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50C PICKMAN RD - BUILDING INSPECTION Commonwealth of Massachusetts 111 Sheet Metal Permit 'r �1t^ScRYtf Date: 1 69 Pe1,,,lpy� AUG - 1 A II 13 �1 o Estimated Job Cost $ Ste© Permit Fee: $ Plans Submitted: YES NO Plans Reviewed: YES NO c(14 Business License #W 7 Applicant License # [ a 3 I l\ J Business Information: Property Owner/Job Location Information: Name: P40 ®JNp P� Unf ptNc��ea`,x,Name: �/_ C�C��3h /l tJl�h� l�l Street: 93 MAI" :S i II Street: rtC-l< AA jj P-A r d C City/Town: ��C�ly _ N f 1. (53�-G'City/Town: Jf\ (ery\ m n , Telephone: Telephone: 7?I- 5 r-�^ �7 F 3 I Photo I.D. required / Copy of Photo I.D. attached: YES NO t 13 (o J J-1 / NI- -unrestricted license s„rfoilti:n� ` �2L�1�1 J-2 / NI-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: HVACz)L Metal Watershed Roofing_ Kitchen Exhaust System_ Metal Chimney/ Vents_ Air Balancing Provide detailed description of work to be done: n fiC.tty r� PN v M C0?o �eNse- C A f e( 2,2n1oS�ir� INSURANCE COVERAGE: 7 I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes 9 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 Massac efts General Law nd tha y signature on this permit application waives this requirement. l Check One Only Owner ❑ Agent A 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 Prot3ress Inspections Date Continents Final Inspection Date Comments Type of License: By [ Master Title ❑ Master-Restricted City/Town ❑Journeyperson r 1 G 0 Signatureure of Licensee Pennit# ' `�_ 1(�y _ ❑Journeyperson-Restricted License Number: ` Fee S 6 ❑ l Check at www.mass.gov/dpl � L Inspector Signaturo of Permit Approval The Commonwealth of Massachusetts Department of Industrial Accidents Wrkers' 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): u NPJ VtL OT/ti Address: �/V� 1 I� S�1 a City/State/Zip: 1At�o W N� CJ3 r(c i Phone #: CO 3 1 � ' a� Q Are you an employer?Check the appropriate box: Type of project(required): IA I am a employer with _employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] t 9. ❑ Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.] 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my properly. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.= (� 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.00ther � 152,§1(4),and we have no 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. 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 i he policy and job site information. �/ l Insurance Company Name: E r k S k [ (GZ t- R A� R"s R G(J Icir- Policy#or Self-ins..Lic.#: R W C G G FS0C2, Expiration Date: <q a (� 6 Job Site Address: CK MRh) 5'8 C. City/State/Zip:SAlem MA, Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 ce I under th p ins nd penalties ofperjury that the information provided bo a . true and correct. Si ature: t� '7,. '-7 Date: ( t Phone#, co �j` 1 Lf — G / Ctse GO3-91Ll DLG ( O O IC'- 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"...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 withbold the issuance or renewal of a license or permit to operate abusiness 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 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 permitAicense 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-NIASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia QTYOFSMXA MASSWASETP, BLUZMDBer 120 WA9JNG CKS7Rtfr YDRoxBt 7�.(�78)745.9595. • $IImERLEYDIRLS<XXZ Fax 7449846 MAYQB 71ica�usS7.P Construction Debris Disposa/Affidavit (required for all demolition and.renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL M,S 54; Building Permit 8is Issued with the condition that the debris resulting from this work shall be disposed of in a properly ikensed waste deposit facility as defined by MGL c 111,S 150A, The debris will be transported by: (name of hauler) The debris will l be disposed of in: a o� � 4� (name of facility) {� (address of facility) Sig a ure of applicant 1, Date