0016 HOLLY STREET - BPA-14-1643 113
RECEIVED
Z-au,—,,Ct►mmMilvealth of isvlussach«setts INSPECTIONAL SERVICES
Sheet Metal Permit
IBiq OCT 10 AID 04
Date: 10-8—lq
s � 2o
' I'cnnit#
Istim;ucd Job('ost: .$ � `—` ----
Permit Pce; 5
Ph"M Submitted: YF.S_ NO to___,_-
Plans Reviewed: 1'ES NO_
Business License#_ -573 —
Applicant Liccnse# ���
Business Intirrmation:
f �,/ Property Owner/lob Location tnti rmatiun;
Name: i 3/T/['c�A/1/C4 4P27
Name:
Street: d (,P/7'/L' S J'1 _ `�---- _—
Street:
City/Town: Y�/J HW Qlcf ,7
city/Town: ��
'telephone: �g �-s �!�
------ � Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES-')� NO_
J-1 / ; l-t mrestricted license Stan— tilt�—
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_ Multi-fantil
Y Condo/Townhouses Other
Commercial: Office_ Retail _
_ Industrial— Educational_
Institutional— Other_
Square Footage: under 10,000 sq. ti.� over 10,000 sq. ft._ Number of Stories:
Sheet metal work to he completed: New Work: —
Renovation:
IIVAC__�/' Metal Watershed Roofing —
_ Kitchen Exhaust System
Metal('hijoney/ Vents
Air Balancing
1,A)Viide detailed description of work to be done:
......... .
-- . _ cam- ; MAtC l0(20
I
I SURANCE COVERAGE:
I have a current liabilit Insurance policy or its equivalent which meats 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:
Other type of indemnity ❑ Bond ElA liability insurance policy ❑ yp
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 Owners Agent
By chocking this boxCl,I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and
ed under the permit
acurate to the best o
with alllpMY ertinent provision of thelM Massachusetts Building Codet metal work and etions Perforand Chapter 1 Issued for this application will be
11 of he General Laws.
Duct Inspection required prior to Insulation Installation: YES__NO
PrOltreSS IitSUREgM
Date Comments
Finalfusuectlan
D:ilo Comments
Type of License:
I
By ❑Master
tine _ ❑ Master-Restricted
City To,.n ❑Journeyperson Signature of Licensee
Pwma x„T — ❑Journeyperson-Restricted I
License Number:
rod5 ....__—'----"----..�
❑..._ —_..----- Check at ry m.t:>s.nuv'rh`I �
I
lul,� '-1d
Inspector Si9noturo of Permit Approval
,! CITY OF S U EM, N'LASSACHUSMS
• ' I31:ILDLNG DEPARTNIENT
120 WASHINGTON STREET,3w FLOOR
1 TEL (978)745-9595
FAX(978)740-98"
K!\tBERLEY DRISCOLL
MAYOR T HOMAS ST.PIBRR 1
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG COMMlUIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Ptumbere
A s 1)cant Information / elglse Print Leelkil
Name(BusimssiOrganizatioNlndiividual): z!J
Address: qy a4e iV-
City/State/Zip: l'U RA Phone#: `)0/-
A�r�e},you an employer?CheekIf
ythe appropriate box: Type of project(required):
1 X`11 am a employer with___L� 4. ❑.I am a general contractor and I T e New project
coni(r a(required):
employees(full and/or part-time).+ have hired the sub-contractors 6.
ion
2.Q I am a sole proprietor or partner- listed on the attached sheeL: ?• Q Remodeling
ship and have no employ= These sub-contractors have It. Q Demolition
working for me in any capacity, workers'comp.insurance. 9, Q Building addition
[No workers'comp. insurance 5• Q We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MOL I I.Q Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.(:1 Roof repairs
insurance required.)t employees.[No workers' 13.Q Other
comp.insurance required.]
;Any oppli,:mt thou check,boa#t mrW also fill out the section below showing their workers'compensation policy imfom,asloa
Ifomeuwmas who submit this affidavit indicating they au doing all work and then hive outside eemmotons muu new affidavit a ne affidavit indicating such.
:Com ,y roon ohm check doia tax muss auxlwd an a�Witiooul shut siwwing the mono of the sub.eontractar,nod their workoss'comp.policy infOmadac
I am as employer that is providing workers'compensadon insurance jar my employees. Below is the pulley end job site
injormadan.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/state/zip:
Attach a copy of the workers'compensation Polley declaration page(showing the 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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250 a day against the violator. l3e advised that a copy of this statement may be forwarded to the Office of
Investigatio oft DI for insurance coverage verification.
I do hereby c tify u r e pains and penaltles ojperjary that the information provided above is true and correct.
It t ire, 1ow
Phone#�1 �S�o—z��
FOfflcial use only. Do not write in this area•to be completed by city or town ojftchd
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other—
Cnntact Person: Phone#:
- — DRIVER'S
- LICENSE -
NONE S47595752
3 son;_..
�I8 02-15 1,969
,E 1
5 sa M isrs E81- *
}s•zIDEAJNIS` JR
a 3B HARRIS RD oas,ssv'
LYNN,MA 01904-1337
y' � �r.»� soo os.a.aon rze.or-swos
COMMONWEALTH OF'MASSACHISETTS
• • • • • •
�ry °,�hSHEET�MAT�AL IJURKER$ '�
ISSUES THEhFOLLOWiNG LICENSE `
AS =A MdSTER UNRESTRICTED---
DENAFtS M' TOBIN :1R It
s t z
3$ tHARRIs FtD,�r t` � �
;LYNN
COMMONWEALTH OF MtASSACC-VSEFIs
SHEET METAL WORKERS
AS A BUSINESS
ISSUES THE ABOVE LICENSE TC -
I
DENNIS M TOBIN JR
T AND T MECHANICAL INC
90 CENTRE ST
LYNN MA 01905-0000
0 0 5 340. 41
rolo Nullipie Times Along Pert mtionn Before Detaching