2 SCHOOL ST COURT - BUILDING INSPECTION Commonwealth of Massachusetts
Sheet Metal Permit
Date: R �� Permit#
Estimated Job Cost: $ 160ed / Permit Fee: $
C� Plans Submitted: YES NO ✓ Plans Reviewed: YES NO
d Mfr /
Business License# Applicant Li nse#
t Business Information: Property Owner/Job Location Information:
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� ST%�G1V'17 `
Name: t'firfiPrT
CC-maae_ Name: y,y,yrQ c&ckB✓�
Street: 457- Street: a Gz 601i= 6T G
City/Town: jA)9i&1,,,4A j City/Town:55►4L&,t
Telephone: R7g Y Boa ' 6-M Telephone:
PhotQID sequired /Copy of Photo I.D. attached: YES NO
Stafflnitial
J-1 /M-1-unr tricted 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: N 1
Sheet metal work to completed: New Work: A�� Renovation: y
HVAC Metal Watershed Roofing Kitchen Exhaust System
J
Metal Chimney/Vents Air Balancing
Provide detailed description of work to be done:
ns?g CIegT
G wt ti a(1� z Ujay L-.< Foycao Hv T' 4,7,. _
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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 L9- 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[],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
City/Town ❑Journeyperson
Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number:
Fee$ ❑
Check at www.mass.govldpi
Inspector Signature of Permit Approval
rhe Commonwealth ofMassaehusettr
Deparament of11i&stria1Aectidents
I CongressStlrge;Suite 100
Boston,M.4 02114-2017
wrvw.massgov/dia
Workers'Compensation Insurance AffrdaviC Builders/Coni radors/Eleebiclans&lombers.
TO BE Fi VMW THE PMM 7TANG AUPHORiTY.
Applicant a
Name(Basiae3s/Oaimtlon/fndividual): LiM
Address: ?=2-r "6.A- . . / r n
City/State/Zip: .1�P,.S&A
n d*1 _ (►114 (9I�$u . Phone#: . 97�`
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popsietonwithnoamployxa. 12. Plmobm."' Wtidtiition"s
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13" Roofrepays:
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t Homeownvs wbo are 1164 A voiAouhide wnhaama mat ealmitamv af6devitiodiramo8rasi:
1Coaaaemn tbm deck this`ti�mat eaectea6a>eddi6aoisl abxtalbwing tln�teof8ie sub-a®umas mE sate afie�oirw116ose eoti6As lava
, employees.rfffiesub�trgr.ffiah�ve,emP1?y�,t)KXm!u[Pmvda�-a'orkas'ramp.Poliq'monLe- ::.: � - _,-:: . . .. .
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Insurance Company Nam.,
Policy#or Self-ms.Lic.M - Expiration Date. -
Job Site Address: City)StatrJTp:
Attach a copy of the worriers'compeandon policy declaration page(showing the policy number and atplrWon date).
Failure to acture coyerage as required under MGL c. 152,§25A is a taieiina]viohttionpunishable by a fine up to 57,500.00
and/or one-year imprismi�t,tuas well as civil penalties in the form da STOP WORK ORDER and a fine of uj to$250.00 a
day ageing the violator.A copy of this etateinent may be foiwaided to ibe Office oflnveaugationa of the DIA fts insurance
coverage v(err/,iificiati/\ag'//(/>
I do hereby the it air ojperjrery that the fnjormadon provided above
is a and correct
Sieoatme• � Date l r
Phone M
Ojokcial use only. Do not mile in this area,-to be ceerV [ed by dy urTown o,BieaL
City or Town• PermitUeense M
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cjty/Ibwn Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone k:
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 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 in individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three'epartnrients 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 not any of its political subdivisions shell
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 fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)muric(s),address(es)and phone number(s)along with thea certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships W)with no employees other then 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 sip 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-insuredcompanies should enter their
self-insurance license number M the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and painted 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 sur to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemtit/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 perarits 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 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. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia