33 FORT AVE - BUILDING INSPECTION (2) cK I2. sz $
ICommonwealth of Massachusetts
Sheet Metal Permit
Date: 3 Permit tt
listimatcd Job Cost: S 6400 Permit PeerPce: Simr �
Plans Submitted: YES NO Plans Reviewed: YES NO
Business License /i Applicant License tt 355,0
Business Intinwation: Property Owner/Job Location Information:
Name: s�o� Sic V-kec�kc' Name:
Street: L�o � n Wv�k Qom! • Street: -e-
City/'Town: jDo K�c�v q-lcx- Cityrrown: 'S�Aevu., W ck
Telephone: `3?°6- �Sl,�-�r{g� Telephone: �261 (Q�),-�o
Photo I.D. required/Copy of Photo LID. attached: YES NO
J-1 / i-I-unrestricted license
J-2 / M-2-restricted to dwellings J-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less
Residential: 1-2 family Multi-ramify_ 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: _
Shect metal work to be completed: New Work: _� Renovation:
11VAC ✓ Metal Watershed Rooting_ Kitchen E.ehatlst System
Metal Chimney/ Vents_ Air Balancing
Provide dcfailcd description of work to be done:
iv.�� \ S �Cvice�•e v� •�n �'o.0 �o�,.�.�voJ.��
CrL �'-,Z ✓s -
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 type of coverage by checking the appropriate box below:
A liability Insurance policy ✓ice 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 chocking this box0,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 shoat 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 tnsoectiolls
Date Comments
Final tttsnection
Data Comments
Type of License:
By_ ❑Master
rile_ ❑ Master-Restricted
01,/Jo•wn ❑Journeyperson
Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number. J✓
Fed 3
GAA ❑- Check at ,v:r.v m,tss rlovi1IL
Inspector Signature of Permit Approval
_.J
CITY OF SM EM. ALINSSACHUSETTS
BUILDING DEPARTMENT
p N a 120 WASHINGTON STREET, 3'FLOOR
TEL (978) 745-9595
FA-x(978) 740-98.4b
KI\BERIEY DRISCOLL THOS44s ST.PiERRE
MAYOR DIRECTOR OF pLBLIC PROPERTY/Bt;1LDL�:G COIXMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information f� Please Print Legibh
Va117C[nosiness Orsanizatiun,'Individual): \l_C�S\ ��� �em�`-'�� �`�r�,��u fU. 3ZV.L,
Address: 9-(O SoQ5-FN�1-Q c-Nl-- Rl <�-
City/State/Zip: \kAC,_ Phone #:
Are yo employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 4— 4• ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ I;un a suit proprietor or partner- listed on the attached sheet.t 7• El Remodeling
ship and have no employccs These sub-contractors have 8. ❑ Demolition
working for me in any capacity. wadcers'comp. insurance. 9. ❑ Building addition
[No workeri comp, insurance 5. ❑ We are a corporation mid its
officers have exercised their I0.❑ Electrical repairs or additions
required.] of
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, 91(4),and we have no 12.❑ Roof repairs
insurance required]t employees. [No workers'
comp. insurance required.] i3.❑ Other
'AnV applicant that checks box f 1 must also fill out the section blow showing their workers'compensation policy inlbmnation.
t I lomcuwners who wbmit this affidavit indicating ihcy are doing all work and then hire outside contractors must submit a new affidavit indicating such.
<:��ntru;wn thus check this box must attached in additiorul sheet showing the name of the sub�contraetors and their workers'comp.policy inforcrwtion.
l am an employer that is providing workers'conlpeasadon insurancefor my employees. Below is the policy and Job site
information. f
I nsurmtce Company Name: YS�-C��'C_1 C,_.f' �fi�'�!-�fC 1�SJCt��C2 CC). 3S'e'eL
Policy A or Self-ins. Liu. 0: �lW C-y00 U. S o� Expiration Date:
Job Sim Address: 33 -Cow\ City/State/Zip: Sus`ew+. vnQ
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to securu coverage as required under Section 25A oflvlGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as wail as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S25O.I1t)a day ogainst The violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for .Ij insuranc^Mid
i p v� t. (b .
do hereby certify under the pains and penallriiees of perfury that the information provided above is true and correct
'gym tT Ire' Date: lG ,l7 r'3
Phone
OJficiul use only. Do not write itt this area,to be completed by city or town official.
City or,ruwn: PermiMccnse#
Issuing Authority(circle one): -
1. Board of health 2,Building Department 3.City/rows Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
I Contact Person: -...._._-_ Phone th
VYORKERS°COMPENSATION AND;EMPLOYERS LIABILITY INSURANCE POLICY _
Information Page'' WC 600001Atlantic Charter Insurance Company VDAC
NCCI Co. No.:29211 Policy Number: WCV00668408
1. INSURED: Prior Policy Number: WCV00668407
Bright Star Heating Co., Inc.
Producer:
PO Box 607 Clement E. Desjardins
North Reading, MA 01864 Federal ID Number:042530071 Insurance Agency Inc
Risk ID Number: 19 Front Street
Salem, MA 01970
Business Type: Corporation
SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS
Other Named Insured: Other Work Places: See WCE107
2. POLICY PERIOD: The Policy Period Is From: 5/10/2013 To 5/10/2014 12:01 A.M. Standard Time
at The Insured Mailing Address,
3. COVERAGES:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our
liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
j Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insured: Part Three of the policy applies to the states, if any, listed here:
i
i
I
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
D. This policy includes these endorsements and schedules:
See WCE1,05
4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates &
Rating Plans. All information required below is subject to verification and change by audit.
Premium Basis Total Rate Per Estimated
Classifications Code Estimated Annual $100 of Annual
No. Remuneration Remuneration Premium
See WC 00 00 01
Minimum Premium: Deposit Premium:
$500 $5,505
Interim Adjustment: Annually
Servicing Office: Total Est
25 New Chardon Street Surchar�
Boston, MA 02114-4721 Total PrG
j �PI? 26 '013 _
Issue Date 04/2612 0 1 3 Countersigned By: ate j
Copyright 1987 National Council on Compensation Insurance Form: 100rm
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SHEET METAL WORKERS
AS A MASTER-UNRESTRICTED
ISSUES THE ABOVE LICENSE TO.
JAMES F MOULISON ty
{ BRIGHT STAR HEATING
RO BO.X 607
! NORTH READING MA 01864 0607
I
3550 02/28/12 926582
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