90 LAFAYETTE ST - BUILDING INSPECTION (9) � �� � '-NO 23�p
Common�vealth of Nlassachusetts
Sheet Nletal Permit
. Da[e: v Z� "l.° ��P Pen„it tt
;� I:stim.itcd Jub Cbst $ 3 C7 d v O Pennit Fee: $ � `J � �
� Plans Submitted: YES NO Plans Rcvie�v�d: YES NO
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� 13usiness License # 3 1 ,0� Applicant License # ���D �____
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rf1 I3usiness [nformation: Property Owner/Job Location Information:
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�' Name: G S V ��\A����� �N`� � Name: �o.�i l� �!'�\� �� �"(,U,�
p v`�e�,��c2l�,w�,
screet: 3 '� �J f o�.�v�o� �s�' � streer. �'1�_ t��,`1��� �', I1—,'E y�_
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City/'fown: ��\U'' � \�_ City/Town: S h� �,G, ,
Celephone:� � �� ���"� �� �� Telephone:
Photu LD, required / Copy oF Plwto LD. attached: YES V NO
s wrr i��ie:�i
J-1 1-1 unrestricted license
J-2 / 1�[-2-restricted to d�vellings 3-stories or less and commercial up to 10,000 sq. ft. / 2-storics or less
Residential: 1-Z family Multi-tamily Condo/To�vnhouses Other
Commcrcial: Oftice_ Retail (ndustrial Educational
[nstitutional _ Other�
Square Footage: under 10,000 sq. tt. V uver 10,000 sq. tt. _ Number of Stories: I
Sheet metal work to be completed: New Work: � Renovation:
1-iVAC _ Metul �,Vatershed Rooting Kitchen Exhaust System V
Metal Chimney/ Vents_ rlir 13alancing_
Pruvide detailed description oF�vork to be done:
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INSURANCE COVERAGE:
I have a current liabilit insurance policy or its equivalent which meets[he 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 � Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the ticensee does not have the insurance coverege required by Chapter 112 of tk�e
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
` C ck One Only
�fiv`�W\ �J ♦ � '" �n`�' Owner ❑ Agent ❑
Signalure of Owner or Owner's Agent
By checking this box�here6y certify that all of the details and Informatlon I have su6mitted(or entered)-regarding this applicatlon are true and ,
accurate to the best of my knowledge and that all sheet metal work and Installatlons performed under the permit issued tor this application will be
in compliance with all pertinant provislon of the Massachusetb Building Code and Chapter 112 of the General Laws.
Duct fnspection required prior to insulation installation: YES_ NO_
Progress [usaections I
Date CommenCs
Final fuspection
Date Comments
Type of License:
By ❑ Master �
7iue -❑ Master-Restricted
CityiTown - ��ourneyperson
Signature of Licensee
Pennit#
❑Joumeyperson-Restricted License Number.
Fee 5 �
��� (��� � Checkatwww.inass.qov/dUl
��u
Inspector Signatura ol Pe�mit Approval
CS VENTILATION �nvoice
P.O. BOX 1409 7-�l � 1,1�t�� C�.�... oate �nvoice#
1-781-246-9300 p1 � �O
FAX 1-781-246-9311 siiai2oi6 s�ats
WAKEFIELD, MA 01880 ��$ ' Z�� �2-3
Bill To
' ADEA'S MEDITERRANEAN KITCHEN LLC �
90 LAFAYETTE STREET
SALEM,MA 01970
DAV[D WINER
P.O. No. Terms Project
Due on receipt
Quantity Description Rate Amount
� 3Q000.00 30,000.00
l. INSTALL 8-10"' STA[NLESS STEEL HOOD WITH MAKE UP AIR
2. INSTALL UPBLAST EXHAUST FAN WITH CURB AND HINGE KIT
3. INSTALL IN LINE MAKE UP AIR SYSTGM WITH LOWER
4. INSTALL APPROXIMATELY 20'(10"X18")CARBIDE STEEL DUCTWORK
5. INSTALL(2) UL300 ACCESS PANELS
6. INSULATE DUCTWORK WITH FIAE RATED INSULATION
Z INSTALL 12'STAINLESS STEEL WALL PANELING WITH MOLDINGS
8. INSTALL UL300 FIRE SUPPRESSION SYSTEM,INCLUDES ALL PARTS AND
LABOR
9. CRANE SERVICE
lO.ENGINEERED STAMPED DRAWINGS
11.SALEM BUILDING DEPARTMENT MECHANICAL PERMIT
12.INSTALL APPROXIMATELY 1S(14" SPIRAL DUCT)MAKE UP AIR DUCT
13.SALEM FIRE DEPARTMENT ANSUL AND WELDING PERMIT
14.SALEM F1RE DEPARTMENT BURN DETAIL
IS.LABOR AND MATERIAL
16.CAPTNEAIRE ENERGY MANAGEMENT SYSTEM
17.CAPTIVEAIRE ELECTRICAL PACKAGE
18.CELLUNOID VALVE&CO2 PACKAGE
NOT INCLUDED IN QUOTE
ALARM*ROOFING*WALL AND FLOOR
PENETRATIONS*PLUMBING*ELECTRICAL*CARPENTRY*
TOTAL PRICE$30,000.00
DEPOSIT$I5,000.00
Tae 625% 0.00
work pending
Total $30,000.00
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� �11 Massachusetts -Department of Public Safety
Board of Building Regulations and Standards • • �
Constructiun Supcnisnr .
License: CS-091228 � `
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DANIEL J OBOYI� - �s,
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Commissioner OB/0?/2018
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� The Comraonwealth ofMassachrr�etts
Deparbnent ojlndustrwlAccidents
'+ I Coxgress Sbeet,Suite 100
Boston,MA 02I14-ZO17
- www mas.�gov/dia
- �'Porkers'Compensation Insurance�davit:Builders/ConUactors/Electricians/Plnmbers.
TO BE FII,ED�{7Tg TgE PII2hII'IZ'p�G AUTHORITY.
' licant Intormstlon Pleue Print b
Name�a,��n�o��rion�a�ria��t�: GS �/�Y� ` a �21n "�r G
Address: � � � tUwrlvv� �� `1`>`QvY�-�`�j'e.`(� , �f� 61auc�
City/State/Zip: � A��.(�2.,��1 � �V`�� Phone#: � 1�J1 — 2C'�' �' — �`�6C�
N�o m employerY Check fhe approp�iste bwc:
i. i mn a empioyer wim �—� TYPe otproject(required):
�P�Y�(full anNor part.Gme).•
2.Q l am a sole puopneMr or 7- ❑New construction
parmcrship and Aave no employcey worlung for me m
eny capacily.[No warkets'�comp.ros�uance mqu'ved] $• ❑RCmOde]ltlg
3.Q I�a h�cowner doing all woik myaelf.[No warkers• ,py,,;�� 9. ❑Demolition
comy.mamsnce 1
4.❑I am a homeowna md wi0 be 6iriog contractms to conduct all work on my jeoperty. I wii) 10 0�j�B addition
eos�ue ihat all aontractms either have workers'compeusation ms�uanu or are mle 11.❑EleCtricel lepairs or eddltiOns
(ROpl1CIOlS WII�I 00 pppIOYW.
I2.❑P�lQi1}1171g7CF781TS 079aaldOIIS
5.❑1 em e Be�n1 connactor and I have h'ned tLe aub-co�actors listed on the atta�ed aLeet.
7hese subcontrauors have employees and have workrad comp,ioy�umce.r 13.�Roof s �
6.❑We are a coryoratim and ita officas Lave uercised We'vright of uemption pv MGL c. 14:�Ot112I I� �
]sZ,5�(<),m,a we na.re no emyloyea.[No wohers•camp.;ns,u�,nm,eq�Qod,) ,8 �' J�
f' [��'
'�Y aPPlicant that checlo boz#1 must alw 511 out the sec4am below showmg t6e6 wmkas'comPmsetlm poHq infmma4m.
. t Homeownm who subimt t6is aflidavit iodiuting thry are domg all wak md tLm 6ire ou�side contrncton must su�it a new a6devit indiwting sucL.
� �Contrecton t�t check this box must atmc6ed eo edditional sAat s6owing the n�e ofthe sub-cmtractas a�state whetber aP not those mtitia 6ave
ea�loyees. IfthesubcontractorsheveemP��,�Ymuctprovidethe'v workers'comD_Po]icymmba.
1 aro au emp/oyer,that rs providing workers'compensatlox insurance jar my employees. Below is fhepalicy and job aite
Injorma6on. ,,y��
Ins�uance Company Name:�!`w�v,�'.� �l.l"\�F.NI Y�\� c� �/Y�{,��u�
Policy p or Self-ias.Lic.#: 1 �' r � 6 ��j Exp'uation Date: 5' �— Z���
Job Site Address: �b 1����-+Y�`�, S'/ � ty�,Q�� �ty/���P: 5��� yv��
Attach a copy ot the workers'compe tion p6llry dec stioa page(showing tLe poticy number and eap ation date}
Fail�ue to secure coverage es required�mder MGL c. 152,§25A is a criminel vfolatioa punishab]e by a Sne up to$1,500.00
and/or one-year imprisonment,as well as civi]penelties in the form of a STOP WORK ORDER and a fine of up to$250.00 a �
day age'vist tLe violator.A copy of this atatement may be forwerded to the OH'ice of Investigations of the DL1 for insurance
coverage vai5cation.
I do hereby ceitijy under thepains andpena/t(¢s ofperjury thot the injormoflon pmvided abore is true and eonec�
Signenue: �+'��� � �(�ln��.t� � Date• �O��i`y V' � �f
Phone#: � S� ' Z��n. C1�0
O�cral use on!}s Do aot wr#e in tlris areq to be eomplded by city or town ofJiciaL
City or Town• Permit/License#
Issoing Authoriry(circle one):
l.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Ot6er
Contsct Person• PAone#:
Information and Instructions
Massachusetts General Laws chapter 152 requues all employers to provide warkers'compensation for their employees.
Piasuant to tlus statute,an emp/oyee is de5ned as"...every person m the service of another under any con4act of Lire,
express or implied,oral or written." - -
An employe�is de5ned as"an 'u�dividual,pa�ersfip,essociation,cmporatioa or other legal entity,or any two m more _
of the foregoing engaged in a joint enterprise,and'mcluding the legal representatives of a deceased etn�loyer,or the
receiver or trustee of mi individual,partoersh�P,association or other legal entity,employinB employees. However the
owner of a dwelling house bavmg not more then three apartmems and who resides therein,or the occupant of the
dwelling house of another wLo employs persons to do maintenance,construction or repair work on such dwelling house
m on the groimds or build'mg appurtenant tLereto shall not because of such em�loyment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall with6old the issuance or
ronewal of a license or permit to operate a business or to constraM buildings in the commonweakh for any
applicant wLo has not produced aaeptable evidence of compiiance wkh the in;arance coversge required."
Additionally,MGL chapt� 152,§25C(�states"Neither the coTmnonwealtL nar any of ifs politicsl subdivisions s1�a11
enta into any contract for the performance of public work until accepteble evidence of compliance with the ms�aence
requirements of this chapter have been presented to the coatracting authority."
Applicaats
Please 511 out the workers'compensation affidavit wmp]Mely,by checking the boxes that apply to yoiu situation and,if
necessary,supply subcontractor(s)aame(s),address(es)and phone number(s)along with theu certificate(s)of
insurance. Limited Liability Comp�ies(I.LG�or Limited Liability Parmerships(iS,P)with no employees other than the
members or partners,are not required to cazry workers' compensation insiaance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Depariment of Industrial
Accidents for�confirmation of insurance coverage. A1so be sure to sign and dah the affidavit T'he af5davit should
be retumed to the city or town that the application for the pennit or license is being requested,not the Department of
Indusuial Accidents. Should you have any questions regarding the law or if you are requ'ved to obtain a workers'
� compensation policy,please call the Depaztment at the munber lis[ed below. Self-insured companies should enter their
self-ins�aance license number on the o 'ate line.
City or Towa Og'icials ' -
Please be s�se thet the affidavit is complete�d printed]e�bly. The Depariment has provided a space at the bottom
of the affidavit fm you to 511 out in the event the Office of Investigations has to contact you regazdiag the applicent.
Please be sure to 5ll in the permiUlicense number which will be used as a reference aumber. In additioa,an applicant
that must submit multiple pemridlicense applications in eny gven year,need only subuut one affidavit mdicating cu*rent
. policy infoimation(if necessary)and under"Job Site Address"the applicant should write"sll locations m (city or
town)."A copY of the affidavit tUat has been officially stamped ar marked by the city or town may be provided to the
applicant es proof that a valid affidavit is on file for future perrrriis or licenses. A new af5davit must be filled out each
year.Where a home owner or citizen is obtaining a licrnse or pemiit not related to any business or commercial venture
(i.e.a dog license or pemnt to bum leaves etc.)said person is NOT required to wmplete this affidavit.
The Departnent's address,telephone and fax aumber: �
T'he Commonwealth of Massachusetts
Department of Indus�ial Accidents �
1 Congress Street, Suite 100
Boston,MA 02 1 14-20 1 7
Tel. #677-727-4900 ext. 7406 or 1-877-MASSAFE
Fvc#617-727-7749
Revised 02-23-15 www•m3SS.gov/dla
REVISIONS BY
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