23B MARION RD - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensation Insurance Affidavit: i3naders/COntractoramecftkbrL adpl=bers
ApplicantInformadon Pnnetrur_tinnf Specialties
PIlaxa Print UAW
Name(Busineworpnizadowwwidusly; P.O. Box 53
Address: t
City/stattvvp: Phone Al: Z 1 — (c to
An ■u employer?Check the appropria1EIWO
1.Q 1 am a employer with 0( 4. 8emral coeuaetor and I TYPO
� 1�(required):
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employees(fhB and/or part-time).* ired the sub-coanaoeors 6• ❑New construction
2.0 I am a sole proprietor or gannet• n the attached sheet t 7. ❑Remodeling
ship and have no employees sub-contraatoes have 8. 0 Demolition
working for me in a�capacity. r'comp insurance,No and its 9. Building
quhad 'comp insurance 5' htye�e�d their 10.Q Elect ical
ropairs or additions
3.0 1 am a homeowner doing all work exmiption er MOL 11.0plumbing repairs or additionsmyself (No workers'comp (4),and we have no 120
msurnee required)t as�es 13. ll lc t �6t t
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f sae aw employer Nkat le prov"Dej workers'compensation bksumacejor Aly OMployoa
f Blow b tArapo!!ty andJob rite
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Insurance Company Name: L y
Policy#orSellias.Lic.#,j L��-7 ( 2�(pf�C
Expiration Data-
Job Site Address: a 31B Ma ken {2eQ., Cayisate�zip
Attach•copy of the workers eompeandoa policy declaration page(showing the piney Number sad expiration dab Failure to secure coveagi as reWired-under Section 25A of MOL a. I52'can lead to the
fine up to 31,500.00 and/or one-year imprisonmeak as well as civil imposition of criminal penalties of a
of up to$250.00 a day against the viohuor. Be advised that a e of this�is the form of a STOP WORK ORDER and s fine
Investigations of the DIA for insurance coverage verification. ant may be forwarded to the Of A of
/do hereby ceralJf ender the pared penaldee ojper/ary that tkelnjoraiadoa+provfdid a ova 4 d eorrsd
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Signature:
Phone#:_
FBoard
onljt Donor write In"area.to be eoapletad by c4 or Iowa offlC14
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hority(circle one):
Heslth L Building Department 3.City/rowa park 4.Electrical Inspector 3.Plumbing Inspector
Contest Person:
Phone N:
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\I 00-35,000 cf enclosed space ,
1 (i C.112 S.60L)
1A-Masonry only
1G-1 &2 Family Homes
'+ Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
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r DIG SAFE CALL CENTER: (888).344-7233
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DING REGLILATIONSZ
Llcense: CONSTRUCTION SUF`k-KVISOWIIn
Number CS W3897 '
Birthdate 05I0V196 ate F I
Expires 05/02/2007 -Tr.no. 12I07 f
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Restricted. 00 -
TIMOTHY J FINN'.
8 UALDORA DRIPO BOX-53 C„ ,-, �, f
STONEHAM, MA 02180 Commisslo
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CrrY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
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PROPOSAL
CONSTRUCTION SPECIALTIES UNLTD., INC.
P.O.BOX 53
STONEHAM, MA 02180
Phone (781) 665-4410 Fax (781) 665-4411
L E N N OX BROAN-NUTONE
HEARTH PRODUCTS_` A NORTEK COMPANY
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Sck�2a 80
We ropose hereb to �nn�Cx d
Y famish material and labor- U�n •��UVG'(,�
complete in accordance with the above
specifications for the sum of..
AS ABOVE
Payment to be made as follows:
or
For central vacuum and intercom installation,
orders a 50% de
completion. For all other work half is due ❑ posit is required.
, payment is due u Pon rough-in and hall is d;
Authorized Si upon completion r� upon
Mature \
NOTE : A11 1
P umbing hook-ups, carpentry work &
,lob site general contractor or building
date of proposal.
, Ptance of Proposal' homeowner. Prices are effe cove for eP o °n offZre
V.GfiC.4pN.n0�Mi4oN om
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Signature � «r.nav,�yY�W You.re wiAo.ir.d 10 do the work . Pe
!f accepted.please Date: mmt w11 na m.ee. ominm.a.e
si and return.
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A,>oc��� �b es
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What is the current use of the.-8/(lu�ilding?
Y(ilaterialof�Building? t�Oc9GY Ndw6ilingj�how:manyunw-4-
1Ni11 the Building Conform"to Law?: -
Asbestos?'.
Architect's Name . l
Address and.
fobs- O
Mechan a Name 2 t Co
Address=and Phones l(o(o
t(�S053 a42 HICRegisttation'
CCnSiNCtiOn SUpeMI80re ucenSe#' -
Estimated s Pemdt Fee Calculation
Permit Fees Estimated Cost X$741000'Resldential'
_. _
$t1fS1000 c4rhmerclal --- - - _..
An Additional' cons add6d 4e,an
Adminlstce* charge..
Make sure that all fields are properly and legibly'written to-avoldlldelaysimpnacessingc
The undersigned doesfiereby'apply-fora Building P/ennitto�build
lo the aboveatated.
specifications. Signed under penaltyoitperjury /� - --
Date
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y
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APFLIiCATION FOR'IIM REFAIR.>RENOA OIY� dDNSR>E7 "1ION
DENT C01 IO . OR CHAN�E:OF CJSE OR 1^r
1:0 SITE INFb Building;
Narn�. t.
Proprly Ia loealed N'a:'Coneervatlon Area YM Hleioric0leb
4 t1.OWNE,RSHIP?INFORM/1TIOtN
4.1 Owner of Land ,
,.. .�_ _.
oft ! b
TelepHon�:
3 0 COMPLETE THIS SECTI6NeFO`R W,Q`RK IN AE_ ONLY "
Addition Existing:
Renovation Number of,Storfea Rarrovated- x
Change mV. se
N�tiv
Oemolitlon Exsti�g
Approximatq year o! Aieapbr flaar(sf) Renovated
c�initructioA or renovation : w
of e�istingrbwtdingy New
ldd,Des .pticn oflrpised,W oit� `l
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