18 THORNDIKE ST - HVAC PERMIT �s
Commonwealth of Massachusetts
4.0
Sheet Metal Permit
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Date: �t W r Permit#
A la 20
Estimated Job Cost: $ �� �� Permit Fee: $
1 Plans Submitted: YES NO Plans Reviewed: YES NO
Business License# CH S 4(;%()6! Applicant License# C-9
Business Information: Property Owner/Job Location Information:
Name: (> �f3.1�dL �� C_ Name: 3C)e C: 1 H`Pr2Sk`
Street: LA �err(��t, A _1>2 W O Street: -"ApFVt I L-e�P
City/Town: (_A J KA( o'-%ns City/Town:
Telephone: qL-7 p Cg 57' & 11 Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES�4_ NO
Staff Initial
J-1 (5unrestricted license
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 lk Multi-family Condo/Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. r over 10,000 sq. ft. _ Number of Stories: 2
Sheet metal work to be completed: New Work: Renovation:
HVAC 7,2L Metal Watershed Roofing 7 Kitchen Exhaust System
Metal Chimney/Vents Air Balancing
Provide detailed descriptions of work to be done:
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INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes L� rvo❑
If you have checked Ye ,S 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 1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best o�wledge and that all sheet metalwork 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
ProaressInspections
Date Comments
Final Inspection
Date Comments
Type of License:
By 11.f Master
Title �.
❑ Master-Restricted
Cityfl-own
❑Jcurneyperson Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number:
Fee$ ❑
Check at www.mass.gov/dpi
Inspector Signature of Permit Approval
Please visit our web site at http://www.mass.gov/dpi/boards/SM
ERIK M.TIMMONS
16R PINEWOOD RD (SM)
WILMINGTON, MA 01887-1930
Fold,Then Detach Along All Perforations
.OMMONWEALTH OF MASSAC(il1S
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SHEifln TALWORKERSx
ISSUES THE FOLLOWING LIC£NSl
s fJhAST�ER-UNRESTR'ITED��-"�� �;H::
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ERIKM.,TIMMONS 1 �.
9GR PINEwOOA RD.,t y
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PWILMINGT61I'44018137
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429 091281FUN
2017 1989
' The Commonwealth of Massachusetts
Department of IndustrialAccidents
I 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: Ts �170 4L
l! C—
Address: _\ ��W e—I Q
City/State/Zip:, Ld Phone
Are ou an employer?Check the appropriate box: Business Type(required):
1. I am a employer with ) 6 employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.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.[TManufacturing
no employees. [No workers'comp.insurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care
with no employees. [No workers'comp.insurance req.] 12.❑Other
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
--If the corpomte officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
1 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 certify,under the pains and penalties of perjury that the information provided above is true Iand correct.
Signature: `�'I-�— Date: [ [- IOW' 11K�
Phone#:
Official use only. Do not write in this area,to be completed by city or town ojjicial.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
e
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-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Fonn Revised 02-23-15
11/21/2016 10:40 AM FROM: De Senctis Insurance Oe Sanctis Insurance Agency TO: 19787409846 PAGE: 001 OF 002
• DeSanctis Insurance Agency
• 100 Unicorn Park Drive
Woburn, MA 01801
To: <19787409846>
Fax number: 19787409846
From: Andrea Toste
Fax number: 781-933-5645
Business phone: 781-935-8480
Home phone:
Date &Time: 11/21/201610:40:01 AM
Pages: 2
Re: Certificate of Insurance- BJ Doyle
Good Morning,
Please see attached certificate as requested,
Thank you,
Andrea Toste (x122)