129 COLUMBUS AVE - BUILDING INSPECTION (2) 109,9
Commonwealth of Massachusetts
Sheet Metal Permit
Date: l kwt Permit #
Estimated Jot) Cost: .S 11 SU6 Pcrntit 1'ce: s 2 g ao ---
Plan, Submitted: YES — NO Plans Reviewed: YES NO
Business License ti 101 Applicant License I#
Business Inlbrtnation: Property Owner/Job Location Intbrnwtion:
L_AWR.r:tyc� � D�ORJt�rN GY�n�,i�blr-�t.1
Nano: KAA ,e Iu tanks lkkl n� Name: \ tL� / li
Street: SSS Uye�.rv� �Sf, Slrcc:t: 1 �-� I`U1V V sA,_
City/Ibwn:� Z,jes�,wry City/Town: SIVr\
I'cicphone:l 1FS�c6s 1-4y J 3 Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES NO
lic
— swrnnau:u
�/ - unrestricted ense
z
J-2/ M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. Ft. / 2-storg or 19,
m m
Residential: 1-2 family Multi-Family_ Condu/Townhouses_ Other
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Commercial: Office— Retail_ industrial_ Educational _ t rZDrn
rn
Institutional_ Other—
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Square Footage: under 10,000 sq. ft. V� over 10,000 sq. tt. _ Number of Stories: 0)" m
to
Sheet metal work to be completed: New Work: Renovation:
I IVAC Metal Watershed Routing_ Kitchen Exhaust Systenn_
Metal Chimney/ Vents_ Air Balancing
Provide detailed description of work to be done: 1 1
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INSURANCE COVERAGE:
I have a current liabilityInsurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes I�No❑
If you have checked Yes,indicate the type of coverage by checking the appropriate box below:
A liability Insurance policy 2-�— 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
By chocking 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
Prouress Inspections
-Date Comments
N rr'n
it i s
r+1
r�1Lr ---
n- .
r`t
1 ,
,,, Final Inspection
Date Comments
Type of License:
By _. ❑Master
rice _ ❑ Master-Restricted
Cirrrru.vn Journeyperson
Signature of licensee
Pennit x
❑Journeyperson-Restricted License Number:
Foe 5 ❑
Check at:vsv•.v.in.c;s.govhlL
Inspector Signature of Permit Approval
CITY OF SALEM, iLlIssACHUSETTS
BUILDING DEPARTMENT
3 a r 5f I?I) 1X/ASHCVGTON STREET, 3'FLOOR
TEL (978) 735-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
�L1YOR TNoxw ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electrlcians/Pl umbers
Applicant Infnrmatinn 1 1, ( p A I' Please Print epibly
Name (Rosiness Drg.viiratio vlmlividual): H Ill-is `/ s RA O �(0.AR5 Atot
((
City/State/Zip: fc.&,JkA (� �AAAoi2i6
Are you an employer!Check the appropriate box: '1•ype of project(required):
I. I am a employer with 5 0 4. ❑ I 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. I 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working tot me in any capacity. worker'comp. insurance. 9. Building addition
INo workers' camp. insurance 5. ❑ We are a corporation mid its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additiore
myself. (No workers' Gump. C. 152, S 1(4),and we have no 12.❑ Roof repairs d
insurance requited.] t employees. [N'oworkers, j}, her V�\-L
cornp. insurance required.)
•Any applirmn luo chucks but A I must alsu NI auI the sectiun bcluse showing Ihcir warkasi eumperomion policy inliumuriun.
'I(omcuwnen who wbn,it this attldnvit indicating they a c doing all work and then hit;outside contractors muss shush a new aff,daviI indicating such.
:t-.,mmctun thus check This box must atmchnl an additiunul shrwl showing the na ne of fh;sub.comraeturs and the it workers'comp,put ley information.
l our an employer that is providing workers'compeamdon insurance for my ciliployees. llelow Is the policy and jub she
irrfornration.
Insurance Company Name:
Policy it or Self-ins. Lie.th \,j( Z-C) V ` 3( U
(� 1 __...._ Expiration Date: 3o )
Job Site Address: ' l C J Aw S L _s Ally( City/state/zip; S CIM
Attach a copy of the workers' compehsatlon policy declaration page(showing the policy number and expiration date).
Fuilura to secure coverrge as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ora
tine up to 51,500.00 and/or mu-year imprisonment,as well as civil penalties in the Form of a STOP WORK ORDER and aline
or up to S250.00 a day against the violator. Ile advi.acd that a copy of this slatcment may be forwarded to the Office of
Investigmiuns of the MA for insurance coverage verification.
/do hereby crrrify under the ins and peoakies of perjury that dre.infuraratlmt provided above i.r true and correctJ"Pllllre' !—�— Dofe: V _a l Ikl.
Phone : —)ti) S 1 - 44u3
Official use only. Da not write in this area,tube completed by city or town o/Jleiat
I
C'iryor'hmn: _ - ___ PermitA.IecnscM i
Issuing Authurily (circle one): -
I. 6onrd cal Ilealth 2. Iluildlnq llepar linen( 1.Cilylrunn Clerk 1. Electrical Inspector 5. Plumbing luspecwr
0, Other
(onfact Person: - Phone .'!: l
CITY OF S.,Lzm2 A-1Ss:wHUSETTS
� ' 8L[LDLN(; DEPAR-nLENT 1_0 WASHLNGTON STREET 1 O F[OOR
T EL (973) 743-9595
KIALBERLEY DRISCOLL PAX(973) TW-934.f
NLAYOR
T;-toad sr.Ft�.vut
DIRECTOR OF PUBLIC PROPERTY/Bc:tLDLNC;CONNISSIONER
Construction Debris Disposal Afttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 CljR
Debris, mid tl[e provisions of ititGL c 40, S 54; section It 1.5
Building Permit 10 is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal
l 11. S 150A. facility as defined by bIGL c
The debris will be transported by:
y
(name ot hauler)
The dcbns will be disposed of in
(nantn of t' cdity)
(addle.cs of taclllty)
u pirure of jMl'f711t.1