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90 NORTH ST - BUILDING INSPECTION (2) �� .�a � � v�\�� Commonwealth of Massachusetts �� /� ��� Sheet Metal Permit � <� `J Date: , / � Permit# , ��. rO- � Estimated Job Cost: $ /t�, u�t� Permit Fee: $ � -1 p Pians Submitted: YES NO Plans Reviewed: YES NO Business License# `��(� Applicant License# �j / Business lnformation: Property Owner/Job Location Information: ,/ /�iL / -, Name:�j�-���r�c�`��fl<+ICn� Name: . JC c= 9 ; Street: � /Jc-f�v�2a� lY�c #'?S Street: �Q � ��j CitylTown: �-�,d5G1� � CitylTown: .��-J�iv� Telephone: f 7� ^ ,«� - 7<;s� Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES_ NO_ smrt�oine� J-1 M-1 nrestricted license J-2 /M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. R./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. C/,over 10,000 sq. ft._ 1Vumber of Stories: Sheet metal work to be completed: New Work:_ Renovation: L_� HVAC L/ Metal Watershed Roofing_ Kitchen Exhaust System_ Metal Chimney/Vents_ Air Balancing_ Provide detailed descnption o work to be done: _����'��(�`l� i Ltvii� �� c-� C`�C�i� �i�J�j � {7 c2�c� , oti- l��rc,�2t c�u�> n(1�tL�,-p I(7t �(o INSURANCE COVERAGE: I have a current Iiabili insurence policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yese�"No� If you have checked Yes•indicate the type of coverage by checking the appropriate box below: A liability insurance policy �" Othertype of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the Iicensee dces not have the insurance coverage required by Chapter 112 of the Massachusetts Generel Lauvs,and that my signature on this permit applicaUon waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box0,I hereby certiry that all of fhe defails 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 Installatfons performed under the permit issued for this application will be in eompliance wi[h all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation insWllation: YES_NO_ PrOEress Inspections Date CommenYs Finai Insoection ��i, Date Comments Type of License: ey ❑ Master -_--G���L �� Title � ��. . � �s,� ❑ Master-Restricted City/Town �Journeyperson r ignatur of Licensee Permit# ^� /� ❑Journeyperson-Restricted License Number. X� / Fee S � � ��„ A Checkatwww.mass.taov/dal ���/ Inspector SignaW re of Permit Approval ,�+�� The Commonwealth ofMassachusetts Print Form �=-\ Department of Industrial Accidents Office ofinvestigations '� � 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Aftidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLiblv Name(susinessiorganization/[ndi�iduap: Atlantic Refrigeration of Hudson, Inc Address:9 Bonazzoli Ave#25 City/State/Zip:Hudson, MA 01749 Phone #:978-562-7552 Are ou an employer? Check the appropriate box: Type of project(required): 1. I am a employer with �0 4. � I am a general contractor and I 6. ❑ New conshuction 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. Q✓ Remodeling ship and have no employees These sub-contractors have g. � Demolition working for me in any capaciTy. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance wmp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.0 Plumbing repairs or additions mysel£ [No workers' comp. right of exemption per MGL �Z.Q Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *My applicant that checks box#7 must also fill out the sec[ion below showing their workers'compensatioo policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new�davit indicating such. xContractors 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. Insurance Company Name:Aon Risk ServiCes, Inc of Florida Policy#or Self-ins. Lic.#:WC094184459 Expiration Date:��20/16 Job Site Address:90 North St Ciry/State/Zip:Salem Attach a copy of the workers' compensallon policy declaration page(showing t6e policy num6er aud expiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to$I,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert�under the pains and penalties ofperjury that the information provided above is due and correct. Signature: Date: Phone#:978'562--7552 O,fj"uial use onty. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: www�w u� maaaa:��ua�1i5 � CommonweaRh of M�sachusetts r,� vV DeoartmeM of Public Safety � � �...�^sc: P�!-(...'^`,�,',..�..'�:; � - �Par.rrxrd oi Pubii�Safieiy :^� n2iiivePuiiuTi i..ii.idC:L.T ��� Pipefitter MasteCt'�1-1G,�I�4YV�`;r � License: RC-01g585 � .�w c F i t\ aJ.,:,�~q.. ' MICHAEL J MA§ �: = V . MICHAEL J MA �``~ ,�'��� "°� YL MCNER CIR � 21 MCNEII.CII�� � " iiopwinion'mia vi�' � . 4 d ; -�.���, ` Hoplantoe MA @1748�, .�J"K}'f� - �:,v�� �����sr � ; ��� _ ✓� �/2.9 Expiration: �.�.� Jll �iSl�..iri•i�� •• Commissione� �3@077 Commissioner �P�retion: O6/03/2017 ' .,.,- ,,.,.. . � .COMMONWEALTH OF fVIAS5�4GHUSETTS• <">° e'•;�OiMMONWEALTH OF MASSAGHUSEYFS. - +: e s s • e a s o o ' • s ' ` `. .60ARD OF .' � BOARQ OF ,. • SHEEiN1ETALWORKERS -': SHEET METAL WQRK�RS `� , ISSUESTHEfOLLOWINGCICfPdSEASA `� , ISSUES THE POLLOWING` LICENSE: � � ; BUSINESSs" AS A MASTER—UNR'ESTRICTED , � ., � �� MICFlAEL J MAGUIRE "� �� � �a� � � . 'a � r18tt'tAEL J MA6UIRE '' ��ATL4t3TIC REFPoGERATION OF HUDSON INC ��- � �� m?�- 9 60NA72011,AVENUE „r �� ZZ MCNE#L CR \� HUDSON MA 01749 ;.. - -� -�� „ � .�.�. � �' � _� ' .: ` ��� 430 �"7•,•�"" �.,, ~ �.,a...�=-bHF3(.lNTl?��-.. �4-3.?�b-$=�35s .M- ���.. • - � ., _ . � � .�.. _ .� +G��ia4-. ��#Z�l'e�- 7§3:F^� \ +__• ar- -�.. r.:�._ _-v.�...`..�_=a--o..._. :., :;. - . �. . .�. , _ . . s�e ' �` �� i:i GENERAL NOTES: � ■� � � I 0. CONTPAGiOP55HRLLSIlPRYB�COPIESOF3XOP�FAWINOSTOPPOJECTMMUOEq660THNT�IIALrtVOFCdIRVNCTOR6VPPlIF11E0URMENT.FlATUPE& YK� MVl1ANCES,RNo WTEq�A15(pN gE qEViEWED PFIOP TOINSTNIATION.COMMCTOH PNO VEND�R MEqUNICf�L DPAWPl�65H/•LL WC11AE: 1.PiPNNEW.5ECT1011S,AxDlEVAIqNSOFA00fifONA1.MEtiUNICAL5V5iEM5,Eq1RNEM.FIXNFES,ANDMGtY�NCFS. R.APPIMdBLECODESPoflwSTAlIAM#l. 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