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12 GREENLAWN AVE - BUILDING INSPECTION Commonwealth of Massachusetts Sheet Metal Permit I)atc: u"�i- 13 Pcrn,itt/ _---- Fstimaled Job Cost: `$ 730b Permit Pcc: 'S Plan, SubmiUcd: YES _ NO_ Plans Reviewed: YES NO Business License /t{ol J 7 Applicant License # $'7"7 I Sa l Ov2 --- Business Information: Property Owner/Job Location Information: Name: C`'1G,( 50Yt KZCLk1n� (ZC6A9 Name: K2V rA/ bI)c>ro- L Street: 7 SAC) Street: IX G-P--eP Lawl1 City/Town: ac)S-t-oM MA- 02t20 City/'Town: SAL /1� qL4 Telephone: W l -32 1 vs Telephone: �f 7 8 y3 Photo I.D. required/ Copy of Photo I.D. attached: YES NO J-1 /a-I- mrestrictcd 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 Z Multi-family_ Condo/"Townhouses Other Commercial: Office— Retail_ Industrial_ Educational h,stitutional Other_ Square Footage: wider 10,000 sq. ft. over 10,000 sq. tt. _ Number of Stories: Sheet metal work to he completed: New Work: Renovation: I IVAC V Metal Watershed Rooting_ Kitchen Exhaust System Metal Chimney/ Vents_ Air Balancing Provide detailed description of work to be done: T n S4I I AA,� © 71 7o K 13Tu !F rAnace q °� Fi11� �} TON A L t 1n 1+ i�nf 4C S-6 A-tL el etV d1tjc-+WO'(K - F , INSURANCE COVERAGE: I have a current liabilityInsurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes' No❑ If you have checked Yes, Indicate the pe 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 wallies this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By chocking this boxC].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 Final Inspectioll D:Itc Continents Type of License: By.- Master rile_ ❑ Master.Restricted CityiTowri ❑Journeyperson Signature of Licensee Pennd# /[j JI s — ❑Journeyperson-Restricted License Number 7 0� Fee$ �— El- -- Check at'•v',r,v.m.iss.�WvLIL titspector Sig attire of Permit Approval r :;.f r '."�"� " r„{r "9°"aF �" .»tan*.-w^ra-.a'�"•.a y,?'r 5x» enp,„ r 3 m F.: CITY OF Slu1L�Ni 11t ASSACHUSETTS BUILDING-D EP A RTN(E.NT F 120 WASHINGTON STREET, r FLOOR TEL (978)745=9595. Eix(978) 740.9846 KI,,IBFRi F.Y DRISCOL L YOR Tmms ST.PtERRB DIRECTOR OF PUBLIC PROPERTY/BUnDNG COMOSSIONER Workers' Compensation Insurance Afttdavit: Bmiders/ContractoiVElectricians7Plumbers Annlleant Information 1_ Please Print Ge ibly Name(Busiix &OrganizatiorVIndividual): C—bal S58h 4z0:P1ICl'f Goourl Address: _ .SctchP SP City/Statelzipi_-6'65fiDN MA bZtZD PhoneN: i . Are nu an emplayerl Check the appropriate box: 1 . Type of project(required): I.AI am a employer withr I 4. ❑ 1 am a general contractor and f [. 6. NewGonstntction N�lFGemployees(fitll and/or part-time).• have hired the subcontractors2.❑ I ntn a soleproprictoror partner-, listed on the attached:vhect,i • Remodeling ship andhave no employecs ll These subcontractors have' DenroWorking.;for me in any capacity. workers comp msdrai nce., Duililing addition[No worker comp...insurance. - 5. 0 We ace a corporation and in,required.) ottiecn have exercised their, 0.❑Electrical repairs or additions 3.[1 1 am a homeowner doing all work right of exemption per MGL 1 t Q Plumbin"g repairs or additions myself.[No workieW comp. c.,152;§1(4),and we have no , 12.0 goof repairs insurance required.]t employees [No workeri", 13.❑Other'' ' sump.insurance rcquircd.J ;Any uppllcaaa that cheeps bar el must alsd rill ebuhe seclion blow showing ihok worktns'compensation polity mfmmodart, r ltxneuwners whosubmitthis tAdavis indicating 1heyaradoingall workandthen hies outride esntroeron mtutaubmitansw amdavit indicating,such, ..; =Contracars that check this box must attached an additional sheet showins the nartw of tttssulucantnetors seta 1howworkers''coinp:pulicyinfomianon:. %um art employer Thar&provld�ng workers'comprnsallon lasuranee for nay employerrx'Below!s the polfry and Job r!!e ' inJorinatton' G; D .. Insurance Company dame:�� SIC)RA S it F)�c�Q,YI '/Y11i' 70 �- 'ja fJ- Policy N or Sclf ins.Lis N: Expiration Date• f Job Site Address: I taU41 Sa CirylSmte/Zip: /r/1¢ A ttach a copy.of the+porkers'.compensation policy dectaratlan.page(showing tha`poll ley number and-expiration date). Failure to sucurc coverage as required under Section*ot•MGL c. 152'can lead to tha imposition of criminal penalties of a tine up to S I,S00.00 and/or one-year imprisonment as well as civiPpcealtiei in the roan of a STOP WORK ORDER-and a fine of up to S250.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of. Invcstigatimts ol'the DIA for insurance ciiv�ragc'vcIII leatlum »' - ' l du ire nodal f1^ re Pains Coo nallG7 of peflit'X rhar ttie h!IArnradon pravldrd ahove is true and correct. Simnture: p 1—Q1 / Dato � �- n •_70 / 302 O/Tcial use oaly. Da not write in this area,to he completed by city bt/own n/J1claL City nr Tuwn: Permit/l.lccrrse q Issuing Authority(circle one): 1. Board of Ilealth 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.01 her ._ Contact Person: ___ _ Phone o: ,