1A HART WAY - BUILDING INSPECTION (2) CrrY of SALEM
• �� PUBLIC PROPRERTY
DEPARTMENT
ataraEataT aatst70tt
MAYOR 120 WAstOM M S RUT a SAtxst,MAUAaune M 01970
TEL M74M95 a PAxr 973•740.9$46
Workers' Compensation Insurance Affidavit: i3unders/Contractorometbidans/Ph mbera
Applicant Information . Cnnetruc+inn Specialties PIease Print UAW
W
Name(mwnewommisadoorrea wasat� .<P'Oa Box 53
NA; 82i
Address: 1
eity/statemp: Phone
Are 'an as employer?Cheek the appropriate boor
1.Q I am a 4. 0 I am a Type arpr°J°ct(�°lreo:
�PloYor with�_ general contractor and I
employees(ihn and/or part-time).* have hired the cob cootractma 6. 0 New construction
2.01 am a solo proprietor or partaea listed on the attached shaet t 7. []Remodeling
ship and have no empioyeee These have L ❑Demolition
working forme is any capacity worker'comp insurance. 9. Building addition
(1Jo worker'comp.Insurance S. � We are a corporation_ sad its
requited.] o89cen have exaeeised their 10.M Electrical repair or additions
3.(] I am a homeowner doing all work' right of axemptiom per MOL 11.1 Phuabing repairs are additions
myseiL(No worker'comp. G. 152,001 and we have no 12.Q pp insurance )t co+Ployors•(No workers' 13. ltA
COMP•lnausacs required.)
'+wwv�a chale box et OWN etafWoutdrseedosbsloed whWtickcotters'eempatedoaroi!eYlpbemettaa , , j
+ttamrow�oaeroewAaftddtaetdrvtthrdindeeduga■des.svo*mdaaahtrmastdiea.aaab,sMori�i.ae 895datrtedkeftVjXL
rComeetmederdm*We box maarustedmWdtdoatebaetbMaSon�ardr addr6WON 'comp Paleyfohm ko.
an an empkev AMbprovidUS workers'eoacpensatlon Aesersnee of
Inforstad f "si'eseployees Below 4 the polity and Job rlre
16 Insurance Company Name:
policy#Orsaw-Ins.Lic.#1 UOL�l
� q ExpiratfoaDate: I� 3 (0,7
M,{�
Job Site A W Citylststerzip;
Attach•copy of thi worker'compsatation po declaeatles pap(showing the popey number and expiration date).
Failure w secure coverage as requted under section 23A of MGL e. 132 can lead to the imposittoa of crimiaai
tine up to 5"00.00 and/or one-year Imprisonment,as wan as civil penalties in the form of a STOP WORK ORDER�a tine
of up to 32S0.W a day spinal the violater. Be advised that a copy of"statement may be forwarded to the Office of
investigations of the DU for inswaoce coverp verification.
/do Aerebr celd&under thepe/rrs and psna/Nea ojpei/wy thorAt Aijorawyow provided above is One and eo►net
Si� 'ature: ^7J� � Date
-
Phone ( 0�
Phone 0: ( — L 6 , - 4'4'vo
OJFcld use pair, of not write In A&area,to be eoapletedbrclq artowdafj7ele(
City or Towne ParmttR ices::N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityfrows Clark 4. Elect
6.Other deal Inspector I Plumbing Impactor
Contact Person: Phone S:
Crry OF SALEM
PUBLIC PROPERTY
DEPARTMENT
move tsrr ronror,ssme.saabxsrsnoasassmss
Consbvedbs D*brb Mposat AIM&vlt
(e.q"69 sY 4WAUdoa and rsss ASW wadi
is sooadsoos wla ms"edldos atdw Sbft DWWing Ca%7S0 CUR seedos 1113
pdm%asd dr provWWm of U(Z s 4d6 S 3M
8undko ftmu M to iamsd wft dw amdldos dut dw dsbrb mubbs Dos
Arts war!"be&Vaud oils,p mp"gees"warts dlgad D dit an d.Qod by UM s
111.s t�o�. •
'I�,(.,deed,.�w,.iii bs trsespor�ald byt 1
town
The ddwW will be dlapoo d of In: q
\(fenn.9 ,t ��
lwm•w fSsititp�
uwa�ua of D.cmit�ppiksat
� 1
�1 -13 -�2
door
rain.rxy,
i
� 00 35ica.c.WO aendwed.apace 1
p ,usnoy
to Wlyspyy atdy I
I If., 1 S 2 Famsy Hanes
Faphretd f
Possess a amain efton of ftva"Mmuserts I"weaving es.
+saaesetiurewea,wndd�srtasige.
i
x e "
�n
PROPOSAL
CONSTRUCTION SPECIALTIES UNLTD., INC,
P.O. BOX 53
STONEHAM, NIA 02180
Phone (781) 665-4410 Fax (781} 665-4411
LENNOX BROAN-NUTONE
HEARTH PRODUCTS 1 A NORTEK COMPANY
1e 4r) - l-Vc
5ra1e� +_
n IEC2vriaJE - C is�o 2 etc :��t n� � ef 6-cf-
���neo.� � �a�ec^'i • �s-�II j,-e�v�✓tox l�-C--3(o Cl�c�otc� III
� tr(CtS „- ¢�
ex) [*0+ G`�r�� �c¢'�i'r1� g (9u�e✓ o- 1��otsS
i
i
I
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 50% deposit is required.
For central vacuum and intercom installation, half is due u
completion. For all other, upon rough-in and half is due upon.
work, payment is due upon job completion.
Authorized Signature
NOTE : All plumbing hook-ups, catpentry work & building permits are the responsibilivi of the I
job site general contractor or homeowner. Prices are effective for up to 3 months from
1 date of proposal, j
Acptance of Proposal i
I w euul'Mwy rd N Ar'b,�ep+d You re a+Wel,etl to tlo the wmk u PI PI :will be
nature mrle u outlined above
Sig
acce ed.please sign and return.
VI
PUBLIC PROPER�'Y
DEP1RrT1VIF.1�iT
Ao7 (7 �1 - p:shl7s019�0i
• ni1.9'Y.7i9S9S•,FaC;97L710:961�,
APPLICATION FORsTHE REPAIR:RENOVATION CONSTRICTION
DEMOLITION. OR CAANCsE OF USE:OR OCCUP "NCY. IFQR A2YEII3TTrTG.
"STRU1'UREOR BUILDING"
_...�__
1.0 srrff INFO T QIO
Locatlon Warne ;. 0.d1 cam' _ Bufld4>g:
PrapertyAddresa _.. 4
Property b bested4n.a:Conservadon Aroa YM l latorb Oi�trbt YIN...
11 Owd4w,4 -ano1 .
e
Nams: ear\ - 1. C O�
3alCOMPls`ETB THIS SECTION FOR'WORK-IN,�nidTluea BUILDINGS.QNLY
Adtlition Ezlsting
Renovation: ;Number of'"Storfea Renovated.
Change in Use New
Demolition �xtptin g.. .,
Approximate,:year of" Area per floor (st) Renovated
constrncdom, renovation
of"exutingbudding New
Brief,Des "ptidn af`PsedW A. moif� S �� 25�
uSte
; cs� cAs\1��
Mail Permihto: VTA—A&.r` .,.metroS� Zt'�iv
tC�f
yyhat.is the uurent use of the Bwidin�7 --- =---�-�—V
9 t IJC�
' Material aFBtiitdtr�4 � o O ,�—=—. H dwelpn .t>ow m
Canf&M to Law? . Asbestos?
yYf11;1t>•,.BuitSllnp , ,
prehReot'slVart►�- ,
Prddteu'and'PhoM�,
Meel►ank'tNart+� ,:
nddre:a arw f9t+ort� ' e a�; c tmp nre iMF�-. o t 7tv _ Za l-b�S �I c
pervlws
.�� t; ®gyp 31 HIC Reyistiatlon ati
EstiMatedOmA of"6d .. a g 6� ..... on
Permit Fsa E ,�D
Estimated C,ostXa7K1000 Residential
An AddttionAI45.001a add*d as an
Adniiniettattve dwoiLl
Make,aurs'that all+Helils are pYoperly and'fe9ibN written to>avoid.del;iys•in.,Proceeatng.;.
The undo aigned'does hereby apply fo►'a Bufldlnp PeM to-let above<stated`
spwffl bons. Sfynect undw,POnaily o P_4#y
IN
o
a `3