12 HERITAGE DR - BUILDING INSPECTION Commonwealth of Massachusetts,
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Sheet Metal Permit At" wt '
9 Date: 08/02/16 Permit# 1016 AUG -4 P 0 0,8
kEstimated Job Cost: $5300.00 Permit Fee: $
t
Plans Submitted: YES ❑ NO ❑✓ Plans Reviewed: YES ❑ NO ❑
Business License# 52 Applicant License# 469
Business Information: Property Owner/Job Location Information:
Name: Central Cooling and Heating, Inc. Name: Princeton Properties
Street: 9 North Maple St. Street: 12 Heritage Dr.
City/Town: Woburn,MA 01801 City/Town: Salem,MA 01970
Telephone: (781) 933-8288 Telephone: (978) 361-7199
Photo I.D. required/Copy of Photo I.D. attached: YES X NO
Staff Initial
J-1 / .I 1/ restricted license
J-2/M� u-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less
Residential: 1-2 family l'> Multi-family Q Condo/Townhouses _a Other
Commercial: Office_a Retail Industrial Educational
Institutional Other C
Square Footage: under 10,000 sq. ft. 00 over 10,000 sq. ft. 0 Number of Stories:
Sheet metal work to be completed: New Work: n Renovation: ✓n
HVAC ✓n Metal Watershed RoofingF-1 Kitchen Exhaust SystemEl
Metal Chimney/Vents n Air Balancing
Provide detailed description of work to be done:
We are replacing an existing Fan Coil Unit (FCU) and condenser. We will be reconnecting to
the existing duct distribution system.
iat`EO � 'l2
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. 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 boxE,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 m Master /I
Title ❑ Master-Restricted
City/Town
❑Journeyperson Signature of Licensee
Permit# r�
(]Journeyperson-Restricted License Number: 1(f'
Fee$ ❑
Check at www.mass.gov/dpi
Inspector Signature of Permit Approval
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
UIV www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aaalicant Information Please Print Legibly
Name (Business/Orgmizationnndividual): Central Cooling and Heating, Inc.
Address: 9 North Maple St.
City/Stategip:Woburn,MA 01801 Phone M(781)933-8288
Are you an employer?Check the appropriate box: Type of project(required):
1.N I am a employer with 70 4. ❑ I am a general contractor and I
p yet 6. ❑New construction
employees(full and/or part-time).'
have hired the attachsub-ced
nttactors
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees
These subcontractors have g. Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp.insuranceCOD p. tnsurance.l
5: El We are a corporation and its 10.E]Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work officers have exercised the 11;❑Plumbing repairs or additions
right of exemption per MGL
myself. [No workers' comp. 12.❑Ro f tepairg
insurance required.]t c. 152,a 1(4),and or have no 13.' err r1 Y �tC.
employees. [No workers'
eomp. insurance irequtred):
*My 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.
tCootractor;that chock this box must attached an additional shed showing the name of the sub-contactors and state whether or not those entities have
employees. if the subcontractors have employees,they most provide thein workers'comp pdtcy number.
I am an tmployer That is provldb�ig workers'compensation insurance for my employees. Below is the polky and job sHe
information.
Insurance Company Name:Arbella Indemnity Insurance Company
0048681113 Ex uationDate: 11/30/2016
Policy#or Self-ins. Lic. #: II II,N,,__ F
Job Site Address 11
�Z 1th qe, ef-• City/State/Zip: ' t-4A 0191-10Attach 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$250.0?'"y y against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA fo insurance coverage verification.
Ido hereby c rtify u 1 err thtns an p Hattiefp jury that the information provided a over ' true and correct
Signature: Date: r52
Phone#: 7819338288
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#:
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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 witli 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 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 pemilUlicense 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 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 Office of Investigations would like to than you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7-2013 Fax #617-727-7749
www.mass.gov/dia
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CENTRAL'COOLING AND HEATING INC
9 N MAWLE ST
0dBURN MA 01801