0120 WASHINGTON STREET Commonwealth of Massachusetts
Sheet IVletal Permit
Date: _ ! L /5 Permit t/_/_
Estimated Job Cost: S 7�jG� Permit Fee: S$ / --i 6 V
PlanS Submitted: YES NO Plans Reviewed: YES NO
Business License# -� 1, Applicant License tt
Business Information: Property(honer/Job Location Information:
Name: (�U77 �����h/GC / Name: (�
Street: ��/ �izj� �LGs Street:
City/Town: I LPle City/Town:
Telephone: /, / Telephone:
Photo l D—rcyuired/Copy of Photo I.D. attached: YES NO
J-1 / i\9-i-unrestricted license a,rn„iu,i—
J-2 / M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. It. / 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. tt. ✓ over 10,000 sq. ft. — Number of Stories:
Sheet metal work to be completed: New Work: _ Renovation:
I IVAC Metal Watershed Roofing _ Kitchen Exhaust System
Metal Chimney/ Vents_ Air Balancing
I'rocidc detailed
/descri rtion of work to be done: /
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5�T l I I to cn ><
D mo
INSURANCE COVERAGE:
I 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 I � 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 •wner's Agent
Signa 9
By checking this box[],1 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
Prouress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
BY.- ❑ Master
nne _ ❑ Master-Restricted
Caytrown ❑JOurneyperson
Signature of Licensee
Perintl e.-
❑Journeypersan-Restricted License Number:
Foe 5
.._— ❑— --- Check at ww.v majs.govhlLi
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In spc' r A royal
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,' "° r C[TY OF &U-EM, � -kss.\CHL'SET"I-S
BUILDING DEP.tRTNIENT
3 4 f aJ 120 WASHLNGTON STREET, 3w FLOOR
TEL (978) 745-9595
FA.X(978) 740-9846
KIMBERL.EY DRISCOLL
"tiL�YOR THObfAS ST.P7EaRa
DIRECTOR OF PUBLIC PROPERTY/OCLL.DLNG CMCAISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractorv/Electrlcians/Plumbers
\iiplicant_Informatiore _ / Pfcase Print 1 c ihiy
Name(Ilusioess Organlratiam'ln livvii/fit 1): / ' V
i\ddreSS: / 3 V WG
City/State/Zip: Phone If:
Are you an employer'!Check the appropriate box: Type of pr7ade
red):
1.(]I am a employer with r L2V Pe ;. ❑ 1 am a general contractor and 1 6. C3 New
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 ani a sole proprietor or partner- listed on the attached sheet. t r• ®"Rem
l ship and have no employees These sub-contractors have S. (] Dem
working for me in any capacity. workers'camp. insurance. 9. ❑ Buil(No workeri coinp. insurance 5. ❑ We are a corporation mid itsrequired.) ofticen have exercised their 10.❑ Elec or additions
3.❑ 1 ant a hotncuwnur doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers'cutup. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' 13.❑ Other
comp. insurance required.)
Ay upplicmn slur ahccka but NI must.ilw rill out the scution bclowshowing their workers'cumpenaariun policy inAirmadun.
'I L.mcuwtvn who ubail this aril,bwit indicating Ihey arc daing all work and then him outside,,m,ctan mntt hmit a n,,,a rr.dav it indiwing each.
Cnnmumn but check ibis box nowt art ac hal in ndditiunal ASabi showing the mane of the subwamraetorr and their workers'comp.pulley information,
!ant an employer that is providing workers'cunrpeusadan insurance for my employees. U¢low is dia pulley and job.d1e
information.
Insurance Company Name:�_�.
Policy 4 or Self-ins. Lic. 0: Expiration Dote:
lob Site Address: City/Statetzip:
Attuch a copy of the workers'compensatlaa policy declaration Page(showing the pulley number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition ofcriniinal penalties of
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the. form of a STOP WORT(ORDER and a line
of up to S2S000 a day ogainst the violator. Ile advised that a copy of this statement may Iie funvurdcd to the Office of
Invcntigulian.t of the OIA for insurance Coverage verification.
i
Ida hereby certify and-t the pain d penulriex of perjury that the infurmatlmt provided ubuve i/%I ue orrd a sect
Si •n t ore' Date: 'J/
Phone :!'
OJlicia!use only. Du nor rvrite in this area, to be cumplefed by city ur town njjlciu2
City or'I'nwn: _ _ Permit/l.lccnsc N__.
Issuing Authurily (circle uric):
1. I;oord cal'Ileailh 2. I1uiLilm! Deportment .l.fitylrmvn Clerk -1. Electrical Inspector i. Pin robing Inspector
h. Other
Cunlacf Person: it
Phone N: