7 SUMMIT ST - BUILDING INSPECTION (3) llb Commonwealth of Massachusetts
1 / Sheet tiMetal Permit
listimatcd Juh ('os[ S l� SCE Permit Fee: S � _
Plans SuhmiUcd: YES NO Plans Reviewed: YES NO
Business License ri _ Applicant License f#
Business 111torn,ation: Property Owner/Job Location Information:
Name: Name: L,/Y K�
Street: 13&<L Street: Svwrnlr l S 1 2e�
City/Town: A/t City/Town: S-9(ol�
I'clephone: "-Slo'& Telephone: W 7 o)
Photo I.D. required/Copy of Photo I.D. attached: YES_ NO
s„rnom:r
J-1 / I'*I nrestricted license
J-2/ M-2-restricted to dwelling 3-stories or less and commercial up to 10,000 sq. R. / !-stories or less
Residential: 1-2 family_ Multi-f:unily_ Condo/Townhouses_ Other
Commercial: Office Retail Industrial Educational
Institutional) Other_
Square Footage: under 10,000 sq. tt. t" ,)ler 10,000 sq. tt. Number of Stories:
Sheet metal work to be completed: New Work: t Renovation: _
IIVAC_ Metal Watershed Roofing _ Kitchen Exhaust System
Metal C'hinmcy/ Vents_ Air Balancing
Provide detailed description of work to be done:
lllew 1-,6+A1 g,d co'd.-A s�er�
INSURANCE COVERAGE: ` �_,�
I have a current Ilabilit Insurance policy or its equivalent which treats the requirements of M.G.L.Ch. 112 YesV /No❑
If you have checked Yes, indicate the a of coverage by checking the appropriate box below: `l_
A liability Insurance policy Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts Goner I Laws,and that my signature on this permit application waives this requirement.
C,hhecck One Only
Owner �" Agent ❑
Signature of Owner or Owner's Agent C
By chocking this box0.I 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
Prorrress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By ❑ plaster
rue _ ❑ Master-Restricted
I
I
❑JOurneyperson Signature of Licensee
❑Journeyperson-Restricted
License Number:
Foe
❑
------ Check al'.v.r_v. I Is i LOV/,IL
In spactor signature of Permit Approval
RCOMMONWEAITH OF MASSACHUSE(TS
AS 1\E E W
ORKr
MA'-TFR UNRESTR1f 7 .
ISSUESy T E`ASOVE LICENSE TO T
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14MES ` S;II VCf2ThI0RHs„, = A:
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6465 04
i CITY OF SALEi.I, ANSSACHI SEM
r BUILDING DEPARTNtENT
120 WASHINGTON STREET, 3te FLOOR
' T EL (978)745-9595
FAX(973) 740-9846
Kl\(BERLEY DRISCOLI
,MAYOR Trlonl,►s Sr.FtE.aRa
DIRECrOROF PUBLIC PROPERTY/BUILDING CM11MISSIONER
Workers' Compensation insurance Aflidavit: Builders/Contractors/Electricians/Plumbers
Aualleant Information / 'o Please Print Leeibl%
Narid(Busitwys,Orgtniratiorulndividual): �-AH eS �!{✓d 02.✓
Address: L/ I9S CLevav 8 Lac(
City/Slate/Zip: A-11✓14 /,-l4 030(-� Phone N:_ 463 -2,3 / S /b
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ lam a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(f ill and/or part-time).• have hired the sub-contractors
1 am a sole proprietor or partner. listed on the attached sheet 1 7. ❑Remodeling
ship and have no employees These subcontractors have a. (]Demolition
working for me in any capacity. workers'comp. insurance. 9. C1 Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its
required,) officers have exercised their 10.❑Electrical repairs or additions
3. 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.(No workers'
m
comp.insurance required.) l3.❑Other
•Any applica that cheeks box el must also all out the sculion below drawing their wmkem'eompmndon policy infurmatlom
'1 h,muoutm"who submit this affidavit indicating they andoing all workand Thee hire ualsida contmerars most submit a new affidavit indicating suck
:Cotomutn that cheek this box moat attached an additionalAwlahueting the nurseof thisub. tm awn,and theirworker'ramp.policy infomuaon.
l am an employer that Is provldlnR workerr'compeuradon hrsurance for my emplayeex Below Is the policy and fob rite
injormuNon.
instance Company Name:
Policy 4 or Self-ins.Lie, d: Expiration Onto:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 23A of MGL e. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S230.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Off ice of
investigaliuns ut'the DIA for insurance coverage verification
/du lrrreby:•rrrljy and pu/n aJ prnuhles ujper/ary dmr the hrfurntuNon pravfdeJ above is rue and correct
g',. t Bat • l �� �6
Phone,/:
Ojftial use turfy. Do trot write in rhlr ureL4 to be coutp/eted by city ut lawn a/J&/ud
I
Cityar'rown: _ Permit/f.lcenseb
Issuing,itu:liorily(circle one): --
1. guard of health Z.Building Dupartumul 3.City/town Clerk 4. Clectrica) inspector 5. Plumbing inspector
6.Other
Contact Person: