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1 HOLYOKE SQ - BUILDING INSPECTION (4) ° Commonwealth of Massachusetts CK ( z-q Y�� °�SPECT�p q�� Sheet Metal Permit �R 1c�;, 1016 bA�: � Z � Permit# � Estimated�Job�ost: $ 31, UtJ(7 Pernvt Fee: $ �� U � Plans Submitted: YES_ NO_ Plans Reviewed: YES_ NO_ NBusiness License# I 3 �p Applicant License# 3 � �o � � 9 Business Information: Property Owner/Job Location Information: � Name: L G S�✓V� V C�� s�fi�vlS Name: �O 1 V �� 1 ' �VT�41 r�li2 .L n S- � Street: L) �1 L 1/� �V��-�/ U�. Street: � i'TU' V-� v�� City/Town: �G1�G� IV �T City/T'own: �Q, ✓tn Telephone: �c C�3 `J�/� �5s� Telephone: Photo I.D. required/Copy of Photo LD. attached: YES NO_ Staftlnitlel � J-1 / -1,�ntrrestricted licen « J-2 /M-2-restricted to dwellings 3-stories or less and commercia) up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family_ Mulri-faxnily_ 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: 1� HVAC� Metal Watershed Roofing_ Kitchen Exhaust System_ Metal Chimney/Vents_ Air Balancing Provide detailed description of work to be done: �e�,.�a�(.� w u r �� e X� � �1�, c��c.�w�rl,c � or.� c, ac� vu.� � �ccvw.o�1�.-� v��t,,,� �l�c�r n1cv�- ��c�/ � ('9�-r-if/��i� INSURANCE COVERAGE: I have a current liabili insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes ENo ❑ If you have checked Yes, 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 permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box ,1 hereby certify that all of the details and Information 1 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. Date Date By rue City(rown Permit 9 Fee $ Duct inspection required prior to insulation installation: YES NO Inspector Signature of Permit Approval Progress Inspections Comments Final Inspection Comments Type of License: ETIMaster ❑ Master -Restricted ❑Journeyperson Signatureof Licensee ❑Journeyperson-Restricted License Number: 3 I `, 11 Check at www.mass.Qoy/dpl Ine t,'ommonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Eastern Vent Systems, Inc. - Address: 4 Dick Tract/ Drive WITI Arey& an employer? Check the appropriate box: 1.10 I am a employer with 18 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole prop etor or partner- listed on the attached sheet. Partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.t 5. ❑ We are a corporation and its officers have exercised their Tight of exemption per MGL c. 152, § I (4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Cglkemodefing S. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other -Any applicant that checks box #I most also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the time of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they most provide their workers' comp. policy number. I am an employer that is providing workers' compensadon insurance for my employees. Below is the policy and job site information. Insurance Company Name: West American Iris. Pokey # or Self -ins. Lie. #: XW W55824483 Expiration Date: 12/31/2016 Job Site Address: 4AS1,& ein - City/State/Zip: X, L11, M4 U 1 � 7 b Attach a copy of the workersrcompensation 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 verification. I do hereby certify Phone #: 603 J -9S_ — ff-S`7 information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town ofciaL City or Town: Permit/License 3/23 J/O 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 #: 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 hue, 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 sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy 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) 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 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 bum leaves etc.) said person is NOT required 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.eovldia