182 NORTH ST - BUILDING INSPECTION (4) e
Commonwealth of Massachusetts , F333-3
Sheet Metal Permit
Date: �` � za %
Permit #
Estimated Job Cost: $ is 00 f Permit Fee: S
Plans Submitted: YES NO Plans Reviewed: YES NO
I
J) Business License # Applicant License # I yLI
I Business Information: i Property Owner/ Job Location Information:
A Name: P�jjy S,IyS Name: Aj<2 �JPG14.E ^
1r Street: 2 ��'1c1 �2y �� Street: S
City/Town: Y S ati City/Town: Sti C o
Telephone: y�� S�4 `Z''�y1 Telephone: 7$ — SyGt" if
Photo I.D. required/ Copy of Photo I.D. attached: YES NO—
S I a rr(Ilifial
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. ✓ over 10,000 sq. ft. — Number of Stories:
Shect metal work to be completed: New Work: Renovation:
I fVAC _AZ Metal Watershed Rooting Kitchen Exhaust System—
Metal Chimney/ Vents_ Air Balancing
Provide detailed description of 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 Q No ❑ _
If you have checked Yes, indicate the type of coverage by checking the appropriate box below:
A liability insurance policy 2 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
20/
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
Progress Inspections
Date Comments
Final Inspection
Date Continents
Type of License:
By ❑ Master
Title ❑ Master-Restricted
City/Town Journeyperson
Signature of Licensee
Permit# ) ' ` / /
❑Journeyperson-Restricted license Number: I —(t' 4'
Fee S ❑ �
Check at,.vww.tnass,govldpl
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Inspector Signature of Permit Approval
The Commonwealth ofMffssachuseur
Department ofladushWAccidents
I Congress Siree;Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITS TEE PERhUrnNG AUTHORrry.
Applicant Information PleuePrint Leeibly
Name(BusineWOfganizationRndividual): 3 Ws
Address: Z D&, J t S 1—
City/State/Zip: ¢, l�or�� ,/4'j4 0/4ba Phone#:
Ewbaw
an employer[Cherk the appropriate box:
Type of project(required):
m a employer with employees(roll aod/orpsrt-time).•
7. New construction
m a sole proprietor or paMenhip a�have nomtpMyeesworlringformein r..f____y capacity.(No workers'cam g. Ll femouel'p krsumnce required]m a homeowner doing all work myself.1No workers'comp,iusumnca required.]t 9. ❑Demolition a homeowner and wrL he hiring contractors to cnduct all work ors my property. 1will10 O Building addition
ure that all contractors either have workers•compensation msurmce or are sole10 0 Electrical repHlTs Or additionspmarors wit11 n0 employees. 12. Plumbing repairs or additions a geoeal connector end I have himd the sub-coin.actors listed on the attached sheet.
e subcontractors have employees end have workers'comp,ins macs 13.0 Roof repairsere a corporation and its o%cars have exercised the rright of exemption per MGL c. 14.0 Other§1(4),slid we bare no employees.lNo workers'comp.mementos required.]
-Any applicant thin checks box Nl must also fill out the section below showing their workers'compsasatim policy ioformetiou.
1 Homrowners who submit this affidavit indicating they are doing an work end then him outside couuacmrs must submit a new affidavit indicating such.
lContrecton that check this box must studied an additional sheet showing the name of the orb-contractors and state whether or not those entities have
employees. If the subcontractors here employees,they must provide they workers'comp policy numbber.
I am an employer,that is providing workers'compensation tnsurancefar my employees. Below is the policy and job site
Information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: Cih,/Statelzip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required order 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 cent f u r thepams and penalties ofperquly that the information provided above is true and correct
Suture- -7 Date -_7
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permrt/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone M
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomtance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their ceutificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line. _
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02 1 14-20 1 7
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax At 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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CITY OF SALEM
DEPARTMENTAL INVOICE FOR CASH PAYMENT
Please Remit to Treasurer's Office, 2nd Floor, 120 Washington St., Salem
Department:
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Date: tJL] —I� D l5 lJ 15 U
JUL 0 6 2016 D
Individual/Company Name: r/ LV� s tL-V F By
Payment For:
514 • $ a D
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Cash Invoice Total: §
Other Information:
'if needed)
)epartmental Signature:
reasurer's Office:
Date Received: �— I
Signature: