11 LOVETT ST - BUILDING INSPECTION z c*, � �
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Commonwealth of lN.lassachusc tse IOHAI SERVICES
Sheet (Metal Permit 10i6 APR I I P 121
Date: 11 1
Permit
M Estinimed Job Cost .S &C _ - —
1'crmit
Plans Suhmiued: YES_ NO_ Plans Reviewed: I.ES NO _
Business license d Applicant License k -_ l?38
Business Infbrmation:_� u G1 acK Property Owner/Job Location
/information:
1 Name: 1QS �rorsm✓iCa�L Name: urr
Street: Street:
city/town: /_ NA/ AV4 4019a �L sSALr�t �/1 0/9 70
City/Town:
Telephone: _J8( -Wr 55-79 Telephone:
Photo I.D. required/Cupy of Photo I.D. attached: YES— NO_
J-1I-1 mrestrictcdlicense
J-2/M-2-restricted to dwellings ]-stories or less and cwnnnercial up to 10,00o sq. ft. /2-stories or less
Residential: 1-2 family blulti-lamily_ Condo/Townhouses_ Other
Commercial: Office_ Retail_ Industrial_ Educational_
Institutional_ Other_
Square Footage: under 10.000 sq. It.-YL over 10,000 sq. ft._ Number of Stories: _
Sheet nnctal work to he completed: New Work: Renovation:
I IVAC bktal Watershed Routing'— Kitchen Exhaust System
Metal Chinmey i Vents_ Air Balancing
Provide detailed description of work to be done:
�l LEA EJr.�7�u�o✓� �,c6i cue /S�f � //c'_
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Mkk uEo y f l S
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INSURANCE COVERAGE: ���(fI
I have a current liability Insurance policy or its equivalent which moats the requirements of M.G.L.Ch.112 Yes)<y No❑
If you have checked Yes. Indicate the rypa of coverage by checking the appropriate boa below:
A liability Insurance policy Other type of Indemnity ❑
Bond ❑
ee does not have the
OWNER'S INSURANCE WAIVER:I am that ware that
signature on ton this permit n waiverathis equirence menquired by Chapter 112 of the
Massachusotis General Laws, Check One Only
Owner ❑ Agent ❑
signature of Owner or Owners Agent
accurate to the beat of my knowledge and that all shoat metal work and Installs tlods performed under the permit Issued for this application will be
By chocking this boat,I hereby comfy that Sit of the details and Information I have submitted(or entered)regarding this application are true an
In curate t the
with o pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
o Insulation Installation: YES__NO
Duct Inspection required prior t
Proaress 111SMMielts
Comments
Datd
Fie�l Its ci�ott
o nmdnts
D:�ta
Type of License:
By Iasler
role ❑Alaster•Restricted
,
$; natLu/re of Licensee l
Cayao•.w+_,�. — ❑Jaurneyperson 9I
i
❑Journeyperson•Restricted Lic rise Number;
r,w i .___ — ❑ __.____ Check at;,.y*." n_._. '_'l 'I0""L
1
b+sputlor Si p+ahue of Permit Approval
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
uVo,workers'Compensation
I Congress Street, Suite I00
Boston,MA 02114-2017wwwmass.gov/dia
Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le¢ibly
,p Name (Business/Organization/Individual): ,k>Sqi 1 4,t/C r1
Address: rdti S
City/State/Zip: A4-0-U06 Phone#: 3D8 7M c7 9(37
Are you an employer?Check the appropriate box: Type of project(required):
1.R I am a employer with employees(full and/or part-time).* 7. ❑New construction
2. I a sole proprietor or partnership and have no employees working for me in 8. Remodeling
ny capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑1 am a homeowner doing all work myself[No workers'comp.insurance required.]t
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.= iiii lther����,,,,�R�R
6.F-1 We are a corporation and its officers have exercised their right of exemption per MGL c.
1�iG�?'7P�L
152,§1(4),and we have no employees.[No workers'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 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 must provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c i under th , aims an penalti ofperjury that the information provided ab ve i true and correct.
Signature: �/ Date: �t l
Phone#: 1`3
Official tr4olonly. Do not write in this area,to be completed by city or town official
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
Phone#•
Contact Person•
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 ajoint 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`leinsing 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 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 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02 1 14-20 1 7
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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