29 TRADERS WAY - BUILDING INSPECTION (2) Commonwealth of Massachusetts
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1� Sheet Vietal Permit
Date: i2 - (q- I Permit #
fdp Estimated Job Cost: $ 3S 1 000 Permit Fee: S
Plans Submitted: YES ✓ NO_ Plans Reviewed: YES - NO_
Business License # Applicant License# ?4 q T
a�o339 ��1
Business Information: n : 1 Property Owner/Jo1b Location information:
Name: l e✓t`IYG� Air Jb1u Det-S Name: ?)Rnt t F �Yte SS-/PL4e+ -G vttjerA
Street: gj I Cass WQnc-c-- G4 Street: 2 t TfaeLtrs VAJ�
City/Town: 1-iGVeJ( OVI City/Town: 5q)ew (VA
Telephone: one:
p 5�i-� 36d �y3y Telephone: -3'r6I 21669
Photo I.D. required/Copy of Photo I.D. attached: YES ✓ NO_
�/J-t
Staff Initial
/ Ni-1-unrestricted license
J-2 / NI-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less
Residential: 1-2 family_ Multi-family_ Condo/ Townhouses Other
Commercial: Office_ Retail_ Industrial_ Educational
Institutional Other v'r r+nC-!�'.s
Square Footage: under 10,000 sq. ft. _ over 10,000. sq. ft. Number of Stories:
Sheet metal work to be completed: New Work: V Renovation:
I IVAC Metal Watershed Rooting Kitchen Exhaust System
Metal Chimney/ Vents_ Air Balancing
Provide detailed description of work to be done:
()AV r�Vu}wafK {'y.f ��� hew N� v� S�S�ehtS
INSURANCE COVERAGE: ��
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes pd"No❑
If you have checked Yes, indicate the type of coverage by checking the appropriate box below:
A liability insurance policy tJ / 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 General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or s Agent
By checking this box[:],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
Progress Inspections
Date Comments
Final Inspection
Date Conimenfs
Type of License:
By ❑ Master
Title ❑ Master-Restricted
CityJown
❑Journeyperson Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number:
Fee 5 ❑
Check at WWW.ma55.(I0Vlrtpl
Inspector Signature of Permit Approval '
CITY OF Sa1I.EM, NLXSSACHUSETTS
BUILDIING DEPARTME1
• 120 WASHINGTON STREET,3'a FLOOR
' TEL. (978) 745-9595
F.tx(978)740-9846
KI1fBERi EY DRISCOLL
i�fAYOR T'HOatAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDINIG COMMUSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/ElectriciansiPlumbers
Applicant information
Please Print
Legibly
Name unsiocss,OrganizatioNlndividual): \/
Address: OT C7
City/State/Zip: &JVW l VIAk 0kZ Phne#: 9 :6 360 4q3`Are vou an employer?Check the appropriate box: Type of project(required):
I. I am a employer with 4. 0 I am a general contractor and I
6. ❑N construction
employees(full and/or part-time),* have hired the sub-contractors
2.0 1 am a sole proprietor or partner. listed on the attached sheet.t 7• emodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp. insurance. 9, 0 Building addition
[No workers'comp. insurance 5. El We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.[No workers'cutup. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [Nro workers' 13.[1 Other
COMP.insurance required.]
'Any applicant that chocks box NI most also fill out tho sectieo bclowshowing their workus'compensation polity inturmation.
I hvneownera wha submit this affidavit indicating[hey ate doing all work and then hire outside contractors most submit anew a?davit indicating such
Co uracmn that chuck this box must attached an additional short showing the.name of the suba:oavacton and their workers'comp.put icy infemution.
i um an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name: EMC. IriSgUr'jpA.Le
Pol icy#or Sclf-its. Lic.#: W CC 5a06 Ig I Ip O aZ 01) Expiration Date:
Job Site Address: a� �f01Gtl-CS- Np.1/ City/State/Zip: SGIe -L MA
,mach 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 fine
of up to$250.00 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 certify under the pains and pea rjury that the infonnaitou provided above is true and correct
sicn t u • Date:
Phone#: 36o 3
Official use only. Do not write in this area,to be compieted by city or town official
-- City or'fuwn: PermitfUcense# _
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cilyffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _.,....._,____ Phone#:
COMMONWEALTH OF.MASSACHUSETTS11
:.
AS A MASTER-UNRESTRICTED '
ISSUES THE ABOVE LICENSE TO:
ADAM- J SPRIZZA
87 '.CA SABLPANCA CT f
HAVERHILL MA"01832-3684
874I: W28%12 993707 -,
=MFA3'S'ACHUSE;TTS' DRIVER'=
LICENSE
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n 6 04 0 1977
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