5D HALSEY WAY - BUILDING INSPECTION CrrY OF SALEM
PUBLIC PROPERTY
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CrrY of SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensation Insurance Affidavit: BuUders/Contractor$MecMcians/plumbers
Applicant Information Cnnargetion Specialties
Please Print t.Ahr
Name( .I P.O. Box 53
Address:
eityistatemp: Phone
A" N as he employer?Check t appropriate boat Type of Project(regtdred):
1.0 I am a employer with 4. [31 am a general contractor and I
employe"(!fill and/or pamdroa).• have hired the subeonttadots 6' ❑New aoostntcboa
2,[31 am a solo proprietor a pacmer. listed oa the attached sheet i 7. Q Rsmockliag
ship and have no employe". Th"e mb•contractap have 11. Q Demougm
worfctng for nu in a�capacity. warkera'comp.Insurance, 9. Q Building addition(No workers'comp,im mans S. Q We are a corporation and its
required.) o8icars have exercised their 10.Q Electrical MAIN or additions
3.Q I am a homeowner doing all work' right of exemPtionper MOL 11.13 Plumbing repairs or addldons
myself(No workers•comp. c. 152.41(4),and we have no
12 t
insurance ]t employcea.(No workers' P-ooreRaim
13. c2c cK1
-Any WHOM 69 deeto bon At awwl arse a0 out the sewtan bdm.ee dy ro,dr.akass aaa�pe�tlee adky iebmatla.
HemaoMao vke nibmh dtira@tda tehdleattaa meyam dales as sndtaad ar.bkeaahldi eaaaaetem mail wWA VIa raw etadavY
=Coemeews an deck dhb bwl aaam attaded as addfdoml drm dmn ft*A agar arm.mbeomeemu red dt W Ndt ittus
I ear an employer that btprovwxs workers'eawpeasedoa harrraaeijor sly ealployeax Blow hr the lnjormatlow 6 polfcy cnd/ob site
Insurance Company Name•
PolicY 4 or Self-ins.Lic.#, U0 L�t (Cj 0 2(D G C () c�
(_ �� Expiration Date: v �fll
Job Site Address 5� *ffy1
k city/3aee2iP-- IYI�� O14�Zt�
Attach•copy of this workers,eompeasad"policy declara ion f
Wp(skewing the potlry camber and expiratloa date).Failure ro sw=coverage as required under Section 25A of MOL a. 152'can lead to the imposition of criminal penalties of a
tine up toS SO.00 a d y d/oraping
onayear imPrtsortmeat,as wall as civil penalties in the form of a STOP WORK ORDER sad a lino
of up to 5230.00 a day against the violator. Be advised that t copy otthis statement may be forwarded to the Offte of
Investigatlons of the DIA for insurance eovarags VaWCation.
/do hereby a der the p ared penddes ojperJary do A*Injorsadow provided o ove u ua 'd
Sianature• /L- c ud
De w
Phone 441
FB�ozrd
onlr. Do not Write lw A&ore;to be eoarpleted by e1V or fea'w oA�14
Uwe: PermltMcense/
hority(circle one):
Health 2.Building Department 3.Cily/rown Clerk 4.Electrical Inspector S.Plumbing Impactor
Contact Person: Phone M.
00-35,000 cf enclosed space - �l
(MGL CA 12 S.601.) -
1A-Masonry only
..� iG-182 Family Homes
Failure to possess a current edition of the
is Massachusetts State Building Cade
is cause for revocation of this license.
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I DIG SAFE.CALL CENTER: (888)344-7233
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BOARD OF BUILDING+. ,,..REGULATIONS'+
License: CONSTRUCTION SUPERVISOR
Number Cs (**t i 5, f
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Bfrthda[e 05l02/1962' `�"�•,' t
Expires 05/02/2007 Tr.no: 12507 .
Restricted: 00'. E
TIMOTHY J FINN
8 UALDORA DR/PO BOX 53 p
STONEHAM, NSA 02180 C i/
�, Commissioner 44
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t0/L0 3F)Vd Z.dIh1090OVES' owlig LEuLt_7.69LG bGi:Ti ;uc+rfar!t:,a
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What's te current us
Material of Building? W fl- if dwelling.,how many units?�—
"I the eurairw rm
Confo to Lahr? Asbestos?
grchit«ds Name ( 1
Address and Phone
Mechanic's Name t�M
�b� 1« n 5' 'rDS2
Address and Phon! o
��m�qR HIC Regis m*m,e
Construction SuPeNiscre trceen�s�e��*�
Estimated Cost Priced � Pem�it FN Cakulatlor
Pertnr Fee i
- Estimated Cost X$7I111000 Residential
Estimated Cost X S111:100O Caminenaa4-- --
-- An Additional $5 00 Is added ae an
Administrative charge.
Make sure that all fields are Properly and logic wMar to avoid delays in processing,•
The'undem%pwd does hereby apply for a oUilding Permit to build to the above stated
Speaillcatkars. Signed under_penalty of perjury
Date a l4; 0'(
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AFFI:YCATI'ON FOR'I`HE REFAIR RFNOU-1w N C,pN 1 t J ,y ON
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1.O StT�INFO TION
Lccatlo ►NamF _ C ¢✓t . c5�` Bir(Iding:
la+oprty is located-ln a:'Consetvatlon Area Y/N._T_HlstorlcCta�rlct YM,
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tea^y
Trblspr+on.a.. :
3 t)COMPt;ETE.7HIa"3ECTibN-FOR-WORK IN FYI T1MGy'> (11LbIF1G9xONLY "
Addjtion" ExdsUng ;
Renovation
.Number of•'Storiee . , "Renovated
Change In less
New
DJ .
emolitlora 1 - Emsting
Approximate year of Area;>per nocr.(st) Renovatetl consitrucUon,or-rerrevation
df existing`twddin
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