59 MEMORIAL DR - BUILDING INSPECTION (3) — 1 C4 c.K 14 g y p t 6% as
Commonwealth of Massachusetts
Sheet Metal Permit
Date: U Permit#
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Estimated Job Cost: $ ��(�� _ Permit Fee: $
Plans Submitted: YES NO Plans Reviewed: YES NO
Business License # 44 01 3 Applicant License# 16,33
Business Information: Property Owner/Job Location Information:
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Name: !�{�..2gg����,p��(�(/'�/(_i�(/f�' 14(i � Name: r \
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Street:4(p/ dJ/� &n 5t --o-A3 Street:
City/Town:JD/'� Q y /�//{4 �/9�3 City/Town:
Telephone: 9"� '��J�-8�g� Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES Z NO_
Star Initial
J-1 M-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 Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft.Y— 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:
PREFERRED AIR,INC. \ 14340
City of Salem 10/29/2013
5000 Cost of Goods Sold:5011 Job'Pe 59 Memorial Drive \ 68.00
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l People's United -Optg 68.00 /
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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 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 ❑
r
Sign a a of Owner or Owner's Agent
By checking this box❑,1 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
Citylrown ❑Journeyperson
Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number:
Fee$ (� /*�) ❑
Check at www.mass.govldol
Inspector Signature of Permit Approval
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+.. AySStCHU'SE,TTS DRIVER'S
LICENSE
9 END 44 NU,MEBER Ni
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E x ROBERT V
j e 15 LESLIE RD
ROWLEY,MA 01969-2318
s � soo an�ma R..msaa
,'v..GOMMONWEALTH OF MR S CHUSETTS -e r
_. .,.BOARD•OF
SHEET„METAL WORKERS
,V ISSUES THE FOLLOWING fIfENSE 1.",_;
AS .A MASTER-UNRESTRICTED
ROBERT V SMITH a „
15 LESHE'"WD'
ROWLEY�..,MA 01969 2318'
1633 O9/28lt5 105771 .
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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: Builders/Contractors/Electricians/Plumbers
Applicant Information /' Please Print Legibly
Name (Business/Organization/Individual): J"k—:PT�{r!/� d/P— 14c,
Address: � � 3
City/State/Zip: ( % hone #: C - _-2
Are you an employer? Check the appropriate box: Type of project(required):
1.N] I am a employer with /J~ 4. ❑ I am a general contractor and I
employees(full and/or part-titre). have hired the sub-contractors 6. ❑New construction
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 Y• t 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.El 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.Ml Other I1,q comp. insurance required.]
•Any applicant that checks box#1 must also fin 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.
:Contractors 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 then 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:
olicy#or Self-ins.Lic.#: V 2� Expiration Date: 6599
Job Site Address: City/State/Zip:
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 the sins and penalties ofperjury that the information provided above is true and correct.
Si afar . Date: 104?2 0
Phone#: l)—
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#: