15-2007 08:06A FROM: TO:17816654411 P: 1 FAX COVER SHEET Construction SperJ8111e3 Unkd.,Im P.O. Bar 53 Stoneham, MA 021W p 8 Fe%Number 784 `I $1 • G 6 5 - Y4 i SEND TO �---.—....,...._. .. Company name Attention �r CX (R(J�C7t� office location offce location e Flela� Lc)a Far numbn Phone number Uryjent RspfyASAP P/wise comment Please revieW ❑ Fof your lnformatlon Total pages,urdudmg cover. COMMENTS u, t use --��LOISh`n--�--�---�=���LS�.C. �'l✓lu?4 �k ���:�. 1 �C_ll.nnne%( ..... �;- . IL --�-- - --fit r _ -��y __ =t_�_.1.5. -Cry✓e-�.._ _,- �f ce �/iCVl�t✓ o ��Vl�' L�OJ ('utC1( EI'I' O -- PUBLIC PROPERTY . DEPAATI� �:�aros�tts�roluscou NXvai d/J 12611ViLUHclsw-3iftEE7 y'SN��Naoit S�7s 01470 ��i©al ��/�� 141:97C=7ii9�59i�Fg7t9 =�J0.9616. APPLICATION FOR THE REPtIR.:RENOYATION.rCONS`I'RUCION. DEMOL-ITIO14. OR CHANGE OF USE!OR;OCCUPANCYUm . FOR ANSI .E QSTING STRUCTURL.OR.BING' 1.o SITE INFORMATION _ Location Name: ..Properly te;located in a;Con'servatCon Aroa YM Mista'Io Clslrict,YM _ 2.0 OWNER3NIP`IN�OR ;R10N 2.1<owner of Land Nm ae: Address: 1� �✓ Tele hone r r 3.O COMPLETE THIS.SECTf16A FOR-WORK IN EY►QTrN� BUILDINGS"ONLY Addition t:Xistl'ng. Renovation Nurnberof Stories Renovated Change in=Use NeW Demolition Ezfstlrig Approximate,year of Area perfloorlso Renovated construction or renovation of existing building Now, auef'Description of Proposed Work: Mail Permit to: _ _ C05 e What is the current use of the Building? Materialof Building? 19 tic if dwelling,how many units? Vrlik�the BuilCii'�-ContoGrnto.Law Asbestos? Archited iMame Address and phone ( ) Mechahle's Name c'Zb Addf0sand"phone, Consftdion<Superviscrs license# @ ��-3�WC Registratbn# Estimated Costof Projed S . ga o — P,ermit Fee:Cakulation - - Permit Fee>S Estimated Cost X=S71S1000 Residential __ -- --- —_-- EstlrrratedEo_stX'0,4101000-Cofnrnerc`�' - An-Addionai,S5s00 is�added'=as an Administiat@2e•Cha<9s,. written t0 avoid,'deleye,in processing. e e9 lY Make'sure that.ak Welds are.pro p �y arrd'zl ib The,undersigned does hereby apply for a`Building PermitIo build,10 the above stated specifications. Signed under penalty of perjury blite of s N w. a - r 0 «