12 OAK VIEW AVE - BUILDING INSPECTION (2) 5-i '7 `I 77
( Cun III onwealth orlMussachusetts IMPECUON LEERVICE'S
Sheet Metal Permit 1114 OCT I b P 113
BOO -
Estimated Job Cost: $ I i'I�J 3
t-'-- Permit Fee: $ _
I'I:ms Submitted: YES_u NO_ Plans Reviewed: I,ES NO
Business License k Q 1 � i --
Applicant License # 1 (�2
Business IInntbrnta\tion: ` Property Owner/Job Location information:
Nano: h �
Street: `� A^I 6jy Street:
City/Town: Ly N M mik a190 City/Town: S O QC1
clephune:�� Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES_ NO_
J-1 94U
nrestricted license Staff Initial
J-2/,M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. It./2-stories or less
Residential: 1-2 Family& Multi-thnnily_ Condo/Townhouses
__ Other_
Commercial: Office Retail
-- Industrial_ Educational _
Institutional_ Other_
Square Footage: under 10,000 sq, ft. >( over 10,000 sq. it._ Number of Stories:
Sbcet metal work to he completed: New Work: -�CRenovation:
ll"C' 'Metal Watershed Routing —
_ Kitchen C-xhaust System_
bfetal ChinmeY/ Vents_ Air Balancing
Provide detailed desc option of work to be dune:
INSURANCE COVERAGE:
I have a current liabilityInsurance policy or its equivalent which meets the requirements of M.G.L.Ch. 712 Y No❑
if you have checked YBs.Indicate the type of coverage by checking the appropriate boa below:
rl�
A liability insurance poliey
Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter t12 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
�\( Check One Only Owner ❑ AgentA
Signature of Owner or Owners Agent -
this.box ,i hereby certify that all of the details and Information I have submitted(^a aer ha P regarding
thisssued application
application true
will d
e chocking to
❑ and Installations performed
y �and that all shod metal work
accurate to the best all
er i knowledge provision
a
In compliance with all paM1lnanl provlalon of the Massachusetts Building Code and Chapter 1110!the General Laws.
Duct Inspection required prior to Insulation installation: YES_NO
Prorrress 1113nCctinns
Connnents
Date
Final Inspection
Comments
Date
—]
;Type of license:
By Master
N11
Title ❑Rtaster-Restricted �
i
cny,Town ❑Journeyperson Signature of Licensee I
Permit x ❑Journeyperson-Restricted License Number. �
❑_ _ Check al':+•vvm.ts•:.11ov:rMl
mspuctor Signature of Permit Approval
CITY OF S.UJ LN4 ANSSACHUSETTS
• BUUMING DEPARTSIENT
• t? 120 WASHINGTON STREET,3ro FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KIN BERi EY DRISCOLL
'MAYOR THomAS ST.Pwim
DIRECTOR OF PUBLIC PROPERTY/BUU DLNG CO%MIISSIONER
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumbeta
Applicant Information ```` P ase Print Legibly
Name lBusitnssOrganiza oNlmlivi'du\all:�N V��i', eC �`C.•1 .� � ays I C
Address: i) ��
City/statejzip: �y N N P , �1� o Phone a:
Are you an employer?Check the appropriate box: " Type of project(required):
1:® 1 am a employer with 3 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the subcontractors
2.[1 1 am a sole proprietor or partner-
listed on the attached sheet: 7. ❑Remodeling
ship and have no employees These subcontractors have 11. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9, ❑Building addition
INo workers'comp.insurance 5. ❑ We are a corpomtion and its 10❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,1i 1(4),and we have no 12❑ Roof repa�tr� n
insurance required.)t employees.[No workers' t3. Other 1I14 l_
comp.insurance required.)
•Any applicant that chicks bats el must also fill uut the sectim below stmwiag their workaa'compmndon policy information
*I Irwmnwnen who snbnhit this•tiidsvlt indicating they are doing all work and than hire outside nanttaIXwa mum submit a new amdavit indicating such.
:Contracton that check this box most anachad an additional chat showing the name or the wb4 rar tors and their worlem,comp,policy information,
l um an employer that Is p to idding,workers'compensaton Insurance for my employees. Below is the policy and job site
information.
Insurance Company Name...
Policy N or Self-ins.Lie.N: Expiration Date: o a q
Job Site Address: ) z � City/State/ZipS e M
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby I under the pains and penables of perjury that the information pro dd, dai ove�pis true and correct
gnature:SiC Date:
Phone#:
Ojrcial use only. Do nor write in this area,to be completed by city or town=Plumbing
City or Town: Permit(License
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Elec6.Other
Contact Person• Phoae
OMMONW OF sj qM
x� 51,
SHEET TALWDRKEk� e
R ISS6ES J E.',FDLL4WtNG -i ttENSE
'ue` $S A3AA5TER UNRESTRIGIED §Da "
s PETEt'. LYDN r *
9 DEVLWAY , r s
�01905 1749
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