175 LAFAYETTE ST - BUILDING INSPECTION (4) q 14 —7 c� cosy
Commonwealth of Massachusetts
/ Sheet IA/Qetal Permit
)ate: _- 10 -ak./3 Permit it ----
Estimated Job Cost: S Y�;QM Permit Fee: $ SOO
Plans Submitted: YES NO ✓ Plans Reviewed: YES NO
Business License g Applicant License At '� (�,YX
Business Information: Property Owner/Job Location Information:
Name: A( ffat` 4 Wy Name: AL- ftgmic gwyA, 1
Street: /� 4401 Aw Street: 1 jam" l f9 Ifif
City/Town: 2106 /� (��� Cityrrown: ,r V`V MA /5IQ70
relephune: '78 6a6I Telephone:
Photo I.D. required/ Copy of Photo I.D. attached: YES_✓ NO_
Huff Initial
J-1 /(M- unrestricted license
J-2 / M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. / 3-stories or less
Residential: 1-2 family_ Multi-ramily/_ Condu/ Townhouses_ Other
Commercial: Office Retail ✓ Industrial Educational
Institutional_ Other_
Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. _ Number of Stories:
Shect metal work to he completed: New Work: Renovation:
I IVAC _i/ Metal Watershed Roofing_ Kitchen Exhaust System
Metal Chimney/ Vents ✓ Air Balancing_
Provide detailed description or work to be done:
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INSURANCE COVERAGE:
I 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 ❑ Other type of Indemnity ❑ Bond ❑
OWNER'S SURAN WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 of the
Massa use s Gene I 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
Proflress Inspections
Date Comments
Final inspection
Date Comments
Type of License:
By [Master p
rice_ ❑ Niaster-Restricted
Otyrio.vn ❑Journeyperson
Signature of Licensee
P on'tX `1V 1q
❑Journeyperson-Restricted License Number: f (7 n
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i
Inspector Signature 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: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: A lw I' M C L:W c L y
Address: b L%kl c A U,
City/State/Zip: 5 A U G-y S " .01906 phone #: ( �' I� L`✓G— 0 Z o I X 2.o L
Are yqu an employer? Check the appropriate box: Brasin!,ss Type (required):
1.Ff I am a employer with,_ SO _,employees (full and/ 5, LJ Rotail
orpartAime),* 6. ❑ Restaurant/Bar/Eating Establishment
2,❑ I am a sole proprietor or partnership and have no 7, Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity. S, ❑Non-profit
[No workers' comp, insurance required)
3,❑ We are a corporation and its officers have exercised 9, ❑ Entertainment
their right of exemption per a 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11:7 Health Care
4,❑ We are a non-profit organization, staffed by volunteers,
with no employees, [No workers' comp, insurance req.) 12,❑ Other
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1,
I am an employer that is providing,workers' compensation insurance for my employees. Below is the policy information,
Insurance Company Name: �1 A R T F Q AO O tit QL25 R W/2 LT CA S
Insurer's Address: S 0 PA OL Pr C I
City/State/Zip: (A) At 7-/-IAM IV c12 `/ S-3
Policy#or Self-ins, Lic.#6S 6 0 U 13 — 1-/ 9 S' PZ I — a- I a Expiration Date: 1 0 of 40 13
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 MOL a 152 can lead to the imposition of criminal penalties cf 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 insure cove verification
I do hereby certify, under the psi sand per aloe fperjury that the information provided above is true and correct.
Signature: Date: 141 hi / 2 u u
Phone# (+h'i) It/6 U2c1 A "Lug
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 Cleric 4,Licensing Board 5. Selectmen's Office
6, Other
Contact Person: Phone #:
www.mass.gov/dig
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LICENSE s
Rs 9a END 4E NUMBER
NONE, S50310558
415-2016 0415-19G5
v REBk -u sEx M i xDr 600
%+A ARANCIS ST
,. N GRAPTON,MA 015361219':
5 DO 01-00,0011 WV Ur-13100B
-COMMONWEALTH OF MASSACHUSETTS
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