0092 LAFAYETTE STREET - BPA 13-488 Commonwealth of Massachusetts
Sheet iNletal Permit
Permit
Fslimated Job Cost: .$ Permit Fee: =%r
Plans Submitted: YES NO ✓ flans Reviewed: YES NO
Business License ;�wPfef TOWN
_ Applicant License kf
Business Inti,rmation: Property Owner/Job Location Infirmmation:
Name: Name: �r.✓� t%'��aG`
Strcct: Street:
City/Town: City/Town: ,elect
1 q
t l Telephone: ��/ '77� 71e'� /7 Telephone: r 7'17- 1-ze3�
Photo I.D. required/Copy of Photo I.D. attached: YES_ NO
s„rr i�dn:d
J-1 /,restricted license
J-2 / M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. 11. / 2-stories or less
Residential: 1-2 family_ Nfulti-t'muily_ Condo/ "Townhouses Other
Commercial: Office_ Retail _ fndustrial _ Educational
Institutional Other
Square Footage: under 10.000 sq. ft. y over 10,000 sq. tt. _ Number ot'Stories:
Shect metal work to he completed: New Work: Renovation:
I IVAC — Metal Watershed Routing_ Kitchen EXh:m5t System _
Metal Chimney / Vents_ Air Balancing
Provide detailed description of work to be done:
INSURANCE COVERAGE:
I have a current liabilityinsurance policy or its equivalent which rneets 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 ❑
A liability Insurance policy L�J 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 Owner's Agent '
By chocking this box0.I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and
Inc
compliance with allf pMy knowledge and that ertinent provision of the all shoot metal work and Installations perfored under the
Building Code and Chapter 112 o!he General nit issued for this application w111 6e
Laws
Duct Inspection required prior to Insulation Installation: YES_ NO
Provress Inspections
Date Comments
Finallnspection
Date Continents
Type of License:
By ❑ Waster
reie _ ❑ Waster-Restricted
i
Cilyra:•:n -- ❑Journeyperson Signature of Licensee
I
Period z ❑Journeyperson-Restricted
License Number: I
FoaS ------ - '----- - -- ❑ _
---- -------- Check at .•r,i•v �n.ts::..lovhlLl
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In spc't r ,proval ,