45 GALLOWS HILL RD - BUILDING INSPECTION (3) i
Commonwealth of Massachusetts
t l � Date: Sheet Metal Permit
I�WW 2-I�I ��- permit#
Estimated Job Cost: $ Permit Fee: $47 7 6
Plans Submitted: YES NO X Plans Reviewed: YES NO k
Business License# Applicant License# 15-X
Business Information: Property Owner/Job Location Information:
Name: Cemkc ,y Ca�jnA +i\a Name: 34qkx4'L -i- Deddrok TIUC[1.e,�
Street: 9 (F Street: Lff- Gal)¢Lq.r 4,11 fZuak
City/Town: 1/ A t&f/l , yyl City/Town: J U 12v\r\ VA c4
Telephone: Telephone: G -2F- 7yy - 7 L/d
Photo I.D. required/Copy of Photo I.D. attached: YES NO
stert bwael
J-1/ I�-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 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:
Z-5 f wU rXim A-lC Sud� a&j duG1Wrrk.
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes 2 No❑
B you have checked Yes.Indicate the type of coverage by checking the appropriate box below:
A liability insurance policy 0 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 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
Prowess Inspections
Date Comments
Final Inspection
Date Comments
Type icense:
By_ Master DA,,
Title
❑Master-Restricted
CiryA# \\
❑Joumeyperson
Signature of Licensee
Pe ❑Joumeyperson-Restricted License Number: y L9
Fee ❑
Check at wvvw.mass.govIdol
Inspector Signature of Permit App(rbw—
I4LTheCommonwealth of Massachusetts
Department ofindushid Accidents
Office oflnvestigadons Map#_Lot#_
9 600 Washington Street Address:
Boston,MA 02111 Permit#
www moss gov/dia
Workers' Compensation Insurance Affidavit: Bailders/Contractors/Elects icians/Piumbers
Applicant Information Please Print Legibly
Name(Bus nesdotgm;zation/Iudividual): C 2 o. W + Tn e
Address:_
City/State/Zip: (,)A}u fn - rn)q 61ral Phone k 7R I -933-W-H
Are you an employer?Check the appropriate box. Type of project(required):
1.® I am a employer with r7O 4. ❑ I am a general contractor and I
employees(full and/or part-time)."' have hired the subcontractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in capacity. employees and have workers' B '
[No workers'comp.insurance comp•insurance.$ 9. ❑ uilding addition
required.) 5: ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself[No workers'comp. right of exemption per MGL 12. Roof
insurance required.]t c. 152,§1(4),and we have no ❑
employees.[No workers' 13.❑Other I h A
comp,insurance required.]
'Any appliceot d atcheeb box#1 must also till out the section below stowing theirwerkae'mtpmsation policy btformudon.
t Monomers who eobnmt this atBdsvitmdioeft guyamdoingallworkendthenhmouW&contemanmuetsubmitanewaffdavitmdimmgsuch;
tContmotme that check this box mmatamebad en additional sheet abowmg the name oft be sulicommatots end inae wbeaw ornotdime iabtine have
ampioyeea. If the eubcmmacon have employees,they must provide aair works i'oomp•policy number.
IaW an eneptoyer dhat Lsproviding workers'eonapensedon haswance formy employees Betow Ls thepolkoyead job sbe
Information.
hiamanoecompanyName: CL6BAL 7'WS $ZAN C I-cT r�j!K ,X (-
Policy#or Self-ins..Lic.# ��nnA e�rr9 fe.2 G Expiration Date:_ 11 196 .761,2
li
Job Site Address: Y6- -a.(1 m /< 17 i 1 i n6 P City/Smtaq i S d ip Al
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 cavil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against die violator. Be advised that a copy of this statement may be forwarded to the Office of
hxvtadaetions of the DIA for insurance coverage verification:
I do h the pdkud pmallo ofpedwy thud the Information provided above Is due and correct
UuMal use only o not write in thirarea,to comp or town odledaL
City or Town: Permit/License#
Inning Authority(drele one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone k
Infor
mation 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 coact 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 to persons to do maintenance,construction or repair work on such dwelling house
llmg employs
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( )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 sub-contractor(s)name(s),address(es)and phone number(s)along with their ca tificat e(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or parmera,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 submWed 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 lime.
City or Town Officials
Please be sure that the affidavit is complete and legibly.' The Department has provided a space at the bottom
� 1
has to contact u the applicant.
of the affidavit for you to fill out in the event the Office of Investigations you regarding app
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 'cense applications in any given year,need only submit one affidavit indicating cogent
policy information wider"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 maybe provided to the
applicant as proof that a valid affidavit is on file for firtue permits or licenses. Anew affidavit must be filled out each
year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)add person is NOT requited to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number.
Tile Commonwealth of Massachusetts
D*uhnent of Industrial Acmdents
-OMM of Investiatlona
6W Washington Street
Boston,MA 02111
Tel.#617-7274M sift 406 or 1-877-MASSAFE
Fax#617-727-7744
Revised t 1-22 06 www.mass gov/dia
r
COMMONWEALTH OF MASSACHUSETTS
--SHEET ME I AL-WURKERS
AS A BUSINESS
ISSUES THE ABOVE LICENSE TO:
i
DOUGLAS A HAMILTON v
CENTRAL .000LING AND HEATING INC
9 N MAPLE ST y.
WOBURN MA 01801-0000
52 08/30/12 968638
LICENSE NO. EXPIRATION DATE SERIAL NO,
Fold,Then Detach Along All Pedorations
4+if;
COMMONWEALTH OF MASSACHUSETTS
t
AS AMASTER-UNRESTRICTED
„I ISSUL'S FtEAf)OVI.:IIGI N;6 1O:' j
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~�. CENTRAL COOLING & HEAT c
9 NORTH MAPLE STREET
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