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1C HART WAY - BUILDING INSPECTION CITY-O .. - .V- -- "' PUBLIC PROPERTY DEPAR`IWMNT � KINOIFJIL6Y'Dt15CWl ..-- Maroa 130WASHINGTMSMEEr*1S1 i;\LCsua{�it�as01470- , APPLICATION FOR,:TEM REPAIR RENOY ITIONr CONSTRUC' ION., DEMOLITI01�. OR CHANGE OF`USE OR OCC[JPANCY..FOR:A1NW EXISTING STRUCTURE OR.BUILDING' 1-0 SITE INFORMATION LacatlonName: � erh� -- - property is ocatki In a:ConbervaNdn Aral YIN . Hlatorio Dlshld°YIN 41rOWNERSHIP'INFOR ON' 2.1<Owner`of Land _ Name: -g r1^ Address: I C cSa(e+m MA- - o tgSD Telephone: ::' tfifi a1g=-1 qS`' b 1.�' Q.. b l `l3— (o©7 3.'0$OMPLETE THIS SEC 0'N FOR-WORK IN EYl T8 rN l U1LDING8 ONLY Addition Existing. Renovation Number of Stories Renovated Change in Use New`, Dernolidon Existing , Appr6ximate;year of Area perlloor(sf) ; RenoGatetl construction or renovation , .. . s.� . of existing;tiuilding New Brief°Description of Rroposetl Work: "Ove- c�- �iS.e h2 C,A1(3CS , Mail Permit-to: 16(o MA . t7 ?to III, What is the curtent use of the Bnuilding? � cQen��ce Material of Building? If dwelling,how many whits? - Will the Buildin�;Coriforrn to.Lq%4? Asbestos?; __. Architedt's Nams Address and Phone77 l ) Mechanic s Name ion Addr'ess,and'Phone 0 Consbucdoh,Supervisom ucense°#C S'a Gil HIC•Fiegistration# Estimated COMW Project S PerrnitFee Calculatlort pl/ Estim ated Cost X S7n1000 Residential _ ---- -- - — -- ---- =--EstimatedCost)ES4V%SiQ00Co::'r'.�'•..� --'---- Ah-Addttfonal s5.00lsaaaedas�an AdminiatratNe.thar9m:. Make sure that all°fields are pruperlyand'egibly:wd ten to avoid derel a<In,processing. The-undersigned does hereby apply fora Building'Pennit to build to.the above stated specifications. Signed under penalty oUperjury date' �d? 0 w _ w °i • i , CITY OF SALEM r PUBLIC PROPRERTY DEPARTMENT xorsatttaY t>atscott. MAYOR 120 WARC4CMNSTRUT a 3AV.EM M&UACHLUTM01970 Tts:9W45.95" a FAx.9M7449" Worriers' Compensation Insurance A1Hdav(t; BuildeWContrattor&Meebidans/plambm Applicant Information "Pie N Print Legibly Name(9twoessiommiaoodfndiv dons): Address: () c��t _ox 51 City/Statw7ip:_ y LQ W ,I MA- L 1g0 Phone# _ 7S L (p CAS— lG 410 Are you as emplayert the Appropriate be= 1.[3'1 am a employer with '1 4. Q 1 am a general roahactor and I �of Prelim(requis". employes(W and/or part-time).• have hired the subconascten 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling ship and have no employees Them wbeonhacm[t have S. Q Demolition working forme in a�capacity. wockera'comp,insurance. (nIo w°rlren�comp insurance 5. 0 We am a corporation and its 9' Q g addition required.) OfilrA a have exercised their 10.Q Electrical repairs or additions 3.Q I am a homeowner doing an work right of axemptioa per MOL 11.Q Plumbing nepyrs or additions Myself.(No workers'comp. a 152,§101 and we have no 12.Q Roof I insurance required)t employes [Not 13.[� �QCe 1pG�comp.inauance required.) ;A1y ANHaud ar eheeb sea al most etso fat out MeHommowum seetloa below eeowdes ark wakes'eompsassdm pdtey - tC Ws bbea mm amw work and ar•kke GOW&eeaeeebn num subnk a saw afQdwN kdlesaea ffixL owing she asps olato sub400ftcom sod th*wariness•eoap,td4'Y bdbnmd m am an employer that Is p vvldlns workers'compeneadoa hpuraaci or injormadiam nn 1 my employes Below b Arpolkcy and Job du ra Insunce Company Name: A- G Policy t9 or Self-ins.Lie.M_I %C Expiration Date: s 3 O Job Site Addrea: 1 WCSM City/Staw/yip. �PYy( () S� Attach a ropy of thi workers'eompenutloa poney daalendon page(rho the Failure to secure coven wag P°�7 numb and exphmdoa data} ge as required under Section 25A of MGL c. 152 can lad to the imposition of criminal penalties of a rule up to S I.500.00 and/or one-year imprisonment,as wen as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violate. Be advised that a copy of this statement may be forwarded to the OtRca of Investigations of the DIA for insurance coverage varit3catioa. l do hereby c"do under as pahss and pena&a of peF]asy that t/y 1n a j trrradon provWd above is hue and correct Sianatun: � Datw 7�I I Q'l i (0(0 �EI� Of ji W use on/lt Do not write G/his area,ro be completed by dly or Iowa o,Q7ClaL City or Town Permit/Lieenst 1t issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City rows Cleric 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone* cny OF SALEM PUBLIC PROPERLY DEPAXrURWr IlkMTwlM 0 Vna 9W74Nw CoasWcdos Debrb Dispmal AftMavit oired 13 rr dWAddos ad mwvrdes wadi) 1s wmdr wide dw a Ws W4 S otd*Sbft �M C�7N CUR sediat tt tJ Debde,erd dr pwAdo e 8ume lymk M is booed wilt dw aonMW dW dw drbde mmglbg Sas tW wed rAed be diroorrd otb a pop�iy liermed wwile dt'orrt i t>.drdned by lEt3.e itl.�tlQl1. The debris w,[till be traa;orErd byt leer frrin! 71u debris will be dirpored of in: 4S �cl��� al�+es lb6 2I1 �0� drrr .d:.rxys 00 6,000 cf enclosed space (MGL C.112 S.fiOL) _ to-Masonry only -.i 1G-1&2 Family Homes Failure to possess a current edition of the .� Massachusetts State Building Code is cause for revocation of this license. i jjJJ ` I I DIG SAFE CALL CENTER:- (888)344-7233 BOARD rOF BI fL- REGULATIONS X� License: CONSTRUCTION SUPERVISOR �I Number CS (553897 I s j Birthdate 0510211962�-a Explres. 0510212007 - Tr.rno: ,12107 Restricted TIMOTHY J FINN 8 vAtDORA DRIPO BOX 53 STONEHAM, MA 02180' G' t Commissioner f { -PROPOSAL CONSTRUCTION SPECIALTIES UNLTD., INC. P.O. BOX 53 STONEHAM, MA 02180 Phone (781) 665-4410 Fax (781) 665-4411 LEN N OX BROAN-NUTONE HEARTH PRODUCTS A NORTEK COMPANY 5 Rw�an t c E-�Cvf C`L( mA, c)lit-7o �— ���ns��l � eu�nex i2�1 � r +act_ a- 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 upon rough-in and half is due upon completion. For all other �work, Qpayment is due upon job completion. Authorized SignatureN-- NOTE : All plumbing hook-ups, carpentry work & 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 The above Meer,apeafiWion,and condinov are utisfhetory eed ere hereby accepted You ere euthon,,ed to do the work u specified. Payment will be made as outlined above. Signature Date: :1 2 `1 L ', If accepted pl ase sign and return. 1 1