2 LYNDE ST - BUILDING INSPECTION (5) AL-
Commoinvealth of Massachusetts o�
Sheet N[etal Permit
Date: 2(- 30 _6014 Permit f(
Fstimated Job Cost: s- 4000,v o Permit Fee: S
Plans Submitted: YES _ NO_ Plans Reviewed: YES NO
Business License # 56 Applicant License # — ---
Business Intbrination: Property ( cr/Job Location Information:
/'(
Name: �yu�(ti Name: A i Ll C l
Street: `Z _ LyLi � Sheet: .2 Ly(I� ta- S>
City/Town: 50.Aem City/Town:
Telephone: -9 76 576 � P S8 Telephone:
Photo I.D. required/Copy of Photo LD. attached: YES— NO_V}9 34} 2` 1 2
J-I / J4 smrr t itiamI-unrestricted license �
J-2/ M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. It./ 2-stories or less
Residential: 1-2 family_ Multi-family_ C'ondo/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:
IIVAC ✓ Metal Watershed Roofing — Kitchen Exhaust System
Metal Chimney/ Vents_ Air balancing
Provide detailed description of work to be done:
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 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 boxC].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
ProLress Inspections
Date Comments
Final inspection
p 1t� Continents
Type of License:
By ❑ Master
Title ❑ Master-Restricted
Cirpiown ❑Journeyperson
Signature of Licensee
PCeOIt x
❑Journeyperson-Restricted License Number:
real -_._ _ epp"v'l
❑ Check atInspector Signature
' CITY of SiU.E.M, NL-�sSACxt;sEz-rs
UILDNG DEPIRTME.VT
p't "1.•., 120 WASHLNGTON STREET, 3na FLOOR
T EL_ (978) 745-9595
FA-x(978) 740-9846
K.IN(BERf FF.Y DRISCOLL
�YiYOR THox SST.PIERRI3
DIRECTOR OF PI:BLIC PROPERTY/BulLONG CO\11StiSSIONER
Workers' Compensation Insurance AMdavik Builders/Contractors/Electricians/Pfumbere
Applicant Information Please Print Legibly
Nalnc (130sioeSsOrga %ln izalion;I nObvidual): 'V C /,/ Y'rl
Address: Y1 F05*eA g
City/State/Zip: _ c,Nt 14 Ua-13 ,MA,D(923 Phone tf: !! 76
Are y mre in employer? Check the appropriate box: 'type of project(required):
I. R•tj - 4. ❑ I am a general contractor and 1
employees(full and/organ-time).
+ have hired the sub-contractor 6. ❑New construction
2.d1 am a sofa 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, worker'comp, insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation mid its
required.)
officer have exercised their to.❑ Electrical repairs or additions
3.❑ I am a hmncowner 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 employees. [No workers' I3,0 Other
cu np.insurance required.] .
•Any applicant out chucks box 91 mast also GM uta the section bcluw showing their worked cumpansatiun policy noiawatiun.
'I L+muowrmn who submit this affidavit indicating ihey arc doing all work and then hire outside COmnetom mml sohmit a new affidavit indicating such.
;Cmuncruru but ch vk ibis box must enach,l un additural Awl shuwina the name of the subconlnetors and iheir wanton'comp.policy information.
1 uni an employer that is providin);workers'compensation Insurance for my emplayees. Below Is the policy and Job site
information. f 11--�
Insurance Company Name: Itt,.1.__ !ia4
Policy A or Self-ins. Lie. th S�� _ Expiration Date:__3 —2c�g - /4
Job Site Address: 2. 4t�tdLo 5v,0eAa't City/State/Zip:
Attach a copy of the workers' compensation pulley 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 S 1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form off STOP WORK ORDER and a tine
of up to$230.00 a day against the violator. 13e advised that a copy Of this statement may lxe forwarded to[hc Oflice of
f inrst igw ions of t he D IA for insurance coverage verification.
I du hdreby cerrify mtn r the pores and p/�enoldes of perjury that the h1forniallor provided,arbove ix true and correct
,�rr /.'t
Si l I c: l ,10_4 Data:
Phone
�: TCC if l SQ
Official roe only. Oa nor write in this area, to be completed by city or town officiut
Ciry or Town: _,__„ ___ Pcrmit/Llccnse N
Issuing Authority (circle one):
I. Board of llealth Z. Building Departntent .1.Citytfuwn Clerk 4. Electrical luspectur 5. Plumbing Inspector
6. Other
Contact Person: _. _, __ Phone ff:
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