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0088 1/2 -90 FEDERAL ST - BUILDING INSPECTION Commonwealth of Massachusetts �- Z �O 3 1 Sheet Metal Permit Date: 1� `�al llo PANit`tkC 19 A !a: 39 CT as D' Estimated Job Cost: $ ,�D��, Permit Fee: $ Plans Submitted: YES_ NO Plans Reviewed::' YES NO -9 Business License# � 4 .00 Applicant License# %-7 Business Information: Property Owner/Job Location Information: Name: Mil i SUS (Name: Leo )< uuyyeI 1 1 Street: Z Irk 1 1 o y\ �9uC Street: C- City/Town: e-©rcKe.�d� `'\ City/Town: SCJ e vy" Telephone: Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO Staff Initial J-1 / -1- estricted 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 St o 'es: Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing ' Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed desep'ption of wor to be done: cites � �1­� c,D CSC . iZ( 2� 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 ype 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 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 dMaster Title ❑ Master-Restricted City/rown ❑Journeyperson Signature of Licensee Permit# I ) Go ❑Journeyperson-Restricted License Number: ` t Fee$ ❑ Check at www.mass.gov/dpl (44,U9 y Inspector Signature of Permit Approval ChyOFSALEM MASSAMUT &�llsraim�rr '.. ]�DlPa '7atS1�r,PAM I�t7�9995. , Hn®ERiBY y PAr 740-MU MA7M DnrAssriwm DcF Construction Debris Disposo/Afifft t (required forall demolition and,renovation wor►y In aocordenoe w>th the shah edition of the State Bu& hW.Code, 7W Cp^ SecWn=.S Debris and the provisiais of till 040,S 54;hdi ft ftm* is bxued with die condWm that the deb*rmdit from this work sha0 be disposed of in a propeiy licensed waste deposit fw ty as deRned by A46L c 111,S 150A. The debris will be trans"by: (na a ofhauler) The debris will be disposed of in: name of fadlity) 3 vu (address of facility Sig a ure of a icant Date The Commonwealth of Massachusetts Department of lndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 Ulf www mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organti Name: Address: 3 City/State/Zip: ©1 Bone CO Are you n employer?Check the appropriate box: Business Type(required): I. I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp. insurance required] B. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers' comp.insurance requiredl* 11 LEI Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. 1 am an employer that is provi5(ing worfr�rs'compensation insurance jar my employees. Below is the policy information. Insurance Company Name: �t\1f\El?loll Insurer's Address: City/State/Zip: Lf Policy#or Self-ins.Lic.# EC- (oOD 40004 ` —;-o �S?4 Expiration Date: I ` I )0l7 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 ve 'fication. do hereby certify, under the pain penalties o erjury that the information provid ab ve is true and correct. Si nature: QiU Date: [U q 16 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia 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 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 your insurance company's name,address and phone number along with a certificate 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 permit/license 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). 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 burn 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-15