76 LAFAYETTE ST - BUILDING INSPECTION (6) Commonwealth of Massachusetts
Sheet Metal Permit
Date: lo Permit#
Estimated Job Cost: $ 1W - ao Permit Fee: $
Plans Submitted: YES_ NO 1/ Plans Reviewed: YES NO
Business License Applicant License # /y/V
Business Information: Property Owner/Job Location Information:
Name: Ar[cn a- Sukj'iy4n M Name: 'F�C (T
Street: I Hec4Iy caur-IF Street: � G 5Ntrcf -
City/Town: eO A 0,15k S City/Town: C CAe" M ,}1
Telephone: 998- 7(07-8Y 9 7 Telephone: (a/7-
Photo I.D. required/Copy of Photo I.D. attached: YES_Z NO_
Staff Initial
J-1 /M-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 Condo/Townhouses Other
Commercial: Office ✓ Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. _ over 10,000 sq. ft._ Number of Stories:
Sheet metal work to be completed: New Work: Renovation: V'�
HVAC Metal Watershed Roofing_ Kitchen Exhaust System
Metal Chimney/Vents_ Air Balancing
Provide detailed description of work to be done:
e„ ae,�,. 5V
�. nU�) Czct :i(r "18o" V1,T l Paruj Vn�k _
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes Lq No ❑
If you have checked Yes,indicate tthhg type of coverage by checking the appropriate box below:
A liability insurance policy L� 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 Ey 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 for 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 of License:
BY Master
Title ❑ Master-Restricted l
ui
CityfTown
❑Journeyperson Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number:
Fee$ ❑
Check at www.mass.gov/dpl
Inspector Signal re of Permit Approval
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
/ Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders'/Contractors/Electricians/Plumbers
Applicant Information Please Printrl e�ibly
Nance(BusinesslOrganizationMdividual):.19-00s;V
Address: — f �;
City/State/Zio: b4MQZN 1n4 019013 Phone#: 97F-777!11Y
Are you an employer?Check the appropriate box: Type of project(required):
1.®I am a employer with yP 4.❑I am a general contractor and I T6. ❑New jestcon (required):
ction
employees(full and/or part-tithe).* have hired the sub-contractors
2.❑I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any'capacity. employees and have'workers' 9. ❑Building addition
[No workers'compo insurance compo insurance.t
required.]. 5.❑.We are a corporation and its 10.❑ Electrical repairs or additions
3.❑I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs cr additions
myself."[No workers'compo right of exemption per MGL C. 12.❑Roofrepairs
insurance required.) or I have hued 152,§1(4),and we have no 13.❑Other
the contractor listed on the attached employees.[No workers' —
sheet comoo insurance required 1
`Any applica:d that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowner;who submit this affidavit indicating they arp doing all work and then him outside contractors must submit anew affidavit indicating such.
iContmetors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. .
If the subcontractors have employees,they must provide their workers'compo policy number. "
f ant an:employer that is providing workers'compensation insurance for my employees.Below is the policy and job site
information .
Insurance Company Name: T/1gYF1, "Q 0-1,e ;/zin-2Q, Gen,.
l
Policy#or Self-ins.Lie: /A n-6-:2 M 9963-v^ T, 'I l Expiration Date:4 b' 2,
Job Site Address: h(p�¢q \l.$ Le� `t� i �_Clty/State/Zip: Ch19�a
Attach 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 of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$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$250.00 a day against the
violator.Be advised that a copy of this statement may be forwarded to the Offioe of Investigations of the DIA for insurance coverage
veriticatiot.
1 do hereby--:ertifY under the pains and penalties ofperfury that the information provided above is true and correct.
Signature: Date: ��ql/Z
Phoi:e: _Y74
COMMONWEALTH OF MASSACHUSETTS
`S:HEET METAL WORKERS!
A$ AMASTER-UNRESTRICTED
ISSUES THEABOVE-LICENSE i6i
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