148 WASHINGTON ST - BUILDING INSPECTION (3) 1' Coninionivealth of Massachusetts RECEIVED
' W/aSk1l}�6�pN SN Sheet N[etal Permit INSPECTIONAL SERVICES
Date: Permit # 1015 FEB -4 A ID I l "
listimated Job Cost: S 20.�rD Permit Pee: S --
Plans Submitted: YES _ NO_ Plans Reviewed: YES NO
Business License # Applicant License #
Business Information: Property Owner/Job Location Information:
Name: A ) `�Lh,,\\Ck Name: /Viand I(tvioce
(�J Street: C1P-r-NTVP- S'r _ Street: Mli► > 14 ,4'
I ff � -�
City/Town: L-� n r1 _ City/"Town: �" `t`r
'relephone: -)&) -5 03ra 9 Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES T NO_
sarr o:in:d
J-1 / M-1- nrestricted 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: I-2 family_ Multi-family Condo/Townhouses Other
Commercial: Office_ Retail Industrial_ Educational
Institutional Other
Square Footage: under 10,000 sq. ti. -)—Q over 10,000 sq, ft. _ Number of Stories:
Sheet metal work to be completed: New ,,York: Renovation:
I IVAC_ Metal Watershed Rooting _ Kitchen Exhaust System
`fetal Chimney/ Vents_ Air Balancing_
Provide detailed description of work to be done:
INSURANCE COVERAGE:':
I have`a Eurrent liability Insurance,policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes❑ No❑
1 CIA
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: 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 Owner'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 Continents
Final Inspection
Date Continents
Type of License:
By ❑ Master
Tine ❑ Master-Restricted
City/Town ❑Journeyperson
Signature of Licensee
Permit X
❑Journeyperson-Restricted License Number:
Foe$_ ❑
Check at:v,,vw.m:Iss.govhipl
Inspector Signature of Permit Approval
Y° CITY OF SALEM, N-Wsakaf USETrs
i
ftamwt;DEPARTMENT
120W.itSHLNGTON STREET, 3noFLOOR
T EL (978) 745-9595
FA.Y(978) 740. M
Kl\IBERLF-Y DRISCOLL
%NLAYOR THoMAs ST.MERRa
DiREcroit OF PUBLIC PROPERTY/Bui Dr\G CO\LMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
I i
V:1111e(BwinesUrgmtimtiotu9ndividuat): � ��
Address:
Cily/State/Zip: l^
ors you an emptoyer7 Check the appropriate boa: Type of project(required):
I I am a employer withr- 4. ❑ I am a general contractor and 1 6. aw construction
dillpinyers(full and/or part-time).• have hired the subcontractors
2.❑ lam a sole proprietor or partner- listed on the nuach°d nhec0. 1 7. ❑Remodeling
ship and have no employees These subcontractors have B. 0 Demolition
working"tier me in any capacity. workers'comp. insurance. 9. Building addition
[No workers comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 1011 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions
myself.[No workers'comp. c. 132,§1(4),and we have no 12.� Roorn:pairs
insurance required.) 1 employees.(No workers' j;.0 Other
cutup.insurance required.)
-Any upplivanl iat chceka bus sl meat also all vul Ilse ration bulowshowina Iheir"111 ,mmpenudon pulivy into"ation.
'I hvnuuwm"whu.ubmil this aladovil indicating they am doing all work and Then Mee ouisideconneton must submit a new atOdavil indicating such.
$'ummcaa thin chuck ibis box must allached an addiliuml ahal showing the name of the sub.vninstun and their woken'comp.pulley InGltmmian.
l one an ensp/ayer(hat 2r providing)torkers'cunrpenrmlon tnsuranee for my employers. Bolow is the polley and/ub site
itsfarination.
Insurance Company Name: !264n 0_ cF"�l//L> _/7,5 a 1
Policy it or Self-rats. Lic.it: �^r�C\1 1a_1 �1[t`l Expiration Date:
Job Site Adtkess: D& -�45ZJn]f `S-� City/State/Zipi /9'�� �! /
Attach a copy,of the woriten'compensation pulley declarallon polls(showing the policy number and expiration date).
Failures to secure coverage as required under Section 25A orMOL c. 152 can lead to the imposition of criminal penalties of a
tine tip to S 1,500.00 und/or one-year imprisonment,us well as civil penalties in the form of a STOP WOR K ORDER and a fine
or up to$250.00 a day against the violator. Ile advised that a copy of this statement may be rurwarded to the Orrice or
Investigation 'Ilse MA r insurance coverage verilicaliun.
1,16 hereby r tlfy s sate h its and pendhies of perjury that the ti funnt(tlon provvi-d of above is true and t'arrrt't
swri t N).) Date! 1^JS
P , ;,: - ) - S - o�/, 4 --
Ol icial use unty. Du nor arise in this area,to be completed by city or town njjlelal
City car Town: _ .. . Permful.lcense p.__.. . .---
Issulag Aulburily(circle one): I
I. Ifoard of Ilcalth 2. Building nepas lmcut 1.Citytfusvn Clerk J. Electrical Inspector 5. Phuuhing Inspector I
6. Other
Cnnlacl Parton: Phone.'1: I
• - - --- DRIVER'S
LICENSE --
"ONe"S47595752
3 tee.
02-151969
1 a 38 HARRIS RD
LYNN,MA 01904-1337
�t j�,�\, s oo m-zs.mv we.aa-smos
3e?-„C M&WEAIA OF MAssAbm 6EfTS
BQARO OF
F a SHEET PtETAL WORKERS
ISSUES jHE FOLLOWIN6 L`7CENSE :
7fS A °MASTER UNRESTt21 CTED
� OENtr'y}S M'�.TOBIN JR
j x
�7
..
124
COMMONWEALTH OF MASSACHcl*ETT,.S
SHEET METAL WORKERS
AS A BUSINESS
ISSUES THE ABOVE LICENSE,G:
DENNIS M TOBIN JR
T AND T MECHANICAL INC
90 CENTRE ST a
LYNN MA 01905-0000
0 0 5 340 41
Fold Mulive Tines Along Peftwione Helore Detaching —