13B GRISWOLD DR - BUILDING INSPECTION CrrY of SALEM
PUBLIC PROPRERTY
DEPARTMENT
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t20oa2mu MNSTRM.SJUM4 1L&UACMWM01970
TIL•9M745.9595 a FAM 972-740.9$46
Workers* Compensation Insurance Affidavit: Builders/Conttraetortmeetrtctani/Phimbers
Applicant Tnformadon Cnnetructinn Specialties
Please Isrint UAW
Name(Bw;ryas/Oepeubeaortadivid alY P.O. Box 53
Address: Stoneham,
MA; 02160
City/State/Zip: Phone# _ `Z g( — �e S-�f 4 I C
Ann as empbyerT Cheek the appropriate boar
1. I am a employer with q 4. ❑ I am a general contractor and I Pe of project(regnlred):
employees(M and/or part-time).• have hived the wb conptctow 6. Q New construction
2.[31 am a sole proprietor or parmer6 listed an the attached sheet t 7. (]Remodeling
ship and have no employees These sub-contrac ow have 8. ❑Demolition
working for me in any capacity. workers'comp,imuraace.
(No workers'comp.insursnce S. ❑ We are a eorperation.sud its 9. C3 Ong additr�
mquhvd.) o@icees have encased their 10.13 IDoctrical repairs or additions
3.❑ I am a homeowner doing all work right of ccemption per MOL 11.0 Plumbing repatn or addition*
myself(No workers'comp. a. 152.¢1(41 and we beveno
insurance )t ) 13. 64Yc � �Q[v
o EMN a"an Out 010
HOMODWOM who
poney
tie d k `ws�a .ehcy.dm�tlm it ,6o�'fasm..w stdr�,wbeostr sub" affid"hmucift FAA
!aw►as sarployr thar hr provldhrt worhore•compsaaadon Grsaroac• or
rnformodaw.. // ! mY smployss Blow is tha potlory and job sbe
Insurance Company Name: V
Policy M or Self-ins,Lis V. / C�S I �i�p 2(0(p fjQ1 Expiration Date: Teo)a
Job Site Address City/StatdZip: � � l_
Attach a copy of sae Workers'eompeantion policy declaration pap(showingthe
Failure to secure coven sa , Pe�7'number sued a:plratba daq),
g4 required-under Section 25A of MOL a 152'cm lead to the imposition otcriminal penalties of a
fine up to 31'500.00 and/or one-year imprisonment,as well as civil penalties in the form ota STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Be advised that a copy pubis gain the may f forwarded to the ORDER
of
investigations of the DIA for insurance covenp verUltation
!do hereby csF=tits the prod paaaldsa olP•r/wY that the iw/orwradow provided ovate d Signature, Correct
tii Dntw `1111 0
Phone N. Ig S 44 VG
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OX66 Do wof write lw tlkls area,to be complct•d by clo or towa odlc%4s Permit/Lleeatshority(circle oneHealth 2.Building Department 3.C1tyl1'ows Clerk 4.Electrical Inspector S.Plumbing Impeetor
Contact Person:—
Phone N:
�I
I 00-35,000 cf enclosed space
j (MGL C.112 S.60L)
I 1A-Masonry only
1G-I &2 Family Homes -
+{ Failure to possess a current edition of the
,j Massachusetts State Building Cade
is cause for revocation of this-license.
}
I is DIG-SAFE,CALL CENTER: (888).344-7233
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Llcense CONSTR;UCaGION SUP
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Expires OS/g2(,2007, Tr no 122t'7 I; � -
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8 VAL'DORA DR/P0 66X^53
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JUL-20-26307 04 :32 PM SURDAM 978 499 9789 P. 03
PROPOSAL
CONSTRUCTION SPECIALTIES UNLTD-,INC.
P.O.BOX 53
STONEHAM,MA 02180
Phone(781) 665.4410 Fax(781) 665.4411
HKARTH6gNNQ2SBROAN-NUTONE
PRODUM A NORTEK COMPANY
mwyw Sle- C '-1 -ao-07
1316 G�-;s, --rol d
&xlern (1 (� I
RQX--, e �— A'.s C, OY �7. Y,� �; �au
k> V-) u " t"(anc) 6�mere13
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 SO%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 fit 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
7Le Yeveptlae4 yea�Nem,�aE medltloe,,n Wles@m9 uG aelbclb'�Yw ao aMeprod W m we an¢u ymtlai Ya,elptl v0 b,mWe 4 P���.P
Signature Date'
�ry
If accepted please sign and return. ae
- C640- CeSSOci�T�`�n -2s ; -P r
What is the current use of the Building?
Material of Building? �� �� If dwelling.how many units?--
Asbestos?
Wlll the Building"Conform to LqW?.
Architect's Name - -
Address.and'=Phone
MechariieVName O'2c Teo
Address ands Phone
1 (o �►�'tr,an� YY1 �s2 ]MR,
Construction Supmvisots-License#' � H IC.-Registnatlon#
Estimated Cost PSDject S Permit Fee Cek ulafion
Permit Fee:i Estimated Cost X S71S100'0 Residential'
_. _
An Addition81,$&OG-I6 added as
AdminlstreWe charge.
Make sure that all fields are°properly and legiblyw►itten to°avoid,deleWr-Vprocessing.
The,updersigned does hereby apply fora Building�P/ennit to build to t/ha'rabove stated
specifications. Signed underpenatty of:parjury /� �""``
. , Date " � if D
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PUBLIC Pa,QPR 'Y
DEPAR
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APPLICATION FOR T>E;E )bEP`e+11IR.=RENOY�►tl'���t� C_pN=TRU � r ON
DEMOLTTION. MIRAAX"'7 -sOF ;F®R>' jEXIilA,
"O $
1:0°SITE I,NFOR„ ' TION:_ " '
Lacatlon Nam!!: .: C .rn a n CS+ 8uikilig
,Property�cdtlresc-i3 B-
MA
Pr'op�Tlli is kJCated 111 a:'CrOneArvatlgrl Aroa 1'/!d . _,`: HlstorEtl D"tetrld Yl'N.77777
.
4 �1DWNERBHIPiINFORNII►�T10N:
2.1 Owner of Land
Narns: Mao
-�Of. Rejee,"
Address,,: 3 CES coo {.
794.
Telephone $1-
3 0 CDIYI LETE.THIS sEGT ONvto YYORK IN EYr6Tilur�'$'UII:DIIVGS GNL""Y
Adtlition <Existlng
Renovation Number.of 5foriee Renovatetl. <
Change in wss
DernoliGor - xisUng.
Apptoximate year of Area:per floor->(sf) Renpvated cbnstructton brrondvation w -
df existin <buittliri ,"- '
9nehDes ,'ption.ofPr- sed Work:
+
CN, Nn VA eAl
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