12 CHURCHILL ST - BUILDING PERMIT APP (002) }� 11 Commonwealth of Massachusetts
'C,11.1 Sheet Metal Permit
Date'
FsIimated Joh Cost: 'S_Woo C e Permit Pee: 'S --
flans Suhmittrd: YES
�--NO flans Re%icwCrl:�YES NO
Business License !t _ Applicant License kF /— ---
Business h,timnation: Property Owner/Job Locution IntinrivuUiun: .
Name: Ped'Fecx Cu"VL.';& Name: i'\0 J3
Street: `75 r7r^((1e3,y 1 Strec1: i'a C(NLL.,CQL C'ldV T—
G
City/Town: avi\k� M4 of N� City/Town: 04� Li
Telephone: 6 /-qw-g;t -)— Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES NO
J-I / Al-1-unrestricted license Y
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 I Multi-family_ Condo/Townhouses Other
Commercial: Office_ Retail_ fndustrial Educational
Institutional/ Other_
Square Footage: under 10,000 sq. tt, v "c'r r 10,000 sy. tt. _ Numher ol'Storles: _
Sheet metal work to Completed: New Work: _ Renovation: &'_�'
IIVAC l Watershed Routing _ Kitchen Exhaust System_
Metal Chimney / Vents_ Air Balancing_
lruvide deMilCd description of work to be done:
t .n!e-i uAk Cr { T�[, K'2<t 1—t'C/t r d' (,-q..5
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 a of coverage by checking the appropriate box below:
A Other type of indemnity ❑
Bond
liability Insurance policy ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter/12 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
-Owner ❑ Agent ❑
Signature of Ownerror 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
ad under the permit
l shoot metal work and installations perform
Iaccurate to the best n compliance with all t MY knowledge Ind that pertinent provision of the l Massachusetts Building Code and Chapter 12 of he G ner issued for this application will be
al Laws.
,
Duct Inspection required prior to insulation installation: YES_NO
Proeress hlsacctions
Date Comments
Final Inspection
Date Continents
Type of License:
By ❑ Waster
nue _ ❑ klaster-Restricted
r
❑Journayperson Signature of Licensee
Por,nit? -- ❑Journeyperson-Restricted
License Number: i
n,e - . .- ---- ❑
- — - - ---- --------- Check at:r•.i_�.u�.�,;s.,�L
In specter 31, oalu of Permit Approval