20 NORTHEND AVE - BUILDING INSPECTION (3) Commonwealth of Massachusetts $(Pl t5° #3-7 (oo�-
Sheet Metal Permit
Date: 7/11/16 Permit#
MEstimated Job Cost: $8,000.00 Permit Fee: $
60 Plans Submitted: YES ❑ NO ❑✓ Plans Reviewed: YES ❑ NO Z
52 469
Business License# Applicant License#
Business Information: Property Owner/Job Location Information:
Central Cooling and Heating, Inc. Bert Philip
.� Name: Name:
Street: 9 North Maple St. Street: 20 Northend Ave. #2
Woburn, MA 01801 Salem, MA 01970 ;
City/Town: City/Town: ` ca
(781) 933-8288 (617) 921-2471co
MT
Telephone: Telephone: Iv
Photo I.D. required/ Copy of Photo I.D. attached: YES X NO "p r
Staff Initial _
J-1 einrestricted license
Z. to
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 00 Multi-family Condo /Townhouses Q Other
Commercial: Office_a Retail _a Industrial Educational
Institutional Q Other
Square Footage: under 10,000 sq. ft. 00 over 10,000 sq. ft. D_ Number of Stories: 3
Sheet metal work to be completed: New Work: n Renovation: n
HVAC Q Metal Watershed Roofing❑ Kitchen Exhaust System El
Metal Chimney/Vents n Air Balancing f3
Provide detailed description of work to be done:
Installation of a new ductless Mitsubishi heat pump. There will be one outdoor heat pump
installed on the left side of the house. Two wall hung fan coil units installed inside. One in
the dining room on the first floor. The other will be installed in a second floor bedroom above
the dining room.
rnraI L--f-;ro -t`a or c- � H '2-
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 bdxE,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,W my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be
in compliance witli all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
m Duct inspection required prior to insulation installation: YES NO
Progress Inspections
Date_, Comments
Final Inspection
Date Comments
Type of License:
r
By m Master
Title
❑ Master-Restricted
City/Town ❑Joumeyperson
Signature of Licensee
Permit#
(]Joumeyperson-Restricted License Number: fig
Fee$ El Check at www.mass.gov/dul
Inspector Signature of Permit Approval
a
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Off ice of Investigations
l Congress Street, Suite 100
Boston, MA 02114 2017
www massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Central Cooling and Heating, Inc.
Address:9 North Maple St.
City/State/Zip:Wobum, MA 01801 Phone#:(781)933-8288
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with 70 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. employees and have workers' 9. El Building addition
[No workers' comp. insurance comp• msurance.t
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.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.o f repairs
insurance required.]t c. 152, §1(4),and we have no 13. er
employees. [No workers'
comp. insurance,,required.]. . .-
*Any applicant that checks box#1 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.
tContmctors that check this box must attached an additional sheet showing the time of the sub-contrectors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide their workers'comp policy number.
I am an empjoyer that is providing workers'compensation Insurance for my employees. Below is the polley and job stu
informadon.
Insurance Company Name:Arbella Indemnity Insurance Company
Policy#or Self-ins. Lic.#:0048681113 Expiration Date: 1 W012016
nn �p 2 1 n` � C Icri
i tT �A Ci /State/Zi : t�'1
Job Site Address: sF tY P
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, .00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to$25 .00 day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigatiofts of the DIA for'nsuran5f c erage verification.
I do hereby certi der th pains d e allies f rjury that the information provided a v is true and correct.
Si afore: t Date-
phone
Phone#: 7 1 9338288
OJficial use only. Do not write in this area,to be completed by city or town official.
City or Town Permit/License #
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
(r! LICENSE
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gC9OMMONW OF MAS$ACHI�SETTS
• • • • • , I
BOARD OF
'
SHEET METAL WORKERS'
ISSUES,THE FOLLOWING,LICENSE AS A 1
I MASTER-UNRE$TRICTED' �
OOUGLAS A HAMILTON
..• ..y�
: CENTRAL C,OOLItilS&HEAT
9 NORT?i MAPLE STREET' " i
WO5URN,MA 01801 17t-1
V 469 12128/2017 8377
tCOMMONWEALTH OF MASSACHUSE7TS
• • • • MO
.
SHEET METAL WORKERS,
ISSUES 'THE FOLLOW' 6 LICENS
AS A 811S1NES5
DOU'LAS A HAMI:LTON
' CENTRAI,.',C0€iL t:NG AND HEATING INC _
9 N MAPLE ST.
�.
WOBURN " MA 01801