1 GERRISH PLACE APT 4 - BUILDING INSPECTION tZS
Commonwealth of Massachusetts
RECEIVEDR ,
Sheet Metal Permit INSPECTIONAL SERVICES
(— Date: _ Pc„ QI§_DEC -2 P 12: 49
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Estimated Job Cost: S t:gOGa Permit Fee: $ Z S
Plums Submitted: YES _ NO/ Plans Reviewed: YES NO
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�P Business License # -3 7 Applicant License #
Business Information: Property Owner/Job Location Information:
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Name: NI/ZZ,v m f�
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ycnl�5 Name: k4
Street: 7Y/ )LvG Street: / -If l-ISh �&"/ 71
City/Town: /f M..4 o2l q 7 City/Town: S���,o n MA)
Telephone: 617 r -o 21S5' Telephone:: ti��id
Photo�quired/Copy of Photo I.D. attached: YES - NO_
Staff Initial
J-t / - unrestricted license
J-2 / NI-2-restricted to dwellings 3-stories or less and commercial LIP 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:
Sheet metal work to be completed: New Work: _ Renovation:
HVAC_J� Metal Watershed Rooting_ Kitchen Exhaust System
T Metal Chimney/ Vents_ Air Balancing
Provide detailed description 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 ❑ No❑
If you have checked Yes, indicatethetype of coverage by checking the appropriate box below:
A liability insurance policy u 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 C],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 License:
By ❑ Master . .
Title ❑ Master-Restricted
City/Town ❑Journeyperson
Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number:
Fee$ ❑
Check at www.mass.gov/cipl
Inspector Signature of Permit Approval
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1 R:WCOMMONVVMTH OF MASA HUSE7TS
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g $ ASHEE7 METAL WORKERS' a
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tt i^STEVEN FiNU Z
11 LONG VIEW
�� GEORGETOWN MA�0113332330 � ° ^+
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The Commonwealth ofMassachusetis
Depardnent ofladustridlAccidenls
1 CongressSlreet,Suite 100
B.oston,MA 02114-2017
www.masxgov/tiro
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE PILED 87TH THE PERM7TING AUTHORITY.
ApplicantInformationle t
Name(Busview/Oigam?ation/Individualy. �/�i L
Address: —T��'�G 1�4 t a(1n rkoY
City/State/Zip: V }Z>v pI' Phone M
Are you an employer?Chert the appropriate box: Type of project(requ]red
1. am a employer wffi_ lovas(full mNmpaa-t®e).' _ 7. New conshuctio
2.0l am stole propeidoeor parepershry ated have on employees"Was forme in S. Q IZyplpdelmB
toy capacity..(No wakesa'comp:idnaatice required.) - 9. �Demmwlition
3.❑I am a homeowner doing ell work myself.[No workers comp.insurance required.)t 10 Q Building 4.01 ama ho n6ownerand will be hiring c®trector;to conduct ell work onmy property. ]willeanue that all contractors eidwhave workers'compensation insurance mare sole 11.0 Electrical repansAura tow�oyets- 12:�Plumbing repave
5.O l am a genus)coirliu[or end l have hhW Poe sub-boffisame listed on theaaedwd sbee[: 0. .Roof r .
7Lmmb< tmcs—haveemp7oymmdbawwo*w'cow menencet - ❑ e�p/a .
6.O We area corporatiemaod its officeisheve exercised thenright of exemptim per idGL e. 14.❑Other// na.
152,§l(4),and vre bare no anployees.[No workers'coup insurance required.] -
*Any apgdiram&M eheeka box#)must AIM'fig sur the section below shodvegcherwurlceis'wmpmaaon policy,mimmation.
t Homeowners who submit this at5davitindicaunitheysre doing an viark and thin hire outside contractors must suhma a new e}fidevit irdimtiog each
tConhaccoia ort chockdiii tion must attached m additional tbeetshowing the nante'of the sub-ccedr9das and state wheeler or not chose entities have
employees. Ifthesub:camtcaWwsheveemployce4tbeymuarpmvichlbea-wmtas'C=4p Po1icYnUMb--
lam au emiptoyer that is providing worhcia'compensation f suraacefor my a4layees. Bdow u thepahey and fob si/e.
Information.
Insurance Company Name:� G-P Lu`�u S �' �� ti' �- O
Policy#or Self-ins.Lic.IP - Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as mqi fired under MGL c: 152,§25A is a criminal violation punishable by 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 romance
. .
coverage verification.
TIZoT hereby ceYIW ander thtins and penalties ofpcifury that the mfora+awn provided above is hue and eorr ecL
Phone M
OJfmW use only. Do not write in this area,to be completed by city or town o waL
City or Town: PermWMeense#
Issuing Authority(circle one):
1.Board of Health I Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
1
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 ofhire,
express or implied,oral or writteA"
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 511 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 Lirmted 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 Depamnent 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 cement
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 proofthat 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 dpg license or pemut 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 02114-2017.
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CrTY OF SALEA MASSACHLEEM
Bu DmDEPAR7mw
120 WAsimci 0pdS7REET,3IDFiooR
UL(978)745.9595
FAX(978)740.9846
KITI6ERLEYDRISODJ 1.
MAYOR 7)I MaSSTYJERRE
DntEcroRoPPuujcPRomm1j;uaDnca)%& 9oN=
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 coo, S 54; Building Permit#/ is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of licant
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Date