13 HUBON ST - BUILDING INSPECTION (3) SDI - 1 � 11C7`f -� � 1 �
Commonwealth of Massachusetts
Sheet NNW Permit
Date: Permit
Fstimated Job Cost: S- l 3 00 Permit Pee: S -
Plans Submitted: YES r/ NO Plans Reviewed: YES NO
13usincss License # (✓ It OS Applicant License # & Y.D5'
Business [111brmation: Property Owner/Job Location Information:
Name: fQPk) Name: Dow-
sweet: `i -raj C14 ,+u-✓ 131v d Strect: 13 I-Iu b,) 34-eec-t
City/Town: /U 5S u , /V H City/Town: SiLv^ 1In
Telephone: &03 - �31 -S%� Telephone: -dQ - 8783
Photo I.D. required/Copy of Photo I.D. attached: YES NO-------------------
_
sr�rn d i�i
J-1 / J6-1-unrestricted 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 Multi-family_ C'ondo/Townhouses_ Other
Commercial: Office Retaii Industrial Educational
Institution�all Other—
Square Footage: under 10,000 sq. tt, t/ over 10,000 sq/. I. _ Number of Stories:
Sheet metal work to be completed: New Work: i/ Renovation:
I TVAC _ \fetal Watershed Rooting_ Kitchen Exhaust System
Metal Chimney/ Vents_- Air Balancing
Provide detailed description of work to be done:
Ne.:j Sr tglz -Z z I+"-c-
INSURANCE COVERAGE:
I have a current liability Insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Ye3�1(U No❑
If you have checked Yes, Indicate the type of coverage by checking the appropriate box below: G/�'
A liability Insurance policy Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General L ws, an>dthat my signature on this permit application waives this requirement.
Check One Only
Owner [S] Agent ❑
ignature 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
Proeress IllspectlOtlS
Date Comments
Final Insoection
Date Comments
Type of License:
By ❑ Master
nne_ ❑ Master-Restricted
City/Town ❑Journeyperson
Signature of Licensee
Pennd x
- ❑Journeyperson-Restricted License Number '
Fee 5 —.—_—
�-- -- Check al'.r,v.v.in.tss.r_ iovhlL
G
hispector signature of Permit Approval
COMMONWEALTH OF MASSACHUSETT5
iEET METAL WORKERS '_` ;
ASS \ MASTFR, UNRESTRICTED
t THE ABOVE LICENSE TO
I �r1cS G ;SII VCt2ThI0- °�
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4 T`ASf I RE'!,U BUID }' ,
"•NN 03062 23'0
� � _6405 04/L9/14 ' lSll,l1
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CITY OF SM-EM, 2ANSSACHCSETTS
t BUILDING DEPARTMEINT
4 9 • ' p •, 130 WASHLNGTON STRLET, 3w FLOOR
5 F TEL (978) 745-9595
Emx(978) 740-98.36
IVNCBERf EY DRISCOLL
VLAYOR THontAs ST.Pt&flRH
DIRECTOR Of PUBLIC PROPERTY/BCBDLNG CO%CMISSIONER
Workers' Compensation Insurance Af<davit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
V tIIt7C(13usine>s.Organization;Individual): �V `Y�l di/U[i 1�2,e/
Address:
City/State/Zip: 14la-14' Phone #: 663 D31 -j_lUr
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-eontractors
am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling -
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. y, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.)
officers have exercised their 10.❑ Electrical repairs or additions
3.❑1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t - empleyecs. [No workers' I}.❑Other
cutup. insurance required:) .
-Any applicant Ilut checks box nl mwt also fill out the section below showing their workers'compensaiion policy imbrtnadon.
'I L+mcuwn.-n+vho submit this of davit indicating they m doing all work and then hire outside contractors mica mhmii a new affidavit indiaring such.
:t:onrrMlela that check Ibis box most attaches!an additional sheet showing Ilan name of the sub.cantneton and Iheir workers'camp.policy information.
i unt an earpluyer that is providing workers'compmrsadan insuroncefor my employees. Below Is the policy rand fob site
information.
I nsurance Company Name: _-.,-___
Policy 4 or Self-ins. Lie. il: Expiration Date:
Job Sit:Address: City/State/Zip:
Anach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A-ot',IGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of STOP WORK ORDER and a fine
cPup to S250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Of Lice of
investigutions of the DIA for insurance coverage verification.
I do hereby certify�pl to pu Its and penaUles of perjury that the inforruatlmr provided abuve is true turd correct
Sien more Date: A .36
Phone d: �03'� _}l� -S-13 gp ---
Offirial use miry. Do not write in this area, to be completed by city or town official
CirynrTuwn: _._.-.. . .__ Permit/l.Icenseii
Issuing Authority(circle one):
1. Board of Health 2. Building Depurlimat 3.Citylruwo Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone M: _
9