27 INTERVALE RD - BUILDING INSPECTION (2) Commonwealth of Massachusetts
Sheet Metal Permit INSPECTIONAL SERV►CES
Date: 4' 3u, I Pennity14 MAY -S q g.39 ,
Estimated Job Cost: Permit Fee: $
Plans Submitted: YES_ NO X_ Plans Reviewed: YES NO x
Business License# 591 Applicant License# y 6 ?
Business Information: Property Owner/Job Location Information:
Name: ( Pn fcal Coplina+Il re� r Tnc Name: 116LSTt�S �i fQh�RS
Street: Street:21 TU-TETWALE 12D
City/Town: -W(h Af /VIA ald'0/ City/Town: StgLCM
Telephone: --M-533- U 8F Telephone: _SO$ (o�lg• )dcj�
Photo I.D. required/Copy of Photo I.D. attached: YES-X NO
Staff inttlal
d-l-/ -I unrestricted license
'c ri.`-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.-X- over 10,000 sq. ft.— Number of Stories:
Sheet metal work to be completed: New Work: Renovation:
HVAC V Metal Watershed Roofing— Kitchen Exhaust System—
Metal Chimney/Vents,_ Air Balancing—
Provide detailed description of work to be done:
— =��ycu t tv �., C ►.�RRI- H6/�T'Pt,m'P S6�StE,m
INSURANCE COVERAGE:
I have a current liability Insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes J@ No❑
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 boxjZ,I hereby certify that all of the detalls and Information I have submitted(or entered)regarding this application are We 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
ProaressInsnections
Date Comments
Final Inspection
Date Comments
Type of License:
By Master
rme
❑Master-Restricted
Cityrrown
❑Joumeypelson Signature of Licensee
Permit# u n
❑Joumeyperson-Restricted License Number: / 7
Fee$
Check at www.mass.novldpl
Inspector Signature of
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DOUGLAS A HAMILTON
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CENTRAL COOLING AND HEAT::G`I
9 N MAPLE ST
WOBURN MA 01801-0000
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations Map#_Lot#_
Ulf 600 Washington Street Address:
Boston,AL4 02111 Permit#
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lgdblv
Name(Businessiorganizationandividual):_ C2n+TrAk Cejgj n 1 44-g -]-in *Mali
Address: q nint-- 11 runt•.D/e Siren-'
City/State/Z* \wln 6-LC-n, VAA Ci t a cr t Phone#: -781- 9.33— Ra X8
Are you an employer?Check the appropriate box: Type of project(required);
1.0 I am a employer with '70 4. ❑ I am a general contractor and I
employees(full and/or part-tune).
« have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
Ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance•
= 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑-Plumbing repairs or additions
myself o workers'comp, right of exemption per MGL
insurandrequired.]t c. 152,§I(4),and we have no 12.❑Roof repairs
employees.(No workers' 13.❑Other
comp.insurance required.]
«Any applicant thatched®box#1 must also fin out the section betowslowing their workers'crompmsefion policy information.
t Homeowners who submmt this affidavit indicating they are doing an work mid then hive outside connactore must submit a new affidevitindicnting such.
tContractotn that check tide box m n attached-en additional shell showing the name of the subcontractors and state whether or not those entities have
employces. If the subrunuacron haveemploym,theymustprowde their worim'conm:poncynornba
lam an employer that is providing workers'compensation insurance for my entployeea Below is the policy and job a&e
Information.
'Insurance Company Name: Ig (� De I G Tin d e tra n r* rnSL t'o,nC u to
Policy#or Self-ins.Lic.#.- 664 N.?-h 1.3 Expiration Date: 11 136' zc IV
Job Site Address:_ oZ 9 lbk-1y/a—Iif f/ i� City/State/Zip: 36* � NA U�2 5,p
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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
Tauter ti of DIA for insurance co a veri5cation
I do hereby 70 the pains and PenalHea ojPafnry that the injormaton provided above is true and correct
D
Phone* -1 R 1 - 933-&6?
1Moxxtu use only. Do not wr fie this area,to a comp by city or town o icial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.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 hire,
express or implied,and 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-contractors)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 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 oonf rmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retuned 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 per mitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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 mind be tilled old 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 numrber.
The Commonwealth of Massachusetts
Dt pa tMent of h dusUW A=dmts
Office of Investigations
6W Washington street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 11-22-06 Fax#617-727-7749
www.mass.gov/dia