135 LAFAYETTE ST - BUILDING INSPECTION (6) Commonwealth of Massachusetts G�c SS-0
4?zO
t Sheet Metal Permit
RECEIVED
Date: qk I INSPEE0WAt SERV1 E ES
Estimated Job Cost: $ ZCI OO b Zoff C �T: 'A�T: ,
Plans Submitted: YES ✓ NO Plans Reviewed: YES NO
A� Business License# V2_7 Applicant License # 370
W Business Information: Property Owner/Job Location Information:
1 11
Name: 410f+�ecSfi t'Ier�4NICA' ��� jojSName: J%-n vt sI[ 'T-Ol-th S
Street: l l Lpwl Wl 2r c C Rog Street: t35 C -I Fe-) -� S>+re et
City/Town: Sk(e%-dsbvr-/ City/Town: Sti1Cr"1 ✓1'1 A
Telephone: Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES v1 NO_
Staff Initial
J-1 / -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 V 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: 1/
HVAC Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney/Vents Air Balancing f
Provide detailed description of work to be done: '"
Forvi�6U, h,4 A Z n5 �n 1\ `"is Verb + di FF-.4 P t-S
1'tW+L� 01
INSURANCE COVERAGE:
1 have a current liability insurance policy or its equivalent which meets 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:
A liability insurance policy d 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 ❑ 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(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
Progress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By ['Master
Title
❑ Master-Restricted
Cityrrown
❑Joumeyperson Sign lure of Licensee
Permit#
❑Joumeyperson-Restricted License Number: 372-7
Fee$ ❑
Check at www.mass.nov/dpl
Inspector Signature of Permit Approval
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information t /1� / Please Print Legibly
Name(Business/Organiza A tion/Individual): nirt e"-, I1 MC.cLtcti
Address: Lj"pi er-Ce F:lmtK
City/State/Zip: Phone#:
A ou an employer?Check thgappropr ate box: Type of project(required):
1.7I am a employer with L_. 4. I am a general contractor and I 6. New construction
employees(full and/or part-time)." 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 g. Demolition
workingfor me in an capacity. employees and have workers'
Y P tY• 9. Building addition
[No workers' comp. insurance comp.insurance.%
required.] 5. We are a corporation and its 10. Electrical repairs or additions
3. 1 am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Roof repairs
insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.%/Other +J A C
comp. insurance required.]
*Airy applicant that checks box N i must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that Is providing workers'compensation Insurance for my employees. Below Is the policy and Job site
information. ^ l L 1
Insurance Company Name: 1 q r rT %C CAI Ci e�
Policy#or Self-ins.Lic.#: 0 C A w5-I I ®'O l//0 Expiration Date: /d I (o
Job Site Address: l3S_ � nife—)* St(—ee�- City/State/Zip: l�
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 Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under fire pains and penalties of perjury that the Information provided above Is true and correct.
Siynature l �t.'t -- - Date-
Phone#:
Official use only. Do not write In this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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