5B HALSEY WAY - BUILDING INSPECTION crrx OP sAimm
PUBLIC PROPEWM
DEPAWMENT
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CITY OF SALEM
• PUBLIC PROPRERTY
DEPARTMENT
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M"y LW VA4mWMSTMT•SALFL.MASSACHUSE s01970
Tt:97a•745-9"S a FAxr 972•740.9a46
Worken' Compensation Insurance Affidavit: BnIIders/Contractorimect><ictans/pb mHers
Applicant Information . Cnna4rpetion $peciaitieS
Fiesta Print Leribly
Name(ewinen/organisaeowTndivi&W) 'P.O. Box 53
Vl* Mee
Address.
eityistatemp: Phone `Z$f — (C
Are you as employer?Cheek the appropriate boss Typo or project(rogr��;
1.0 I am s employer with c_ 4. O 1 am a general contractor and I
employees(ihil and/or paUdime).• have hired the asb•cooencpow 6. ❑Now construction
2. I am a sob proprietor or partneo- lined an the attached sheet i 7. ❑Remodeling
ship and have no"Joyce$ These have 8. ❑Demolition
working for we is a�capacity. workers'comp.Insurance.
(No workers,camp,irom ea 5. 0 We are a corporation and its 9' 0 Building addition
re4wmd.) officers have 555have
their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of e:temMOL 11.[]Plumbing repaire or editions
Myself(No workere'comp o 152.41(4� no 12.0 goof
nmommee required.]+. employee.(No workers'
reRairs
comp.insurance requ d&I 13. (Act b{1
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ramaw aerptoyar rhat4prov/dlnr worbrs'eowpaxwdow►wayrasei jor wq irwployeat Arg Is tke pogc3,and o8 sAw
l orwado0%
Insurance Company Name:
Policy N or Self-ins.Lie,iV.- (O Z10 G c)L1
rr .� Espiradon Date: IT w �s
Job Site Address S 45 W cM City/stmarzip: `E'k l I` 1 (} 1C(.70
Attach a Folly of the workers'wmpsauatlos po deehuatlor pap(oho— the
Failure w secure covers sa f pi&y number mW expiration date).
p requited umder Section 25A ofM3L a 152'can lead to the imposition of criminal penalties ofa
fine up to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
Investigations of up to 5250.00 a day against the violator. Be advised that a copy of"statement may
forwarded to the Office of
*(the DIA for insurance coverage verification
f do harebr earlJy andor dap and ponakbt ojpsrpuy that dra in jorwtadow prov/did a ovr/t errs and cornet
Sismature:
Dwtw
Phone M: rZ� S Y4 l.,o
OJJ7cld ate only. Do not write in this area,to be coerpkwbr ciq,or tows,oQfe/4
City or Town: Permit/Lieessa N
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/rowa Clerk 4. Electrical Inspector S.Plumbing Inspector
Contact Contact Person:
Phone N:
i 00-35,000 cf enclosed space
(MGL CA 12 5 60L)
4 1A Masonryonly
1 G 1 &2'Family Homes -
Failure to possess a current edition of the -
=r Massachusetts State Building Code
4 is cause for revocation of this license.
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DIG SAFE CALL CENTER: (888).344-7233
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�'' BOARD OF f3�k41NGPREGUL�'T�A�'
.Cleanse CONSTRUCTrIQN SUPER171S0�
Number CS
Blrthd ate:
Expires 05/02/200� Tr.no 12Z67 �
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TIMOTF7Y J FINN t
a�"'. 8 VALDORrPI DRlPO{BOX 53 �j-'� �; ).,
- STONEHAM MP;-p2i 80- porYim�ssiond(' � �
PROPOS
� o O 0 g 0 CONSTRUCTION SPECIALTIES €i1VI.TD., INC.
P.O. BOX 53
S'TONEHAM, MA 02180
Phone (781) 663.4410 Fax (781) 665-4411
LENN X l3r�oAN-lvvTaN EARTH PRODUCTS A NORTEK COMPANY
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I kP ose here y to famish material and labor- comKete 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. ff�For central vacuum and intercom installation,half is due upon rough-in and half is due upon 1' completion. For all other work, payment is due upon job completion.
Authorized Signature ~
NOTE : All plumbing hook-tips, e
job site general contractor or homeowner, Prices t arpermits
effective for up to 3 months are the responsibility of
date of proposal.
Acceptance of Proposal` j
V °� uM:om1Ym,Yn aY W Yn Lweby wmDIM Yea YroeulAmiaq't0'd01M Ypfk ypfa'E DYy,Mn!will GC,IIy)e YY O*n"lb) c
Signature
acee *e l Oate: I
LP• P si and return. _ --------
oQ
What is the current use of the Building? unib4�
Material of Building? a OC if dwelling.
how many Ww theBuMhV
Conform to Law? Asbestos?
Amnited°s Name t
Address and'Phons -fob4 -A I D
Mechanles Name _ li►1fl a21 7
Address and Phone to �em�on
Construction Su
pntvieors Ucense 0 HIC ReyistFatlon P
Pro act: 3� permit Fos Cak:uWw
Estimated Cost _
Estimated Cost X=7IS1000 Residential
Permit Fee=
Estimated Cost X i11ltsti000 C er
pmrnciel —
-- An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and'leyibly written to avoid do"in proceeding.
The undersigned does hereby apply for a Building Permit to build tothe above stated
Signed specificcatlons. 3 under penally Of perjury
bate
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77 PUBLIC OR1,01 ERTY
DEP�1R t�T'T
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WO I:7TI N :OR „AAN XL
1:OSITE INFO,^ , TION'
Locatlon Name;. (Idtng .
777
Propety 1s loCai'ed-lif a:'Cronservatton Hroa-YM T_Hlstarlc"Q"'teMd Y/N
Z OWNERSHIP INFORM/1TIdN
2. OMirSar bf 4s cl
Ndrne:; Afd`o n
Address:
(Telephone,
07
77.
3 0 COMPLETE -114 -SECTIbN4FC Rr WORK IN EYISTING,BUIIDfFIGS ONLY
.Addition: f itas(8tiriy
Renov;kWn Num,'ber of Scoriae , Renovated °
Change=irt toss Netiv
Demol(Gan �wating. _
Approximat0 yearn,"f Areaer floor-fst) RarroVa`tetl
_p
ctinstrucUcn:orrenbvation" -
ob existing twilding` New
9rieGDes' ;'ption ofPi seta Work: aUt'. `h �QSt
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