25 JACKSON ST - BUILDING INSPECTION CK1 � �
Commonwealth of Massachusetts
Sheet Metal Permit
Date: Permit#�i IS A N= 19
. 60 Ae //__
Estimated Job Cost: $ Cjdjo, Permit Fee: $ W
_ Plans Submitted: YES NO Plans Reviewed: YES NO
Business License# / L/ rJ 7 Applicant License#
Business Information: Property Owner/Job Location Information:
Name: Ck Kt,S50n112fY1tYlQ t CDO(,iri9Name:1^eY�RrA��.
Street: _? 5A-C-Ke" 5* Street: L$— 'S A-e c-SOr 51-
City/Town:
fiCity/Town: 5O57V -n /114 6Z I--O City/Town: SA U M M /1
Telephone: 0 s 7 — L/t 7 " / Telephone: (, / ? 7 ,7 9 7 3 7Sr
Photo I.D. required/ Copy of Photo I.D. attached: YES /� NO_
$lett i11111:1l
J-1 unrestricted license
J-2 / M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq, ft. /2-stories or less
Residential: 1-2 family Multi-family Condo / Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories:
Sheet metal work be completed: New Work: Renovation:
FIVAC Metal Watershed Rooting Kitchen Exhaust System
Metal Chimney/ Vents Air Balancing
Provide detailed description of work to be done:
1 n S'1"19'C.L.tYTt?Jd� o� fFGC.. !t-e.c✓ dt�Gf G;iC�u� /Ai�� in f�Tt'�C�
=n S-rg-c.�.�r-sem o-� 3 T-�-�•r le„-.-h�-a-ti �9--Ic .
-1 Sia��m St
a
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 YesNo❑
l
If you have checked Yes, indicate the t pe of coverage by checking the appropriate box below:
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
v — s Owner Agent ❑
Signature of Owner or Owner's Agent
By checking this be ,I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation: YES NO
ProeressInspections
Date Comments
Final Inspection
Date Comments
Type of License:
By Master
E
Title
❑ Master-Restricted
City/Town
❑Journeyperson Signature of Licensee
Permit# e ,r
❑Journeyperson-Restricted License Number:
—7
Fee$ ❑
Check at www.inass.gov/dpi
Inspector Signature of Permit Approval
The Commonwealth ofMasaachuseus
Deparasvtent o71x4;f0 rrlACcidents
I 1nongressSbw4 Suite IN
B.osion,M.4 Q2114-1017
www.maxxgovMa
WWorkers'Compensation Insurance Affidavit Builders/CoMradors/EhNriciaos/Plumbem
TO BE FH.ED WITH THE'PEItbHTTING AUTHORITY.
Apnllcantltaformetion Pleaschint IEaihJY
Nam(Bosmess/O,gaoiration,ilnmvi,h4: C, A:i 55
Addtess:
City/State/Zip: 1�� S'Ta'i IVA- Phone i}: PS-) -y/ "7-.5-C / 7
Are you as empbyery clerk tae apprraplate boz: - s .
Type ofprb)eet(required):
I.OI am h employer wiPo enepbysxa(full aodrmpuFtm�el.'- 7. New construction
F6.0
=asokpayarmashipmdLevenoemployersWOOSformem S: :0Itemode)ing
�Y�tY•lNo woken'wmy L"attsaoee .) _
9. o Demolition'
100fiv0dmgadtlinon.
amahomCowadw�9bebitingeaauaamstocmdudallworkmmypoperty. Iwdl'compeatadmint mmsole 11.0 Electrical repays or additions
O �m .. 12.0PIumbft'rga6soraddition's
13• . Roof bm sabcoatiect=have employees andh■ve wvd:ea'eemp.inaamce O rep*xe m a corporelimaud its offisershave eaeicieed Porurigtt of eai:mptionprMQ,a2,§l(4),and we haveuo employers•INu worm'domp'mstaaaere.gumdl'
•Aq appheaat t eaeeb boa 61 nuat"fill hat tbewWan belowabovvingPoeb wmkePs ®P�ey
t Homeowma who submit Pols.eGdavit iiidiraebgtbey are dabg as work mdilghha oatside eafiBcScftimt crab"a new affidav&iodimCog OWE
lCwvaitm that check Oa box must MaciWao,eddiaonal aaeetati6wmg tbcmii*efthe cab-WWiMm and state whedzi amtttioseeouues rive -
employem.IfPoesob-c9 aLsreempl.%r+rs t>wymmtP s&ev-x'mkma�:mmA Policys®9aq :!::: ..-...
lam an Amployec rAatlfs '
providutg tpiorkers eoeiPensaaon tnanragaelor my didfo6 site_
hafornradoa.
Insurance Company Name:
Policy#or Self-ins.Lic:M Eapuafion Date:
Job Site Address: City P,
Attach a copy of the workers'compensation policy declaration page(showhigtpe policy number and expiration date)-
Fat7ure to seaae coverage ae ie9uired under AJGL c. 152 §25A is a criminal violation punishable by a Sae up to SI 500.00
and/or one-year m*p8munmi,as well as civil penalties m the form da STOP WORK ORDER and a fine of up to$250.00 a
day against the violetoi.Acopy of fliis statement may be forwarded to the Office oflnvestigetib®s ofthe DIA for itlauascs
coverage verificetiorl•
I do her cerci ua djsmahief ofpojury thaf rhe mformarron provided above is ove and eorreet
:sionee.mn
Phone#. 5---7 - q1
OffmW ase only. Do nm write in chis area,fo be eompJWed by u0'or town offteW
City or Town: PermiU cense#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.G7tylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone M
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 writtep"
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 duan three apartments and who resides therein,or the occupant of Bre
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 eommanweaft 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 mmti7 acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'comtpensation 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 thein 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 confmnatien 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'
conq)ensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate lime.
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 Investigation;has to contact you regarding the applicant.
Please be sure to fill in the permitticense number which will be used as a reference number. In addition,an applicant
that rust submit multiple permit/licemse 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 die
applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be filed 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 dqg 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,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
r
COMMONWEALTH OF MAS"'MiUSMSz�
w � �SHEETyM'B"T"tA WORKERS x 'r'
' ,` ISSUES THE�FOLLOWF l`tCE-
f—AVA' RASTER-l1NRfiST +lT
6��RRBE�R,yT�M CHAISSOPI�B� �� "� a %x " '
20 r849 w
•382123 ; , ,
07Y OF SALEK MASSACHIBEM
BurwwDErAFmznr
1M WAS10WMSnRffr PROCR
UL(47)7 5.9595.
RIFAXMT 7149846
571+�EEYDR(S�7lL
APAYCR n �sS71
Dnmcrm cFFUUJcrROFWJY/sunDnaccuMMWCMR
Construction Debris Disposa/AfdWit
(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 coq S 54; Building Permit B is issued with the
condition that the debris resulting from this work shall be disposed of in a property licensed
waste deposit facility as defined by MGL c 111,S isa4.
The debris will be transported by.
�J
{name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
Right J@ Mobile Report Job:
+'� wrightsoft' Ri g p Date: 6115/2016
Entire House By: Chaisson Heating And...
Chaisson Heating And Cooling
7 sachem at,Boston,MA02120 Phone:8574175619 Email:Robert_chaisson@yahoo.com
Project Information
For: Roger Barille
25 jackson at, Salem, MA
Phone:6177997375
Email: Rogerbarile@yahoo.com
Design Conditions Indoor: Heating Cooling
Beverly Muni, MA, US Indoor temperature(°F) 70 75
Elevation: 108 ft Design TO(°F) 61 11
Latitude: 43oN Relative humidity(%) 30 50
Outdoor: Heating Cooling Moisture difference(gr/Ib) 25.6 33.8
Dry bulb('F) 9 86 Infiltration:
Daily rangeoF) - 18 ( M ) Method Simplified
Wet bulb('F - 72 Construction quality Average
Wind speed (mph) 15.0 7.5 Fireplaces 0
Component Btuh/ftF Btuh %of load
Walls 3.8 6798 35.8
Glazing 0 0 0 Ifilaam
Doors 36.4 764 4.0 MI
Ceilings 1.6 2127 11.2
Floors 2.7 3645 19.2
Infiltration 3.1 5677 29.9
Ducts 0 0
Piping 0 0
Humidification 0 0 Ltas Ams
Ventilation 0 0 (Wings
Adjustments 0
Total 19011 100.0
Component Btuh/fl= Btuh %of load
Walls 0.5 970 5.0 v\tl IrtanGars
Glazing 37.5 13894 72.2 Irlf?lanatim
Doors 14.1 296 1.5 Ceilings
Ceilings 1.2 1650 8.6
Floors 0 0 0 Qha
Infiltration 0.3 533 2.8
Ducts 0 0
Ventilation 0 0
Internal gains 1890 9.8
Blower 0 0
Adjustments 0 Gairg
Total 19233 100.0
Latent Cooling Load= 1630 Btuh
Overall U-value =0.043 Btuh/ft2--°F
Data entries checked.
tltOft, 2016-Aug-1509:15:34
Wri
g Right-Suite®Universal 201717.0.04 Right J®While Page 1
...\WstmpW2168e6e-55f6478b-bcbc-9324c4428660.mp Calc=MJB Front Doorlaoes: N