14 GREENLAWN - BUILDING INSPECTION (2) Commonwealth of INlassachusetts
p Sheet Metal Permit
Date: 7 - , ` /3 Permit #
Fstimated Job Cost: Permit Fee: S
I'lans Submitted: YES NO Plans Reviewed: YES NO
Business License N I ga57 Applicant License f#
Business Intormation: Property Owner/Job Location Information:
Nance: ChaISS6n tk4HN 16,o0UJ J Name: 8A-rill P- -
Strectl SQGKOA Street: 14 6rg-een Ccrwn
City/Town: L30s+cr.1 mf 6212o City/Town: SaWl t" 1y2A
,rclephone: 1 - PY,5� Telephone: (917 7` 5 - 73 7!�-
Photo I.D. required/ Copy of Photo I.D. attached: YES— NO
�� Slaff Initlul
J- -unrestricted license
J-2/ NI-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less
Residential: 1-2 family 4Z Nfulti-tamily_ Condu/ Townhouses_ Other
Commercial: Office Retail Industrial Educational
Institutional Other—
Square
Square Footage: under 10,000 sq. tt. over 10,000 sq. ft. _ Number of Stories:
Shect metal work to he completed: New Work: Az� Renovation:
I IVAC_ Metal Watershed Roofing_ Kitchen Exhaust System
Metal Chinmey/ Vents_ Air Balancing
Provide detailed description of work to be done:
h atA[1 &-n-an 6F I -� S e o-A 0Z STD f��t� /✓D /12af-/)
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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 ❑ 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 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 o License:
By laster ^_
nue_ 1 ❑ Master-Restricted � (l/./"/''--
City/Town ❑Journeyperson
Signature of Licensee
.` ❑Journeyperson-Restricted License Number: O`
Fzz 5 ----- — ❑ ---
'� Check at:vsv.v.m.c;s.;wvhlnl i
Inspector signature of Permit Approval
60M MONWEALTif OF MASSACHUSETTS
SHEET METAL WORKERS
AS A MASTERUNRESTRICTED
.. --ISSUES THE ABOVE LICENSE TO
ROBERT ,14 CHAISSON �.
T SACHEM ST {
ROXBURY MA 0 2120 284,
14257- 01/28/15 305522
I
CITY OF SM1 EM, NUSSACHUSETTS
BUll.01I 1G DEP ART.\IENT
• t?O WASHIINGTON STREET,3"'FLOOR -
T EL (978)745-9595
FMX(978)740-9846
KIN
(BFItLEY DRISCOLl
T
MAYOR HOMAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COJLMISSIONER
Workers' Compensation Insurance Affidavit. Builders/Contractors/Electriefans/Plumbers
Applicant Information (" I ,_ J Please Print Leeibly
Name f0usiix Orgini:atiorvindividuap Lv: \AleSdn k_ctT�r\rif
Address: 7 Stl lz, kw C t
City/State/Zip: bb5b2n MA02AZID Phone #: 791 —3-- I - I ( q J
Are Ou an employer?Check the appropriate box: 'type of project(required):
I. 1 am a employer with 1 4. 0 1 am a general contractor and 1 6. PINew construction
employees(full and/or pan-time).' have hired the sub-rionttactors
2.0 1 am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling
ship and have no employees These sub-contractors have S. C]Demolition
working.for me in any capacity. workers'comp.insurance. 9. 0 Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its.
required)
otTiccn have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 1 I.0 Plumbing repairs or additions
myself.(No workers'cutup. c. 152,§1(4),and we have no 12.❑ Roof epairs
insurance required.]t employees.(No'workers'. 13.0 Other! f{11X1 C
comp.insurance required.]
'Any applicants that chucks box xl must also rill out the mctioa below showing their worker'compensation policy infurmatioR
I htmeownen who submit this anlrmvit indicating they are doing all work and than hire outside conttncitim muss submit a new alildavit indicating such.
:comrmton that chwk this box most allachxi in additional sheet showing Iho name of thb subscmmraoton and their workers,camp.put Icy infomution.
lam an employer rhat Is providing workers'compenisallon hisurancefor my employees.- Below Is the policy rind fob site
hiformation. µ1
Insurance Company Name-C. ' 1 - S4eVZr11 15 60 m 4d)zpi M14 7JO/ - 3a��/ -�3..
Policy 4 or Self-ins.Lie.4:� Expiration Date:_ //!
Job Site Address: I Cl rLLQ.P\ L6" SAttftl in 4 City/State/Zip.
,%ttach a copy.of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the forth of a STOP WORK ORDER and a tine
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
Investigation of the DIA for insurance coverage verification
I do hereby certify under die paint td penaties of perjury that tha iirformallon provided above is true and correct
si nalnre �� Darin 7 -e
Phoned:
L
only. Do sotwrite in this area,to be completed by city ur town ojJfelaL
n: Permit/L.icenseflhority(circle one):
Health 2. Building Department 3.Citylrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
son: Phone K•