7 PIERCE RD - BUILDING INSPECTION S� ?
Commonwealth of Massachusetts RECEIVED
INSPECTIONAL SERVICES
c4-Q` ° �' Srn Sheet (Metal Permit 2114 OCI 10 A ID 04
Date: =1 y
Permit t/
Cstin,au Job cost: s. C:30 - ----- -...._
----'-'--- Permit r c: s
Plains Suhmilted: YF.S NO -
— Plans Reviewed: 1'ES NO
Business License# 73 ---
Applicant [.icense ff
Business Intbrntation:
Property Owner/JobLoca(ion fit forma tion:
Nance:( .3ji�r'nh�il�Ci1 ^' ,►yt t
J Nam e:
ti'Ji)`he S� 7U
n Street: ev ee QC!
City/Town: r//
City/'town:
Telephone: _ 8/
Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES V0
J-1 / D1- unrestricted license s��rt—'
J-1/M-2-restricted to dwellings 3-stories or less and conunercial up to l0,000 sq. 1't. /2-stories or less
Residential: 1-2 family Multi-tamil
Y_ C'ondu/Townhouses Other—
Industrial Commercial: Office_ Retail
Industrial Educational
Institutional_ Other_
Square Footage: under 10.000 sq. ft.X- over 10,000 sq. tt._ Number orstories:
Sheet metal work to be cmnpleted: New 1Vork:
_, Renovation: _
IIVAC_ . Metal Watershed Roolin
b____ Kitchen Exhaust System
Metal C'hinmcy/ Vents
_ Air Balancing
I'rovidu detailed description of work to be done:
>a Tu
�Att_ �An)TelaCTOtt _.
µ 10-1 L-r--m 1
i
�1
cj
INSURANCE COVERAGE:
I have a current liabilityInsurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes No❑
If you have checked Yes.Indicate the type of coverage by checking the appropriate box below: _
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not have the Insurance coverage required by Chapter 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 Owners Agent
By checking this box[],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 it2 of the General Laws.
Duct Inspection required prior to Insulation Installation: YES NO_
Prouress 11138CCt1ens
Date Comments
Final 1115tlCCt10l1
D tto Comments
Type of License:
By ❑Master
title _ ❑piaster-Restricted �v
i
cay,lo.Yn —__ 0journeyperson Signature of Licensee
❑iourneyperson-Restricted {
License Number: If A
--
i ❑-.—,-...------ Check at:•,•.r.v n,.l.;s auv:-1iil �
I
i
Inspector Signature of Permit Approval
CITY OF S.UX.A1, NIASSACHUSET I S
r BUILDING DEnit-nilwir
120 WASHiNGTON STREET,3'a FLOOR
TEL (978) 745-9595
KIMBERLEY DRWOLL FAX(978)740-9M
MAYOR T H0x&s ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BL'iIDLNG COMNIISSIO,iER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricions/Plumbers
Applicant information Pies g rint Leaibiv
Name(BusinesslOrganizatioNindividual):-1 a 'J F' a-kAn\ra
Address: O eu h<—�, Sl
City/State/Zip: tr) tlG
City/State/Zip:- 7 (-acic)s Phone
Are you rn employer?Check the appropriate box:
Type of project(required):
1. 1 am a employer with L _ 4. 11 I am n general contractor and 1
employees(full and/or part-time).* have hired the t.•uh contractors 6 []Now construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet,t 7. ❑Remodeling
ship and have no employees These subcontractors have g. []Demolition
working for me in any capacity, workem'comp,insurance.
[No workers'comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employces.[No workers'
comp. insurance required.j 13.❑Other
Any applicant that checks hoe 81 must also rill out the section below showing their workers'compensation policy infonmtion.
Ihmnuwasxa who submit this affidavit indicating they one doing ell work and then hint mouide contractors moor"bask a oew affidavit indicating a wL
=C.mtmc`on"oo'heck this bmt most attached an additional short showing the tame of oho sub.connitctwa and their workers'camp.policy information.
I am an employer that is providing workers'compensadon insurance for my employees. Below is theMley and Job die
information.
Insurance Company?lame:
Policy#or Self-ins.Lira#: Expiration Date:
Job Site Address: Ciry/State/Zip:
Attach a copy of the worker'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Scction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. Be advised that a copy of this statement in that may be forwarded to the Office of
Invesligaliu o' he D for insurance coverage verification.
I do hereby ertJfy a e pales and penahles of perjary that the information provided above is Irmo and correct
Dow
OJJlcial use wdy, Do not write In this area,to be completed by city or town afftciaL
City or Town: PermitfLicense#
Issuing Authority(circle one):
1. Berard of Health 2.Building Department J.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other,_
Contact Person: Phone#:
DRIVER'S
f - LICENSE ---
13 NONE S47595752
'$ 02-151969
M., .E ;s sez
�sszrDEPJNIS JR
a 38 HARRIS RD mdifsw
;\\f LYNN,MA 01904-1337
j ��, aWOI-ibibil qav bi.112009
°s COINMONWEALI'H OF.MASSACHI SETTS
l 2 SDARD OF,
E '. �HEET;METALn�IORK€R$
ISSUES�THEFOLLOWIN6 LICENSE I '
AS A t1AST€R UNRESTFOZT,Ep
.i s
COMMONWEALTH OF MASSACHUSETTS
SHEET METAL WORKERS
AS A BUSINESS
ISSUES THE ABOVE LICENSE TO
I
DENNIS M TOBIN JR
T AND T MECHANICAL INC .
90 CENTRE ST
LYNN MA 01905-0000
U U 340 41 -
.-
Fold Moli0e Tines Along Ferto2tione Be'om Detaching