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0 SPRINGSIDE AVE - BUILDING INSPECTION Commonwealth of Massachusetts RECEIVED�� ' NsFEVIGNAL SER�ti'rCr'^.� 00 Sheet Metal Permit � Date: n. - lole DUH -3 A D 01 Permit DO Estimated Job Cost: $ l3� Permit Fee: $ Plans Submitted: YES NO_ Pluns Reviewed: YES NO I� Business License # ee eoT Applicant License # i� Business Information: Property Owner/Job Location Information: l � �ONni �� r�St toy Name: C/pw`i S t Iyo., Name: Oxvc StreetWIAq j Street.. O SP6rSjSade Ave— City/Town: YA_S -A Pf 03 C) City/Town: /AA Telephone: Telephone: 01101 — Q?Y3 Photo 1.D. required/Copy or Photo 1.D. attached: YES V-�NO — Staff Ostaff dn:a -I / M-1-unrestricted license J-2 / NI-2-restricted to dws 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less Residential: I-2 family_ Multi-family_ Condo/ Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft—ioover 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work<��— Renovation: HVAC Metal Watershed Rooting_ Kitchen Exhaust System Metal Chimney / Vents Air Balancing _ Provide detailed description of jwork to be done: Ale4,/ GcutvlM,, 9-0)71nj CO J/ f S7J* -P/-,4C- to()K 8 ru MA,tL Tb 1i \NI>a.if-,-W1g s-r -- � mta, V-ST) U1 - INSURANCE COVERAGe:'A' I have a curren71iability.Insurance policy-or its equivalent which meets the requirements of M.G.L. Ch. 112 Y s No ❑ If you have checked Yes, indicate the coverage by checking the appropriate box below: _ A liability insurance polic;-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 Prot<ress Inspections Date Comments Final Inspection Date Comments Type of e: By Master Title ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee S El Check at wevw.mass.<aov/dpi Inspector Signa a of Permit Approval The Commonwealth ofMassachu$ens Department oflndusindAccfdents I Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/ContractorsMectricians&iumbers. TO BE Fll"WITH THE PERhIITrING AUTHORITY. Applicant Information Please Print Le b ly Naive(Businessiorgamratictift&viduat):_ ��riQ✓1.� �h� LL° .. Address: `/ 1.✓r f f i gpl f ,S "e4- City/State/Zip: /114J) �N Phone#: &03 d 3) -rib Sy Are you an employer?Check the appropriate box: am a employer wuh Type of project(required): employees(full end/mpart-time).• 2.Q I am a sole proprietor or pamrershi act have no - ew f.01LSWetion any capacity-[No workers'comp.insurance tegtmM�.)Y�working formJhe 8. Remodeling 3.❑I am a homeowner doing all work myself[No workers•comp.iatmanco req9. ❑Demolition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my 10 Q Building addition cmure that all connector, either haw workers•compemation insurance or are11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hued the subcontractors listed on the sit These sub-ronttaams have employees and have workers'comp.immm,at13.EJ Roof repairs 6.❑We are a corporation and its ot5ccs have exercised theirright of exemption p14.❑Other152•§1(4),and wehave no employee.(No workers'camp.:.�•..A....requne -Any applicant that checks box#1 must also fill out the section below showing Their workers'compensapon t Homeowners who submit this affidavit indicatingm8 Imust submit a now affidavit indicating such. ps?information.;Contractors that check this box must attached dditional wheel showing the mane of the sub-contractors and state whether or act us entities have employees ifthe subcontractors have employees,they must provide their workma'comp.polkyaumber. I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site informa6an. Insurance Company Name: 1It., Policy#or Self-ins.Lic.#: /r (Ve j.K,3a 0-j" Expiration Date: lv'� /^, ,ll Job Site Address:_ © -SP/_',t55)d2 Av*- City/StatPjMp- Sq 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. Ido herebycertify under airs penahies ofperjury that the information provided above is true and correct Suture: Date ✓r^"� ani 'hone#: Oficial use only. Do not tyke in this area to be completed by city or town official City or Town: PerndVLicense# 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 thew 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 commonweakh 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-contractors)name(s),address(es)and phonenumber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLQ 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 lime. _ 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 perrrrit/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 perrinits 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Cf>OMMONW LTH OF M S�A �tl7Sl .f.S ;F T, OTAL WORKERS r v!iSSUES THE FOLLOWING LltrEN ASA d= MAS I'ER UNRE& RIfCTE, JAMES P SILVERTHORN £. �N 4 TKSCHEREAU$LVD , 4' �NASHUA4:Nkl A03062 ?32P;� a n /n s 6405 R q ` : Q4/2812018�� 4 32649 `]