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190 OCEAN AVE W - BUILDING INSPECTION (3) Commonwealth of Massachusetts UK Sheet Metal Permt� ," #AlrtW°;ls lV Date: 1O 25 1c, tQ(bP, pit r � Permit Fee: $ y �'Estimated Job Cost: $ Gv. Plans Submitted: YES NO Plans Reviewed: YES NO Business License# Applicant License# 3138 1 Business Information: Property Owner/Job Location Information: 61 Name: M.fit[apiyssa f4)(AC, Name: (130 OCQ I`n A"�Y'Z WeS. — Street: Z£3 DALr- ST Street: ?PT T&, SCrD City/Town: , NAA City/Town: SPinrn F MA Telephone: Telephone: 7B I — '6`( (- 9-7&1 Photo I.D. required./Copy of Photo I.D. attached: YES NO Staff Initial J /M-1-unrestricte�Iicense 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: u 0 000 sq. ft. 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: = new has -1�aNr�4. InC,0c4. r\` GAVCA-yC, q*- At CSr+s IGr1c -}a (x C(bl.jt, L:p% 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 YYM,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 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 Comments Type of License: By ❑ Master Title El Master-Restricted City/rown ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: 3 (3 S Fee$ ❑ Check at www.mass.gov/di2l QU Inspector Signature of Permit Approval :a The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: .lbr-l,Loqussa NA G Address: 78 City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail part-time).* 6. ❑Restaurant/Bar/EatingEstablishment 2. I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales line].real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers'comp. insurance required]* 11.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp. insurance req.] 12.0 Other *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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 cjlrtify,.under the ff* s and penalties ofperjury that the information provided above is true and correct. Signal re: Date: to Is 1 11 L, 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.Cityrrown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other r Contact Person: Phone#: www.mass.gov/dia 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 performance 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 your insurance company's name,address and phone number along with a certificate 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). 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAF) Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-I5 11/2/2016 _ Mass.gov Ucensing and Permitting Portal , State Offices&Courts State A-Z Topics State Forms Accessibility FACls s, An Official website of the Commonwealth of Massachusetts x �n eLicensing and ePermitting Portal �R Announcements Register for an Account Login Need Help? For technical assistance in using this web application,please call the ePLACE Help Desk 3138 e - Team at(844)733-7522(@ or(844)73-ePLAC between the hours of 7:30 AM-5:00 PM Monday-Friday, with the exception of all Commonwealth and Federally observed holidays. If you prefer,you can also e- mail us at ePLACE helpdesk cDstate.ma.us. For assistance with non-technical, please contact the issuing Agency directly using the links below. Contact Alcoholic Beverages Control Commission Contact Division of Capital Asset Management and Maintenance Contact Division of Professional Licensure Translation Information-Click Here Document Attachment: In order to upload required documents, this system requires Microsoft Silverlight which can be downloaded for free here. Convenience Fee: Please note there may be a convenience fee for all online credit card transactions. There is no fee for online payment by check. Home Manage Licenses, Permits& Certificates File & Track Complaints Please refer to the Licensing Entity's website for additional information regarding the status and discipline information shown below. For DPL information,please visit the DPL website. For ABCC information, please visit the ABCC website. Information Pertaining To: Sheet Metal Master 3138 Licensee Detail License Number: 3138 Licensing Entity: Board of Examiners of Sheet Metal Workers License Type: Sheet Metal Master Tvoe Class: M1 https://elicensing.state.ma.us/CitizenAccess/ SearchaLicense.htm 1/2 11/2/2016 Mass.gov Licensing and Permitting Portal , License Issue Date: 09/10/2010 License Expiration Date: 08/28/2018 Status: Current Current Discipline: Other Discipline: Name: MARK A DELLARUSSO Business Name: DBA Name: ©2015 Commonwealth of Massachusetts. Mass.Gov®Site Policies Mass.Gove is a registered service mark of the Commonwealth of Massachusetts. https://elicensirg.state.ma.us/CitizenAccess/ SearchaUcense.htm 2/2