231 NORTH ST - BUILDING INSPECTION (2) l 5 ZZ ,$-70
t -n
Commonwealth of Massachusetts RECEIVED
INSPECTIONAL SERVICES
Sheet Metal Permit
1114 NOV —4 P 1- 35
` Date: Permit N_
I?stimated Job Cost: y /0&0
O . 90 Permit Pee: S
�- Plans Submitted: YES— NO Plans Reviewed: YES _ NO ___--
Business License k Applicant License t/ fza�S
Business Information: /. Property Owner/ Job Location Information:
Nano: invnsort ero?er�v maw° Name: Pn�r-'r �Vme S _
Street: D -Tr iri-� j A-ve Street: 2-3 / /✓o* -57-
City/Town: L�nrn !n0. Otge Z- City/Town: Sir/err? nV&
'reicphone: 0 r? a 1 1- e) l 16 Telephone: 7$- 1 - 3 ;?1-S-& N
Photo I.D. required/ Copy or Photo 1.D. attached: YES NO
1,Jrr I11I1l:1]
J-1 / i\I-I- mrestricted license
J-2 / M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less
Residential: 1-2 family P11-1, Multi-ramily _ Condo/ Townhouses _ Other
Commercial: Office_ Retail _ Industrial _ Educational
Institutional_ Other
Square Footage: under 10,000 sq. ft. ✓ over 10,000 sq. ft. _ Number of Stories:
Sheet metal work to be completed: New Work: ✓ Renovation:
I IVAC —]L Metal Watershed Routing _ Kitchen Exhaust Systen,
Metal Chimney i Vents_ Air Balancing
Provide detailed description of work to be done:
S v POL,N + I#.I STA 1--L- ilNO F(JlGNRGES tJ 4T N -TWO 2o.✓ES C- 11 w,7N
i
INSURANCE COVER-AGE:
I have a current liability Insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes 9'No ❑
C
If you have checked Yes, indicate the type of coverage by checking the appropriate box below:
A liability Insurance policy M Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by No
112 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this boxi],1 hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit Issued for this application will be
In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct Inspection required prior to Insulation Installation: YES_ NO
Prouress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By-- Master
rive— ❑ Master-Restricted
City/Town
❑Journeyperson i
Fee i Signature of Licensee
❑Journeyperson-ReT,
stricted /z�-2S
License Number:
-_
A - -- ❑ - -- Check at.w.w.vin.n,..noVhIL1
Inspector Signature of Permit Approval
.t
,•T° C["I'Y OF SAL.EM, MASSACH USE-ITS
l BUILDL\G DEPART),IE.\'r
3 � ail 120 WASHLNGTON STREET, 3'FLOOR
TEL (978) 745-9595
Fia(978) 740-9846 .
KI\tBERLF-Y DRISCOLL
;v11YOR THoMASST.PIE w
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information LPlcace Print Legibly
N;Iir1 t:(11au11ess,Organiratinru9ndivufual): ttl U✓7_ SoYj�� tlt�,nAl,�rrtGn7
Address: g Till 1 7 ( Ave
City/State/Zip: L ydrl ma 01902 Phone #: 0_7 a t,)- 991e
Are you an employer?Check the appropriate box: 'type orproJeet(required):
I.�am a employer with 3 4, Q I am a general contractor and I
employees(full and/or part-time).• have hired the subcontractors 6. ❑New construction
' 2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 1 7. faRemodeling
ship and have no employees These sub-conlmetom have S. Q Demolition
working for me in any capacity, workers'comp. insurance. 9. 0 Building addition
lNo workers'comp. insurance 5. 0 We are a corporation and its 10.❑Electrical repairs or addiiions
required.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MOL I I.Q Plumbing repairs or additions
myself. (No workers'comp. c. 152, §1(4),an J era have no 12.0 Roof repairs
insurance required.) t employees. [No workers'
r. ircd.) 13.❑Other
comp. insurance
-Any upplicam ilea checks ties et must ilsu fill uul the eechun bdowahowing their workers'cumperomlan pulicy inrinmarlon.
'I Lvnuuwowr who whmil this aaflrMvit indicating they am dc;ng all wark and then hire outside contnacere moul.suhm)r a over sfndavit indicating such.
1'umrxwrs shut chock this bus their workon'comp.pulley infamanon.
l ear un employer shut is providing lvorkers'compensadon insurmicefor my employees. Below is the policy and job slid
information.
Insurance Company Name:
Policy JJ or Self-itts. Lic. th Expiration Date:
Job Site Address: City/Slav:/Zip:
Attach a copy of the workers'compensation pulley declaration page(showing thepullcy number and expiration data).
Failure to secure coverage as required under Suction 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
tine up to S1,500.00 und/or one-year imprisomncnt,as well as civil penalties in the form of n STOP WORK ORDER and aline
of up to 5250.00 a day against the violator. De advised that a copy of this statement may be furwdrded to the OI'lice of
In vest i9ai pins ol'ihe DIA for insurance coverage verification.
l de,hereby certify wtuterijle u t ad pendhles of prrjury that the fefurruatlwt provided ubuve ix true mrJ correct.
SUL t e' MZ7 Date: 40 // /bf
Mort#:
Of/iciul use may. Donal,twrite in this area,to be completed by city ur tolver o iriut
City or Town: Perm lul.ied rise 10__.._
Issuing Aulhurily (circle one):
1. Board oftIeallh 2. nuilding Departluew 3.Cily/Town Clerk J. F.Ieetriell Inspector 5. Plnmbing Inspector "I
6. Other
Cuntacl Pertnn:.__.. ..._.._._._ Phone lt: I
Su
Wb
Ja
a W-DE
�POYd�E�
, r