21 FLINT ST - BUILDING INSPECTION i
EI`I'�-OF�L 1
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DEPARTMENT S
KIMBERLEY DRISCOLL _
MAYOR 120 WASHINGTON S7REEr SAIY.Iy,,%l.&Scnatl:SEI-rs 01970 `..l
1Fii 978-745-9S95 0 FAX:97&740-9846
APPLICATION FOR THE REPAM RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
Property is located in a; Conservation Area Y/N Historic District Y/N_
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: _
3.kOMPLETE THIS SECTION FOR WORK IN FYICTLUG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
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Mail Permit to:
What is the current use of the Building? �-5z
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Material of Building? CA "`"� If dwelling, how many
Will the Building Conform to Law?
Asbestos? U
Architect's Name
Address and Phone
Mechanic's Name ��
Address and Phone iy`L% rb—1 llJ✓�/�'� J�'�T ��/A/� /'i/l. / �d'7�!'W /�
Construction Supervisors License# 06I/3l HIC Registration#
Estimated Cost . QJof Project$ Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $6.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building;Permft to the above stated
specifications. Signed under penalty of perjury
Date
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NOTICE "ZI NOTICE
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EMPLOYEES EMPLOYEES
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The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
ZURICH-AMERICAN INSURANCE GROUP
NAME OF INSURANCE COMPANY
ONE TOWER SQUARE
HARTFORD, CT 06183
ADDRESS OF INSURANCE COMPANY
(6ZZUB-7556A19-6-06) 05-01 -06 TO 05-01 -07
POLICY NUMBER EFFECTIVE DATES
CORPORATE DESIGN INS AG 64 BRIDGE STREET
SALEM MA 01970
NAME OF INSURANCE AGENT ADDRESS PHONE #
OUELLETTE , ROBERT DBA 144 FEDERAL STREET
ROBERT OUELLETTE CONSTRUCTION
SALEM
MA 01 970
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
�147 W20PIG02 TO BE POSTED BY EMPLOYER
Page I
INSURANCE BILL
Bill Date 02/20/06
�T
THE Account Number 08 10025136
R"TFORD `- Pavincht but Date 03/12/06
Billing Compam- Current:Balance A4ini Due'
I lardord Piro Insurance Company $538.90 $302.50
T Please Pay Eith4 Amount T
Account Summary(Activity since last bill) �' I
Previous Balance Payments Received New activity New Feels) Adjustments Current Balance
$83440 -$302.50 $0.00 $T00 $0.00 $538.90
Please pav either the Current Balance or no less than the Minimum Bar.By paving the Current Balance in full,you can avoid lature service tees associated with
administering vour payment plan.If your payment is not received by the due dale.a late Ice ofS30.00 will be assessed.
Please see the reverse side for additional details on your account.
Summary of Policies for ROBERT OUELLETTE
Policy Number Description Policy Period Status Current Balance Minimum Due
08SBADU3939 Business Owners 09/I8AA-09/I9/05 Expired $0.00 $0.00
08SBA13U3939 Business Owners 09/19A)5409/I8/06 Active $53L90 $295.50
New Fce(s) $7,00 $7.00
Totals $538.90 $302.50
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Contact Us
3 For Customer bervice Can: - -- - Report Claims 24 boars a day:
a Toll Free 1-866-467-8730 Toll Free 1-800-327-3636
Monday-Friday
91 Automated Service is Available tnsur vine Agency:
24 hours a day.7 days a week -------
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