84 HIGHLAND AVE - BUILDING INSPECTION (5) 1 1
Commonwealth ot' IvIassachusetts
' 1 Sheet Nfetai Permit
Uatc: Permit #
I slimated Job Cost: S-jPjC6<,) - ---
Permit Fee: y _
I'lans submitted: YES D(- NO— Plans Reviewed: YES_ NO --
Business License r< Applicant License# - -7 ffz 3 - --
Business Intin-nmtion: Property Owner/Job Location Information:
Name: Gr No j Urt'• Name:
Street: 73 Ltjy1 5fi Street: tTl�yh 1k� f.P
City/Town: City/Town:'5
fclephone: 9-Shr -(�Q-�jp Telephone:
Photo I.D. required/Copy of Photo LD. attached: YES_ NO_
J-I /�I-1- "restricted license scorn"in't
J-2/ M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less
Residential: 1-2family_ Multi-family_ ('ondo/Townhouses
_ Other—
Commercial: Office_ Retail Industrial
— Educational_
I,stitutional_ Otherce
Square Footage: under 10.000 sq. tt._ over 10,000 sq. tt•_ Number of Stories:
Shect metal work to be completed: New Work: —
Renovation:
IIVAC Metal Watershed Roofing —
_ Kitchen Exhaust System_
Metal ('hinu,ey/ Vents_ Air Balancing
1'10vide detailed description of work to be done:
tn.c ,� S�P01� 7re.r, lc
-
t"
r1 e��.
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 Y_s,Indicate the type of coverage by checking the appropriate box below:
Bond❑ ❑
A liability insurance policy Other type of Indemnity ❑
OWNER'S INSURANCE WAIVER:I am and that marsh nat the ure Ionerns permit application waives this equlremenee does not have the insurance coverage quired by Chapter 112 of the
Massachusetts General laws, Y 9 p
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
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
By checking this box0.1 hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true an
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
Prnnress Illspections
Comments
Date
Final llimection
Comments
Data
Type of License:
By _ 79 master
nue ❑].Master-Restricted
i
❑Journeyperson Signature of Licensee
i
Por�rot x _, ❑Journeyp n-Restricted License Number:
Faa i -- —- —
----- --- Check at:^ry n rs nov'"L
inspccmr Si raluro of Permit Approval
CITY OF SM ESN 4 1'aSSACHUSETTS )
BUILDIING DEPART.%M-4T
• 120 WASHINGTON STREET,Vat FLOOR 1
f TEL (978)745-9595
FAX(978) 740-9846
KI.\IBERLF-Y DRISCOLL
Ttt �s oM Sr.PIERRs
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG COWMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
`l I�
Name(BusitxssiOrganizaltiordIndividual): �T'['tit(e�._ G7 P[.t'N'hy 11. C L f .
Address: ���C Faa n S7• �e �GS
City/State/Zip: ,aL-I-rrd,,le )MA CJy {(�(a['honek: ���6 �--10- ,-U?-q
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the stub-contractors
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet,t 7• ®Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers'comp. insurance 5.;o-we are a corporation and its !0.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employers. [No workers' 13.0 Other
comp.insurance required.]
•Any applicant that checks box 91 must also fill out the section below showing theirworkens'compsh"tn,policy imumatioa.
'1 fomeowners who submit this affidavit indicting they an;doing all work and than hi-outside contractors must submit a new affidavit irdiczting such.
:Commeton that check this boa must attached an additional Shaer showing the name of the sub-comnctm and thou wo kM,ramp,policy information.
' l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name:
Policy 4 or Self-ins.Lic.N: Twc 3lOi I 9, Ey Expiration Date-
Job Site Address, City/State/Zip; ! ', ]W1 LltLQ 0Ic N
Attach a copy of the workers'compearatica palicy deciaration page(shawing tke policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year impr.'sr,v^art as we!)as c::u'f,s- hies in the femr.of u STCP WORK ORDER and a fine
of up to$250.00 a day zgainsi the viclatcr. I3c adv€s d thzt a:cpy of this statcc :nt;may be fs wzr.dcd iu.l-c O:'ice of
Investigations of the DIA for itu:r,-ance ccvcmgo varifcatien.
B do here4--cent}:trader gw pains stripe-rahl"afPerjuey tA�t fAr lnfarowadon provided above is irate and correcf. -- -
gym. dr _C_ ,J �-.. _--. t ate• � �2
Phoned
Offtciatl use wily. 179 dim write in(Iris ff c¢ :v be rump tetra by +'ry or fawn
City ar
INS uiag Authority feircte a net):
1.Itoaud of Ilealah 2.RniMing Department 3.C6iyrr: wn.Clerk J.3tictdntal [aspectar 5, ?Ittvhing Iaaptctor
6.Other
Contact Person,
L