2 LARCH AVE - BUILDING INSPECTION (2) Commonwealth of Massachusetts
Sheet Metal Permit
Date: -7/i -, Permit#
Estimated Job Cost: $ Permit Fee: $ olt/
Plans Submitted: YES_ NO X Plans Reviewed: YES_ NO X
Business License# Sol Applicant License#
Business Information: Property Owner/Job Location Information:
Name: C'en+c-al CoOlino +1a2re} Tnc Name: ff<.e0 17
Street: 9 Nerjjn ryiaDlT S-ftee,�- Street: 2 Larct?
city/Town: Wc,6urn, /YIA 0401 Cityaown: 24(ewc m2oq
Telephone: 7 F;L q 33- 2 . U Y Telephone: �7X-76 7- �=k
Photo I.D. required/Copy of Photo I.D. attached: YES_X NO_
Staff Waal
dd-/ I-1 unrestricted license
o--rrestricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less
Residential: 1-2 family X 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: 2
Sheet metal work to be completed: New Work: Renovation:
HVAC.>c Metal Watershed Roofing_ Kitchen Exhaust System_
Metal Chimney/Vents_ Air Balancing
Provide detailed description of work to be done:
T/ig jtA n eui oMcn cArel i y el a13= �jnF dl l - 2AI P
//
INSURANCE COVERAGE:
I have a current liabili 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 ® 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 am 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.
Duct inspection required prior to insulation installation:YES_NO
Progress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By ® Master
Title
❑Master-Restricted
Cityrown
❑Joumeyperson Signature of Licensee
Permit# 4
❑Joumeyperson-Restricted License Number: 4 6 1
Fee$
❑ Check at www.mass.nov/dol
Inspector SI ature of Permit Approval
COMMONWEALTH OF MASSACHUSETTS M`ASSACHIISET ,S,' DRIVER'S
. :. . •. . , ra , LICENSE
PLUMBERS AND GASFITTERS
REGISTERED AS A PLUMBING CORP da 01.262011¢.NONE•tl$9413.7w91"
ISSUES THE ABOVE LICENSE TO: --
�1142-2015 11-0 52
MICHAEL BERNASCONI r•" i-nm saexM +e
CENTRAL COOLING 8 HEATING INC s . e
58 ALBATROSS RD ;y r BERNASCONI
2 MICHAEL C yiaslcst'4--.
e 58 ALBATROSS RD
QUINCY MA 02169-2658 QUINCY,MA 02169.2658
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28.0.6 05/01/14 210316. ,
EXPIRATIONDATE SERIALNO.
COMMONWEALTH OF MASSACHUSETTS
. .
PLUMBERS AND GASFITTERS
LICENSED AS A MASTER PLUMBER .
ss
`ISSUES THE ABOVE LICENSE TO'.
MICHAEL C BERNASCONI
m
- s
56 ALBATROSS RD
OUINCY ` MA 0216,9-2658
5137 05/01/14 169605
• ,.
COMMONWEALTH OF MASSACHUSETTS
PLUMBERS AND GASFITTERS r
LICENSED AS A JOURNEYMAN PL,iMBE
ISSUES THE ABOVE LICENSE TO:
MICHAEL C BERNASCONI 2
58 ALBATROSS RD
QUINCY MA 02169-2658
26474 05/01/14 16960.
LICENSE NO. EXPIRATION DATE SERIAL NO.
COMMONWEALTH OF MASSACHUSETTS.
AS A;,MASTER-UNRESTRICTED.
- -ISSUES THE ABOVE LICENSE TO:
MICHAEL :C BERNASCONI
58 ALBATROSS RD
QUINCY: MA 02169-2658
359 11/28/13 16572
. . r
AS A BUSINESS
i,^3f)V; i!Ctt L n):
DOUGLAS A HAMILTON
CENTRAL COOLING AND HEATIN
9 N MAPLE ST _ p;
WOBURN, MA 01801-0 EFO''
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52 08/30/14 222999.
d 4 o COMMONWEALTH OF MASSACHUSETTS
AS A MASTER-UNRESTRICTED:
„ISSLWS lH ABOVI I ICrNSF I
DOUGLAS A HAMILTON
CENTRAL COOLING 8 HEAT
9 NORTH MAPLE STREET
x''*'"' .WOBURN MA 01801-1.71,i
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations Map#_ Lot#_
600 Washington Street Address:
Boston,MA 02111 Permit#
Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information. Please Print LeEibly
Name(Business/Organization/Individual)'. C e n-�t-a I l f-)G 11 /1A + H COI+in
Address: 9 m 64,6 ma.el2 Sh-ee-)`"
City/State/Zip: Wnbuf I YNt9 61?01 Phone#:
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-time).
s have hired the sub-contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
These sub-contractors have
ship and have no employees 8. ❑ Demolition
working for me in any capacity. employees and have workers'
co insurance.t 9. ❑Building addition
[No workers' comp.insurance mP•
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 I LF
-1 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12. Roof
insurance required.].i c. 152,§1(4),and we have no ❑ repairs
employees. [No workers' 13.19 Other &Y&,-
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. .
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside cant actors must submit a new affidavit indicating such.
1Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontreetots have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance jar my employees Below is the policy curd job site
information.
Insurance Company Name: G L 6 B A L _TW Su k ANCF A -6 T W6 P i( I SN1-,
Policy#or Self-ins..Lic.#: ?5:n cA] �2 2 (o,2 to Expiration Date: 11 /16 Za 6/a
Job Site Address: Z LcLcL k Nv-2 City/State/Zip: So.�'QVw M 6
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 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 under the pains and penalties ofperjury that the information provided above is true and correct
Signature: 1z - Date: g a L/�/z
Phone#:
Offrcia[use only. Do not write in this area,to be completed by city or town offrciaL
City or Town Permit/License#
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 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 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 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.Deparlment 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 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 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.)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
Mpartment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 11-22-06 www maSS,gov/dia