3B HART WAY - BUILDING INSPECTION (2) What Wtho current use of the 8u ding?
�F70 if'dwelling,how many units?
lulaterial of Building? Asbestos?
Will the Buildinq•Conforrtr to.Law?, -
Architeas Name ( )
Address and'Phons taj O. .
e—, ,t1
Mechanic'sMme "` \n �'Vl
Address and'Phone
Construction Supervisors Licren¢seM# CSQ53�t 7 HIC E2egistration#
Estimated CostofProj Perm Me*Calailation
Permit Fee i Estimated Cost X.S7/57000'Rasklentlal
---- — — -- Estkrrateil;e�$+cls700 Felmmerc��l ---
An Additional"S5:OOfis:added';as.an-
Administraflye ctrar9e.
Make sure that all fields are properly and legibty;written to.avoid'delays,in Processing;
The undersigned doewhereby apply for:a•Building PenTi to build to.theabove stated,
specifications. Signed underpenaly of penury X .
.Date 01
�f
c ,
3� N
a
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTumNT
MAYOa 120 mASF4IVOTW.t 51'ReaT•SAttat.MAStACFtGSETiS 01970
Tm-M745-9595 a Flex:97a•740.9a46
Workers' Compensation Insurance Ailldavit: Builders/ContmctorsMeetrictant/Plnmbers
ADolicaut Information Cnnc+nswfann Q;edtsllf1YC Please Print i egibty
Name(Business/ownvasowbdividtta y P.O. Box 53
ern,
Address: MA. U2130
City/St ualzip: Phone#:- 441 o
Are�P•as employer?Cheek the appropriate bast
1.Q"I am a employer with � 4. Q I am a general contractor and I1r,
Type
of�1 eft( � :
2.❑ I employees
�e(dill andlor part-time).• have hired the stub coneacton • Q New construction
poration and its
proprietor or partner. listed on the attached sheet t . ❑Remodeling
ship and have no employees These wb eonpsctan have . ❑Demolition
working far me in air capacity. work comp.innuanee. Huildlas addition
q 'comp insurance 5' We have Am exercised then repair or additions
.�Electrical
3.❑ 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(No workers'comp. a. 152.j1(4).and we have no
iosuance required.]t employees•(No workers' 12 Q t
camp imunow XC
F�
;Any wv9a+the crest.box sleardw fill am the reedstwo.Sbmisaswrw '
aomeo.m TAG vibeit"af>fdevhibdMa 6 dw we ddng A wa t d am Wee co po'lNOW Admit 9 new faa.rb tedk+gas east.tCoanaeeas 69 cheek ads hoe num aeaebad anaddidand Sheet sbor6q tie was of the nb•eaeuaeton and&*wae6n'oemP Duey tahmudes. .
/oas as eerployer that Isprovldlns wonterx'caaepansattea brraraneejornry rarpWZL Below br thepa/try oatJob rite
Jajorwattow Q
Insurance Company Name: 14
t ',
Policy#or Self-ins.Lie,M W C/9 L &to z b u 0 0
pp � �"� pp Expiration Datte11• lJ g dfn�n Job Site Address: CF�X� C061W _City/S4te/23p: ( tL2 y y l,A-� (� `Q-7(7
Attach a aopy of the workers,compensation policy declared"page(showing the potley number and UPlra—don dad).
Failure to secure coverage as requited under Section 25A of MOL a. 152 can lead to the imposition of criminal fine up to S1,300.00 and/or one•year imprisonment,as well as civil peWdes in the lotus of a STOP WORK ORDER penalties a of
of up to S2S0.00 a day against the violamr. Be advised that a copy of thL statement may be forwarded to the Oflfce of investigations of the DIA for insurance coverage veri8eadon.
/do hereby eerr!/yyader the pain and peaddp ojper/ary that the/ajonaradoa providsd lost a Is bw and correct
Sienature. /� �� �/��� Da w �� 0')
Phone M:
F
d me onIA Do not write In ikk area,to be eoarplatad by clq or Iowa odfch d Town: PermltiMense Authority(circle one):
d ofHealth 2.BuildingDepartment 3.City/rown Clerk 4.Electrical Inspector S.Plumbing Inspector
r
Contact Person: Phone N:
Crry OP SALHu
PUBLIC PROPERLY
DEPARTM Dfr
�. :�.�esraror>t>ns.i�ta.N..so.�Otff�.
Tassa►r 64sss.aswMI464 u
Cons&ucdo a Debirb Disposal Anwsvu
ir�i asr eaoondos,d eesorde.W
is umdseoe wide the Mm t s��°S� ao !
T CMX seedom 111
lDdw%m+a
h„Al 4 v issoee wbt eoodtdoa dut dN d'Mt eawdeind ltos
Lhi@ wwk drn be 'iosr of t,•p:op.�► wasee disposd Aeine�►sr a.Qa.a by 36t1t.e
T hd ddWW Win be trsnsp d@d b3R �r
C� nc'oCjC � 14 UYbj� \(28
lases bsiMr!
The dells will be disposed Off":
(2,4f,4,br, SecYA-es
pum.et ihrf
lb, («r��►� C YVI��e �/lA
(aid.e
� 1
li a(lo
dW
t
00-35,000 cf enclosed space
(MGL CA 125.60L)
1A-Masonry only
} 1G-1&2 Family Homes -
Ii Failure to possess a current edition of the -
1 Massachusetts StawBuliding Code
is cause for revocation of this license.
t r DIG SAFE,CALL CENTER: (888).344-7,233
u
- BOA RD OF "DIN REGU lO
_ Llgease CONSTFAUOiTION SWPERUIS��e ''_
Nymber CS
8irthdate 0�0�2Aa 96� � � ,., �
ExP�res�5/0212007, Tr.no 12"ld7 ''
j
a TIMOTHY
�, _; 8 UALQORPt DR/PO�BQIF 53 �� ��•
STONEHAM, RAf�-0 7`BD CornMISaionar i
—$c64
PROPOSAL
CONSTRUCTION SPECIALTIES UNLTD., INC.
P.O.BOX 53
STONEHAM,MA 02180
Phone(781)665-4410 Fax (781) 665-4411
LENN X BROAN-NUTONE
HEARTH PRODUCTS A N O R T E K COMPANY
sys�-• .-�
�,s 1� lre nc�rx t2 t -3 t 4 c�e�)X PN'ree 4Ce.Lt, &�W„ AR00
L`
�ac
Cc , to P�'-r
n
We propose hereby to furnish material and labor- complete in accordance with the above
specifications for the sum of:
AS ABOVE
Payment to be made as follows: For special orders a 50%deposit is required._,
For central vacuum andintercom installation,half is due upon rough-in and half is due upon
completion. For all other work, payment is due upon job completion.
Authorized Signature
NOTE : All plumbing hook-ups, Carpentry work& building permits are the responsibility of the
job site general contractor or ogmeowner, Prices are.effectige for up 1o'3 months from
date.of proposal
:
Acceptance to ProQsa},
` ^ ra�W Yarm whorlad bCp eW wrtr •,,.. ..
' Srgtlnara': wWa-0.W.a .
Date: �1 W 07
pted please sign and `return.
�40 �t r'�OAS d0�� � � ��Q•A� �T
EITStOF _
PUBLIC PROPERTY
DEPAR'I1�IE►�1T �
~'"1O� ` t3ow�ssihwixws'ninr•
s��wruoassrRoi9to
Ttii W.W74 9s9s i* .ems z+o aeK
APFI ICATION FOIL TRE-REFAIR:=RENOYA. .CzONSTRUCTION
UM
DEMOLITION. OR CHANGE OF USE OR OCCC� NCY '>E`OR ANY F:IISTIN(
STRUCTURE ORH_UII.R N� _
1.O SITt:'INFO ,:,_ TIO'N
PPropeny Ad&G -
ce �� 01�70
Ptropsrly le ktealed-In a;Coriservatlon Area YM >Hlstorlo Qistrld Y/N _
7:O OWNERSHIP,INFORMATION
;Ll Owner of Lano1
Name. M
don o
3000MPIETE THIS SECTION FOR WORK-IN �iATtu�,l3UILDING$,ONLY
Addition' - xtstin
Renovation Number of Stories Renovated.
Change in llss _
New
Demolition Exi:.ting
Y Area;pot floor(st) Renovated
Approximate earof
construction-or renovation.
Of`exWling building NeW
8ui:f Description ofpr sed'Work:. � Q
�novt✓ `t- ��. -�
cto�5ecrs �
Mail Permit toi `-`v ww r• . �OS� p Zf (�