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1 HOLYOKE SQ - BUILDING INSPECTION Commonwealth of Massachusetts Sheet Metal Permit � // Date: �P 00 Permit# as Estimated Job Cost: $ Permit Fee: $ 2 Plans Submitted: YES_ NO_� Plans Reviewed: YE-7S//_ NO IN G Business License# 13(D Applicant License# / tp8 (� Business Information: T Property Owner/Job Location Information: Name: _ i '� t(1� CYrS 111 • Name:rArNmonWcc'fh L�bS Li bIC1M7QCQ flti't- � / Street: Q City/Town:�P;��(1Cw� IU �A 0y} 307 b City/Town: sc�yr� m Telephone: (43 - 59,5- U,0) Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES_ NO_ Sten Initial J-1 /eunrestricted license J-2/M-2-2-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 \// Retail Industrial No/ Educational Institutional_ Other_ Square Footage: under 10,000 sq. ft. V/ over 10,000 sq. ft._ Number of Stories: Sheet metal work to be completed: New Work:J Renovation: HVAC_ Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents_ Air Balancing Provide detailed description of work ito be done: _i _r v;� C.n MS�z.�� 11") ALJC, Iia �f ply, Air ,��, INSURANCE COVERAGE: J I have a current liabilityinsurance 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 Bel, 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[a/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 Proaress Inspections Date Comments Final Inspection Date Comments Type of License: By 94aster Title ❑Master-Restricted City/Town ❑Joumeyperson Signature of Licensee Permit# 3 � (2 R ❑Joumeyperson-Restricted License Number: Fee$ ❑ Check at wwww.mass.gov/dal jyy�Of�v . � qGl V�TiJ J �1`J BSS Inspector Signature of Permit Approval Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ArJolicant Information _ Please Print Legibly Name(Business/Orgmizationnndividual): Eastern Vent Systems Inc. Address: 4 Dick Tracy Drive City/State/Zip: Pelham, NH 03076 Phone#: 603 595 8559 Are u an employer?Check the appropriate box: Type of project(required): LM I am a employer with 18 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition workingfor me in an capacity. employees and have workers' Y P 9. ❑ Building addition [No workers'comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E]Plumbing repairs or additions myself. o workers' corn right of exemption per MGL Y (N P• 12.[]Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any 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. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: West American Ills. CO. Poliey#or self=ins.Lic.#: XM55824483 Expiration Date:: 12/31/2016 ` , Job Site Address: ©nk An\VAXL �Gl1yt`4 City/State/Zip: JCGrvs 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 tl Vdkse e/na ties of perjury that the information provided above is true and correct. S�nature: / 7 p Date: /U (! 6 Phone#: Oficial use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone At: V GOIVIMONWEJILTH OF MA 5/1GIil1S • • • • • SHEET7AETAL W©RKE4i5 r"ISSUES tPE,uFOILETWIK16`-lICEN&E'; , * .. ASaA 4451NE5ZY TIMCITHY ANGELOSANTO CIA STERwvi4T*"SYSTEMS INC 'a 4 DICK TRACY DR a 1 PELAM NH 03076 �xa� " lib '�4 illi4�16 •"�2 :,. I. GOMMONWEALTIinOF::MA.'"^ACHUSETTS. ' ,° e i <x BQA SHEET METAL:WORKERS,;;. j ISSUFS THEFOLLOWING LICENSE AS A b°§ MASTERUNRI�STRICTE TIMOTHY ANGELOSAN70' a '; STONEHAA9 MA 02180 3348 x 3768 08@812018 11521 `