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59 MEMORIAL DR - BUILDING INSPECTION (2) Commonwealth of Massachusetts l" Sheet Metal Permit �- Date: Permit# Estimated Job Cost: $ Permit Fee: $ Plans Submitted: YES NO_ Plans Reviewed: YES_2 NO i Business License Applicant License Business Information: Property Owner/Job Location Information: Name: //Q�JL�Q/�QQ� /{��/f J G Name: Street: l 6/��/�� Street: S�,s��j p City Town: /���/ N/�6/ 03 C;ty Tawn: ��� Telephone: 7 Telephone: 7- Ai3-�/,F Photo I.D.required/Coy of Photo I.D. attached: YES_ NO_ Staff Initial J-1 / -1-unrestricted licen 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. X over 10,000 sq. ft._ Number of Stories: Sheet metal work to be completed: New Work:_ Renovation: _ HVAC Metal Watershed Roofing_ Kitchen Exhaust System_ Metal Chimney/Vents_ Air Balancing— Provide detailed description of work to be done: l/�7/S�G✓ l� 1'I Pl�� G/�/,1C�� I/1��� f717e �J gt,L 9tL2a� �P",t-)E()-i-0 G � t INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes�r No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy P� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:lam 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 XW Agent ❑ Signature of Owner or Owners 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 f 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 '0 Master Title ❑Master-Restricted - CityfTown ❑Journeyperson Signature of Licensee Permit# ❑Joumeyperson-Restricted / z Lic rise Number Fee$ : Check at www.mass.gov/dpi Inspector Signature of Permit Approval &,atgr OMMONWEALTH OF M/ASSACHU'S —S jy: OAR QF SHEET➢ifETAL WORKERS a z y �; iSS�UES,TF4E FOLLOWING LICt=NSE ASS Az as o„E BS1StNESS ���1iDMRS FAVAZZA -+ •'�'"� ,� '` "PREFERREUAfRiNC 467 BOSS'©N STREEV x s _ ?i�-py �•a���s, �o :NOA3:,. � TOkOIELp MA Q1983 493 ��-�` O1(2412018 „ 12399 ,« f n; l The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia U�vWorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Preferred Air Inc Address: 461 Boston St#A3 City/State/Zip: Topsfield MA 01983 Phone#:978-750-8282 Are you an employer?Check the appropriate box: Type of project(required): I.Q l am a employer with 22 employees(full and/or part-time).• 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working.For me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[:]Plumbing repairs or additions 5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 14.❑✓ Other HVAC 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] "Any applicant that checks box isI 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 must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name ofthe 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. Insurance Company Name: Arbella Policy#or Self-ins.Lic.#:422005661401 Expiration Date:08/01/17 Job Site Address: 59 Memorial Dr City/State/Zip:Salem MA 01970 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif under the pains an enalties of perjury that the information provided above is//true and correct. Si natur 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#: