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347 HIGHLAND AVE - BUILDING INSPECTION (2) Commonwealth of Massacky t #�"% Sheet Metal Permit 16lb AUG 18 AD- 0-9 Date: Permit # Estimated Job Cost: $ 85 © Permit Fee: $ge I Plans Submitted: YES _ NO_ Plans Reviewed: YES_ NO _ i Business License # Applicant License # No3 Business Information: Property�Owner/ Job Location Information: Name:�r;� Q"'T SyS �r � S Name: �cskti �t Ani//*Va` 3,0l-�-✓' Street: 6-2 Street: 3y`? City/Town:� M City/Town: �c-��✓1 Telephone: 41��`t6a 3�oU Telephone: Ce 7 -7 l Photo I.D. required/ Copy of Photo I.D. attached: YES_ NO -- Staff Initial 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 v_ Square Footage: under 10,000 sq. ft. ✓ over 10,000 sq. ft._ Number of Stories: Sheet metal work to be completed: New Work: _� Renovation: _ HVAC Metal Watershed Roofing_ Kitchen Exhaust System_ Metal Chimney/Vents_ Air Balancing Provide detailed description of work to be done: F ANCE COVERAGE: current liabili insurance policy or its equivalentwhich meets the requirements of M.G.L. Ch. 112 Yesave checked Yes, indicate the a of coverage by checking the appropriate box below: ity 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 wait/es this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owners Agent By checking this box 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_tl� Proeress Inspections Date Comments I i I Final Inspection i Date Comments i Type of License: By Master Title ❑ Master-Restricted City/Town i ❑Journeyperson Permit n ignature of Licensee ❑Journeyperson-Restricted /6 /— Fee g License Number: 276 Check at www.mass.goy/dp1 i Inspector Signature of Permit Approval I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADulicant Information Please Print Legibly Name(Business/Organization/Individual) �3'.�- Address: City/State/Zip: p J`14 ct46ct Phone#: q7B cj6a 3T?oc:) Are you an employer?Checkthe propriate box: Type of project(required); L 1 am a employer with 4. ❑ 1 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. _ 7. ❑Remodeling ship and have no employees These sub-contractors have 9. ❑Demolition working for ran 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 I.❑Plumbing repairs or additions myself.(No workers' comp. c. 152,OR,and we have no 12.0 Roof repairs insurance required.]t employees. [No.workers' 13.L�tether �dagG comp. insurance required.] — *Ally applicant that checks box al must also fill out the section below showing(heir workers'campensation policy information. t Homeowners who submit this emdavit indicating they are doing all work and then hire outside contracmrs must submit anew affidavit indicating such. - ICommetors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. lam an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site information. / Insurance Company Name:_/`/,0,43 Policy#or Self-ins.Lie. N: (�)C / 3 O G l[ 17 /J H+f' Expiration Date: qq7��t�"� Job Site Address: y 4.34(,run A t —City/State/zip:- 7'40t n t 7(l Attach a copy of the /asre ' pens do policy declaration page(showing the policy number and expiration date). Failure to secure coved rider ection 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 a ' pri nment,as well as civil penalties in the fort of a STOP WORK ORDER and a fine of up to$250.00 a daato. Be advised that a copy of this statement may be:forwarded to the Office of Investigations of th a ov ge verification. I do hereby ce i er the pri n n The information provided above its true and correct. Si nature: qct Da, /A /.,� Date: Phone ft: � 6-* Offrci use only. ,Do no write in this area,to be completed by city or town official City or Town:_ _Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person; Phone#: a COMMONWEALTH OF MASSA6HUSETTS BOARD'OF SHEETMETAL WORKERS; ISSU_ES THE FOLLOWING LICENSE AS A" •? MASTER UNRESTRICTED KENNCTH B. PATTEN `- LANDER RD,— a LYNNFIELD,..NFA=01940 2117• ` - ,' z U 1963 ' 06 2$/28P7 1178 DF�IV�R'�: " ' LI ENS "Al 1 ,{ a'5` NONE',! O NONE?S.5$$48360 A967. 4 P1SS��„_ 161E�Srt 1466% M. i +a KENNET B T 1 t 1 Y _ 111%i a 10 LANDER LYNNFIELD,MA 019402117 V/� 6DDM064I6Rev014A09