47 FEDERAL ST - BUILDING INSPECTION (3) ED
Commonwealth of Ma PPO SERVICES
� n Sheet Metal PerlMitjAN 19 P 1: 0 1
Date: Permit#
Estimated Job Cost: $ / /JOb Permit Fee: $
t(� Plans Submitted: YES_ NO_ Plans Reviewed: YES//_ NO_
Business License# �93 Applicant License# l 40 ,j
` Business Information: Property Owner/Job Location Information:
Name: ///?-C cJFE/21 Q//� �LIC Name: fEVj6 6l j�d q z 5r
Street: �CS �/l� J� Street: �/ /�
City/Town: M/¢ O/J�j�j� City/Town: c �iLI-1�//6{��i1 A11W Ol*
Telephone: ZZf 7J� L2 Telephone:
Photo I.D.required/Copy of Photo I.D. attached: YES_ NO_
staff Initial
J-1 / 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. Y over 10,000 sq. ft._ Number of Stories:
Sheet metal work to be completed: New Work:_ Renovation:
HVAC Metal Watershed Roofing_ Kitchen Exhaust System_
Metal Chimney/Vents_ Air Balancing_
Provide detailed description of work to be done:
f o Q —
INSURANCE COVERAGE:
I have a current liability Insurance policy or its equivalent which meets the requirements of M.O.L.Ch.112 YesANo❑
If you have checked ygq,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 permlt application waives this requirement.
Check One Only
Owner ❑ AgentX
Signature of Owner or Owners Agent
By checking this b i hereby certify that all of the details and Information I have submitted(or entered)regarding this application ere keg and
accurate to the be% y knowledge and that all shoat metalwork and Installations performed under the permit Issued for this application will be
In compliance with all pertinent provision of the Massachusetts Building Code end Chapter 112 of the General Laws.
Duct Inspection required prior to Insulation Installation:YES_NO_
Progress Inspections
Date Comments
Final Inspection
Date Comments
iTy/p'e of License:
I�g
BY Master .
Tlue ,❑`Master-Restricted
Cllyfrown
❑Joumeypetsan Signature of Licensee
Fertnhs
❑Joumeyperson-Restricted License Number:
Fee 5 ❑
Check at www.mass.gov/dyl
Inspector Signature of Permit Approval
The Commonwealth of Massachusetts
Department of IndustrialAccidents
x a I Congress Street, Suite 100
Boston,MA 02114-2017
a www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Orgmization/Individual): Preferred Air Inc
Address: 461 Boston St#A3
City/State/Zip: Topsfield MA 01983 Phone #:978-750-8282
Are you an employer?Check the appropriate box: Type of project(required):
I.❑I am a employer with 19 employees(full and/or part-time).• 7. New co nstruction i
2. 1 am a sole proprietor or partnership and have no employees working for me in
❑ 8. ❑ Remodeling
any capacity.[No workers'comp. insurance required.]
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]r 9. El Demolition '
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.�ROOf repairs
These sub-contractors have employees and have workers'comp.insurance.:
❑� Other HVAC
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. '
152,§I(4),and we have no employees. [No workers'comp.insurance required.] €
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. -f-
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;y
tContractors 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.
/am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name: Arbella
Policy#or Self-ins.Lie.#:9127690815 Expiration Date:08/01/16
Job Site Address: 47 Federal St City/State/Zip:Salem MA 01907
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure.to secure coverage as required under MGL'c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby er i y under the pains and penalties of perjury that the information provided above is true and correct.
Si nature Date:
Phone#:
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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