12 CHESTNUT ST - BUILDING INSPECTION Ih C,
Commonwealth of Massachusetts a ,}Vj„ r
Sheet Metal Permit 201E AUG 18 A 0 09
P (g-(
-� Date: Permit#
Estimated Job Cost: $ °' Permit Fee: $ �g
Plans Submitted: YES_ NO Plans Reviewed: YES— NO
Business License# Applicant License #
Business Information: Property Owner/Job Location Information:
)Name )Cy �uc- 6�356'vi 5 Name--�e_-�-_�
Street: roa Street:
City/Town E} �� C��`1G"( City/Town:
Telephone: X6715 `tGQL 3800 TelephoneA-7F
�5 2(5-
Photo
tSPhoto I.D. required/Copy of Photo I.D. attached: YES_ NO__
Staff lnhial
J-1 /M-1-unrestricted 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: 1-2 family Multi-family_ Condo /Townhouses_ Other
Commercial: Office Retail Industrial Educational
Institutional Other_
Square Footage: under 10,000 sq. ft. L-'� over 10,000 sq. ft. _ Number of Stories:
Sheet metal work to be completed: New Work: (/ Renovation: V
HVAC Z Metal Watershed Roofing_ Kitchen Exhaust System _
Metal Chimney /Vents_ Air Balancing
Provide detailed description of work to be done:
1vlR�� —D "SD C� C' . `X23
INSURANCE COVERAGE:
I have a current liabili insurance policy or its equivalent which meets the requirements of M.G.L, Ch. 112 Yes No❑
If you have checked Yes, indicate the pe of coverage by checking the appropriate box below:
A liability insurance policy LAS/ 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 Owners Agent
By checking this bo ,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 1/
Progress Inspections
Date
Comments
I
i
i
Final Inspection
Date Comments
Type of License:
By
U40-a�ster
Title
❑ Master-Restricted
City/Town
i
❑Journeyperson
Permit# Si Lire of Licensee
Fee$ ❑ rnJoueyperson-Restricted �� 3
Li rise Number:
Check at www.mass.goy/dpi
i
Inspector Signature of Permit Approval
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of lit vestigations
k1ri 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ABBlicant Information �1 \ ¢¢ Please Print Legibly
Name(Business/Organization/individual): � �'i� 5 ✓ ���
Address: CoO� -t IY_�T���lq� � r�
City/State/Zip o �'M49 ooh L Phone#: Q70 `f(,l 3 E)TC)
Arree,you�n employer?Check the ppropriate box: Type of project(required):
1.LSL.i�dm a employer with= 4• ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. t ?. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for 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 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§l(4),and we have no 12.0 Roo repairs
insurance required.] t employees. [No.workers' 13. therU�==
comp.insurance required.] —
*Any applicant that checks box W 1 must also fill out the section below showing their workcn'compensation policy information.
t Homeowners who submit rNs amdevit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
lCowactors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers comp.policy information.
I am an employer that is providing workers'compensation hisurance for my employees. Below is the policy and job site
information. �(/A,, J
Insurance Company Name: / `!`� —�✓LS �d
Policy#or Self-ins.Lic. : V1)\ C- OCD (]_j 971 N1N14Expiration Date: -7—) —/ -7,�
Job Site Address:�� C S�Q�-t/� .n _City/State/Z.ip:�,n/L 1' t tT 66L,
Attach a copy of the workers' Vonmpensationotic,declaratton page(showing the policy number and expiration date).
Failure to secure coverage a reqion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 an o one-ynt,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a d inst thdvised that a copy of this statement may be forwarded to the Office of
Investgations of e A for incverification.
/da hereby ify nder the p in res of erjury that the information provided'above is true and correct.
Signature: po.. Date: U�it G-(`,
Phone N:
Offsci use only. Don write its this area,to be completed by city or town official
City or Town:_ Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
I '
Q COMMONWEALTH OF MASSA&USE" S
!® o do 'i° ' o 0
BOARD OF
SHEETWETAL.WORKERS"
ISSUES THE: FOLLOWING LICENSE ASA ,
,•MASTER UNRESTRICTEED -z "
KENNFTH 8. PATTEN'
1�t LA'NDER RD ��•
LYNNFIELD,MA•01940 2117 "
s ^IU
2 '
1963 `06674120M 1178 I+a'
M.
L2SSlti�k� SETTS DRIVER'S
LICENSE"
Tei 91 fir- �4i,.� 9 ENO• qd NUMBER
5NONE)558.$49$6Q
ti{n"sk -..fig r'NOPE ar 9Ex'M. v rsd":::-
KENNETH!B.
. R.e 10LANDER RD
LYNNFIELD;MA 01940.2117
.V/ Gpp OSOe�AISRev OT11A49
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