B-19-1080 - 0004 BARTON PLACE - Building Permit Commonwealth of Massachusetts
Sheet Metal Permit
Date: Z / Permit#
Estimated Job Cost: $ k �� d ® Permit Fee: $ C % 51
Plans Submitted: YES NO Plans Reviewed" YES NO
Business License# L �2 Applicant License#
( Business formation: Property Owner/Job Location Innfo�rma�tioln:PP,-,r\-Tfz-V5T
�. Name:
Street: /� � T / Street:
City/Town: ?J—City/Town: ��y1� >�I✓j�
Telephone: /' - 8 3C� , Telephone: ar `� D 2- 3
Photo I.D. required/Copy of Photo I.D. attached: YES NO
Staff Initial
J-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: 1-2 family Multi-family Condo/Townhouses Other
Commercial: Office Retail Industrial Educational
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Institutional Other = ,
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Square Footage: under 10,000 sq. ft., over 10,000 sq. ft. Number of Stories: r
Sheet metal work to be completed: New Work: Renovation: Ln
HVAC Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing w .
G!>
Provide detailed.description of work to be done:
M Al LIED
INSURANCE COVERAGE:
1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes❑ No❑
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
1
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 Comments
Type of License:
By aster C
C �
Title ❑ Master-Restricted
City/Town
❑Journeyperson Signature, f License
Permit#
❑Journeyperson-Restricted License Number: -2— 2,3
Fee$ ❑
Check at www.mass.gov/dpl
Inspector Signature ermit Approval
.. CITY OF S��L.El�i, NLkSSACHUSETTS
• BUUM124G DEPARTMENT
120 WASHINGTON STREET, r FLOOR
TEL (978) 745-9595
FAX(978)740-9846
KimB RT EY DRISCOLL
MAYOR THOMAS ST.PMRRE
DIRECTOR OF PUBLIC PROPERTY/Bl.'ILDLNG CO'.%LMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / lease Print Le ibt
Name(BusimbssiOrganizatioNlndividual): (- / r
Address: /�1
City/State/Zip: Q 0 Phone #:
Are you an employer?Check the appropriate box: Type of project(requireM:
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.❑ 1 am a sole proprietor or partner-
listed on the attached sheet. 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. []Demolition
working for me in any capacity. w rs'comp.insurance. g, ❑Building addition
[No workers'comp.insurance 5. a are a corporation and its 10❑Electrical repairs or additions
required.) officers have exercised their
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' 13.❑Other
comp. insurance required.]
*Any applirunt that ch%*s box AI must also fill out the section below showing their workers'compensation policy information.
t I lnmeowntxs who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contrectors and their workers'comp.policy information.
1 am an employer that Is providing workers'compensation insurance for my employees. Below Is the policy and Job site
information.
Insurance Company Name:
Policy 4 or Self-ins.Lic.ft: Expiration Date: a
Job Site Address: City/State/Zip:
Attacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration slate).
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 S250.00 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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
. i ens t mr • '
Datii: !�/— c
Phone d:
Official use only. Do not write in this area,to be completed by city or town oJfciaL
City or Town: Permit/I.1cense
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 il:
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Fold,Then Detach Along All Perforations
COMMONWEALTHSOF,iagiA HE SETTS
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e SHEET LfiIETAL WORKERS
ISSUES THE FOLLOWING LICENSE
# A ;s {VIAS1' R UNRESTRICTED-
BASIL I O HENRIQUE2 Z
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FOXBORO,;MA r02038 `' i , �;`,t
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12923�' Tf28/2021