0047 WASHINGTON SQUARE NORTH, U1 - BPA-14-670 (c� 70- 113 CK t43rsc6�Zs�
Commonwealth of Massachusetts
Sheet Metal Permit
Date: 3/2/14 Permit# 2 5
Estimated Job Cost: $ 800 Permit Fee: $
Plans Submitted: YES NO X Plans Reviewed: YES_ NO
Business License# 5 9 Applicant License# 2035
Business Information: Property Owner/Job Location Information:
Name:Morris Heating & Air Cond.Inc .Name: Barbara Swartz
Street: 56 Mitchell Rd Street: 47 Washington Square t1 j
City/Town: Ipswich City/Town: Salem 1
978-356-9900 978-594-5849 GC C r
Telephone: Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES X NO_
Statt Initial
J-1 M-13 nrestricted 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_ Multi-family_ Condo/Townhouses Other
Commercial: Office X Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. X over 10,000 sq. ft. _ Number of Stories: 3
Sheet metal work to be completed: New Work: Renovation: X
11VAC - —Metal Watershed Roofing_ Kitchen Exhaust System
Metal Chimney/Vents_ Air Balancing
Provide detailed description of work to be done:
Installation to extend the bathroom supply branch duct for 2nd floor
to toe space and rough in two return duct risers for bedroom
and office .
INSURANCE COVERAGE:
I have a current liabili 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 Owners Agent
By checking this box[3,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
❑ Master-Restricted
Cityirown ❑Journeyperson
Signature of Licensee
Permit#
❑Joumeyperson-Restricted License Number: 2035
Fee$
❑ Check at www.mass.gov/dpl
u 3'l0. 1
Inspector Signature of Permit Approval
i CITY OF &U.&LI, INWSACHUSETTS
BUIMINIG DEnILTNlENT
\ 120 WASHINGTON STREET,3'a FLOOR
TEL (9713)745-9595
FAX(978)740-9846
KINIBERLEY DRISCOLL
MAYOR T1 oms SmIsiERRB
D)RECTOR OF PUBLIC PROPERTY/BU DLNG COSLNQSSIONPER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le )bly
Name 1Businc�organizatimvindividuaq: Morris Heating & Air Conditioning Inc
Address: 56 Mitchell Road
CitylState/Zip: Ipswich, MA 01938 Phone#-978-356Li 9900
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with 2 2 4. 0 I am a general contractor and 1 6. 0 New construction
employees(full and/or part-time),* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet t 7. ®Remodeling
ship and have no employees These sub-contractors;have 11. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. []Dui
[No workers'comp.insurance 5. 0 Building addition
We are a corporation and its 10 0 Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers'
comp.insurance required.) 13.0 Other
•Any applicant that checker box pl mutt alxu till out the secrim below s i howing chor workers'comp mu stion policy intormsdon.
'I lmtwownen who submit this affidavit indicating they ate doing oil work and then hire mmide cootmotms must submit a now affidavit indicating uu;&
:Contmmon that chock this box must attached an addition/xhscl showing the home of the sub_,ommc wm and the6 wodtera'comp.policy t mfmmmim.
Issas an einplayer that is prudg workers'eontpensatlon insurancefar my employes. Below isthepulley andjob siteinformation.Insurance Company Name: Federated Mutual Insurance
Policy it or Self-ins.Lio.#: 9336422 4/1/14
Expiration Date:
lob SireAdtln:ss: 47 Washington Square Salem, MA 01970
City/State/Zip:
Attach a copy aLthe 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 S 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 S250.00 a day against the violator. lie advised that a copy of this statement may be forwurded to the Office of
Investigations of the DIA for insurance coverage verification.
Ida hereby certif udrr the pains cord t naldes ofperjury that the information provided above is true and correeL
Sitmalt Date 3/3/14
porn 978-356-9900 or cell 978-265-2995
F
rfa,useonly. Du not write in thin area to be cunrp/eted by cityortown o riot or Town: ___ Permit/hieer
Issuing Authority(circle one):
1. Board of llealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Pcrson: — Phone#:
COMMONWEALTH OF MASSACHUSETTS
SE METAL WORKERS
HE
EM
AS A'MASTER-UNRESTRICTED
ISSUES THE ABOVE LICENSE TO
TIMOTHY J MORRIS !m`
13'" LESIE RO N
LPSWICH MA 01938-1012'
2035 03/28/14 137120
0 0 •
Fold,Then Detach Along All Perforations
COMMONWEALTH OF MASSACHUSETTS -
e e • ••e o :e •ee -- .
SHEET METAL WORKERS
AS A BUSINESS
ISSUES THE ABOVE LICENSE TO
j
TIMOTHY, J M'OR'RIS
MORRIS HEATING AND AIR CONO;ITI0�1 '
8 'SCOTTS WAY
ESSEX MA 01929 0000
50 09/08/14 242573 _
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"FoW,Then Detach Along All Perforations
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