Loading...
13 OLDE VILLAGE DR - BUILDING INSPECTION f Commonwealth of Massachusetts -7 Sheet Metal Permit Date: 12/19/16 Permit# � Estimated Job Cost: S •" rO t SM.00 Permit Fee. $ 54 0 0 Plans Submitted: YES ❑ NO ❑✓ Plans Reviewed: YES ❑ NO❑✓ f (� Business License# 52 Applicant License# 469 f 111 Business Information: Property Owner/Job Location Information: ``— Name:Name: Central Cooling and Heating,Inc. Thomas Stanga 9 North Maple St. 13 Olde Village Dr. Street: Street: a Woburn, MA 01801 Salem,MA 01970 r" City/Town: City/Town: e' 4 (781) 933-8288 (978) 745-2738 Telephone: Telephone: ; Photo I.D. required/Copy of Photo I.D. attached: YES X NO Staff Initial (_n J-1 Ounrestricted license Cr 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_a Other Commercial: Office 0— Retail n Industrial n Educational Oi Institutional n Other ja Square Footage: under 10,000 sq. ft. no over 10,000 sq. ft. _a Number of Stories: 2 Sheet metal work to be completed: New Work: n Renovation: ✓n HVAC i v l Metal Watershed Roofing El Kitchen Exhaust System n Metal Chimney/Vents n Air Balancing Li Provide detailed description of work to be done: Replace existing Fan Coil Unit (FCU) and heat pump. We are going to be reconnecting to the P g P p g g g existing duct distribution system. �l Yn i LPL /a i5 /q � 4 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 thWboxiiiii,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to thebest 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 Il NO Z 7, Progress Inspections Date Comments Final Inspection Date Comments Type of License: BY m Master Title ❑Master-Restricted City/Town ❑Joumeyperson Signature of Licensee Permit# - 'Kell Keyperson-Restricted License Number: `t(0l Fee$ ❑ Check at www.mass.govldpl e�f AI Inspector Signature of Permit Approval z ' 9anm. RY' � JfJf s70llkRt:1'St N'ANbDVER.MA 018dS3351 �i �- M n:. 60p MIT."URw01.iSAy9 i, ��'� k } ro Ilyl9NVIIF.ALTW F'Nk� USET.TaS. _ SHEET`1VEETAL'`N/ORK1S'R5�r � AS SUES WE-FOLLO-WNG'L'IOENSt AS A_ f , DOUGLAS A HAMILTON` OENfELf�{GR �UNG 8 'EAT Ojw 8 NORT# 10A7•}E'S7FjEET . WOl3URN,MA''0180f4l-lt 483 1,1J2812q.7 8377 xh�OliIIMONNfEi4LTH OFrM bMU;s R - �; '"�_..SHEET fnIETAL iNQRKERB i <ISSUES. F©©ILOWING-.LICENSE,ASA } w. 1 CENTRAL`COOUM�O AND HEATING INC9 x 9 NORTNelAA'Pt BUR al 52 0013012018 1143 •=s.. 'S h2 ; The Commonwealth of Massachusetts Department of lndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 0211 4-2 01 7 www.massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organimtion/Individuaq: Central Cooling and Heating, Inc. Address:9 North Maple St. City/State/Zip:Woburn, MA 01801 Phone#:(781)933-8288 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 75 4. ❑ I am a general contractor and I l employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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' [No workers' comp. insurance comp. insurance.: 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]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 HVAC employees. [No workers' 13.❑■ Other comp. insurance required.] *My 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 contactors must submit a new affidavit indicating such. tContractors 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:Arbella Indeminty Insurance Company Policy#or Self-ins. Lic. #:0048681113 Expiration Date:11/30/17 Job Site Address: 13 Olde Village Dr. City/State/Zip:Salem, MA 01970 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 ce i nder Al pa and lties ofperjury that the information provided above is true and correct Si nature: Date: 712/19/16 Phone#.- 781 9338288 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#: 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"...eve person in the service of another under an contract of hire "...every P Y , 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 subdivisiong.shalll-- 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 sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASS_AFE Revised 7-2013 Fax # 617-727-7749 www.mass.gov/dia