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Building Permits (3)
RE� ED Np� 09 2015 i � �r�ctitc�r Office Use Only &p-14 tea: EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: Map: Parcel: OWNER -)roc Mike CONTRACTOR expires 180 days from Email Address: NAME West Denn13;'Ii M s TE-s Email Address: Residential Coi(508) 280-6964 Esc Cost of Construction f 5' CSI -58633 HIC-169393 Home Improvement Contractor La # Construction Supervisor Uc. # Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor Insurance Company Name: Compensation Comp. Policy# WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Siding: # of Squares Replacement windows: # Roofing: # of Squares ( ) Remove pdsting' (max. 2 layers) Old Rings Highway/Historic Dist. ( ) Replacing Eke for like 'The d&ds will Location I declare under penalties of pedury that it will be justcause for denial orrevocation Applicant's Ownerssignature Wood Stove Replacement doors: # Insulation correct to the best of my knowledge and belief. I understand that my false answv(s) LCiL at. 268, Section 1. Appmved By Data Building Official (or designee) Zoning District: flistorical District: Yes No Flood Plain Zone: Yes Water Resource Protection District Within 100 R of Wetlands: Yes No Yes No No The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleadcians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORMY. AvOicant Information Please Print Legibly Name (Business/organization/Individual): Address: Phone #: Are you an employer! Cheek the appropriate box: 1.0 I am a employer with employees (full and/or pan -time}• 2❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ lam a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensue that all contractor either have workers' compensation insurance or are sole pmpriemn with no employees. 5.❑ lam a general contractor and I hnve hired the sub-eamacton listed on the Attached sheet. Then subeomnctas have employees and have workers' comp. insurance: 6.❑ We are a corporation and its officers have exeretxd their right of exemption per MGL c. M I1(4), and we have no employee. [No workers' comp. insurance required.] •Arty applicant that cheeks brat 61 must also fill out the section belov t Homeowners who submit this affidavit radiating they are doing all :Contractors that cheek this box must atachd an additional sheet six employees. If the subcontractors have employees, they must provide Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other ving then workers' compensation policy infommtion. and then hire outside contractors must submit a new affidavit indicting such. the name of the sub-emmacmrs and grate whedw or not those entities have workers' comp. policy number. I am an employer that Is providing workers' compensadon Gtturaace for my employees. Below is the policy and job site lnformadon. Insurance Company Name: Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/StatdZip: 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 certify under Signature: Date: Phone M O1licial use only. Do not write In this area, to be completed by city or town offiklal, City or Town: PermWLicense true and correex 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 than apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) 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 cant' 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 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia OWNER AUTHORIZATION FORM DaMico owner of the property located at 53 Lewis Bay Boulevard West Yarmouth, MA 02673 (Property ) 747 , . an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a buAding permit and to perform work on my property. Date r` i Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction .nr License: CS-0584)58 633 MICAAELJMCQkR t PO BOX 52 : IV W BOX 52 MA r„nl' Expiration Commissioner 04110=16 pi ���ie �pdnv�,o�ule�a� o�Ci�� aacfic�el,�. Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement C" ntfactor Registration w Registration: 169393 Type: Individual 017 MICHAEL MCCARTHY MICHAEL MCCARTHY , TM P.O. BOX 52 WEST DENNIS, MA 02670 2U961 G• v _ �,;:z'. Update Ad ess and return nrd. Mark reason for change. xsasnt E Address Renewal L. II Employment jD Lost Card The Commonwealilr vfMassaehusells Department ojJndrlstrlaMeefdents I Congress Street, Stifle Mo Boston, MA 02114-2017 www.massgov/dla Wworkers,compe,itsatioulniurtin - cAffidavit: Bailders/Contneton/Mectrieians/Plombery TO BEFfUDWrmTnEPERmrmNCAi rnORrry. Applicantinformation Mike c a —6O-PIeasePrint Le�(y Name(BasirretslOrganizatiott/Gdividuaq: _ 'wADe1FS2 Address: West Dennis, MA 02670 Anise a tnpleyery peck them prtela box: _ 1. I ect (required): rn ■ errylora with aploym (Ihn erdhr par4ame}• onstruction 2[]1emasobPropidwwparloadripendhawmemployeewaking fumeinay eling3.[] aptly. [NO worten• comp. he nKe lequirad.) IF I am a Mew nane,dotng on wort myselr (No wottm• came tonaarrerequired]1tionerr o hormowva W wv'n 6e Mine rorarctors b artdrtl JI coat a ary propary, t coat g addition crown aw m corereetas either be`o vnkors- apermlion tm ,,,, a m We proprietors with an apoyeez cal repairs or additions S.[] 1 rn a general ardraaa and 1 hero hued ate rdreontreclas lukd en as anached sheet 12.[]Plumbing repairs or additions . `Fhem mbconinamis have employees and hove wortm' comp. innaeme i 13.[] Roof repairs 6.[] we are a earpaalton "A its elricm have exercised their right oreceaelon MCL e. 14. dOther pa IS2.1101 and we have m a otiloyeea. [No wortm• comp: hmaura mqukrd.l •Any apprara that checks boa at was aim fill ant the anion blow slowing aver wortm' ante wtial policy hrfornrtton. t tlomeowwas who MLmlt iris a?davil Indicating they are doing an wit and cite like awide connector, anrt mina anew alrdevit hdicuurg such. lCone"em a MW ehed this bait anal emched an addllieal Am drawing We arm artba mll aW oan d d state whether or ou not thenfran Mw awayce . Vote subcrararJas hove employee, they eat provide their wortm• conarL policy Rumba. - - 1 met an employer that Is provldlng, workers'tompensallon lnsrrrdnerjor my lnjormaaon employers Below Is the policy andlob site Insurance Company Name- ATM M.,l.r_I . T_. . r Policy p or Self -ins. Lie. p:Expiration Date: )1)if )11 Job Site Address: CilyNtatemp: Attach a copy.or the workers' compensation policy declaration page (showing the policy number sad expiation date} Failure to secure coverage as required under MCL e.152,12SA is a criminal violation punishable by a fine up to $1.500.00 and/or ono-yar imprisonment, as well as civil penalties In the form Us STOP WORK ORDER and a fine orup to S250.0o ■ day against the violator. A copy of this statement may be forwarded to the Office of investigations of the DiA for insurance coverage verification. 1 do hereby flint OJJklal rue only. Do not write in this arm, to be completed by city or town oJJlelot City orTown: Permit/Ilcense t/ Issuing Authority (circle one): 1. Board of ilealth 2. Building Department 3. Cityfrown Clerk 4. Electrical inspector S. Plumbing inspector 6.Other Contact Person- Phone WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMRTWPAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICYNO. VW4100.6017656-Ff PRIOR NO. I VW41015-6017656-2014A ITEM 1. The Insured: Michael McCa" Constriction Inc DBA Meiling address: P O Box 52 FEIN: "-"'3862 West Dennis, MA 02670 Legal Entity Type: Corporation Otimer workplaces not shown above: See Location 2. The policy period Is from 12/15=14 to 121IS2015 12.•01 a.m. standard time at the Insureds mailing address. 3. A. Workers Compensation Insurance: Part One of the poky applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work ki each state listed in item 3A The Omits o1 liability under Part Two are: Bodily Injury by Accident $ 500,000.each accident Bodily Injury by Disease $ 500,000 policy Omit Body Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below Is subject to verification and charge by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated • No. Total Amial OI Annual Rertameraaon Remuneration Premium INTEA 0712979 INTER SEJ CLASS CODE SCHEDI/ Minimum Premium $550 GOV STATE I GOV CLASS MA 1 5479 Total Estimated Annual Premium $29,332 Deposit Premium $7,748 State Assessments/Surcharges $28,601.00 x 5.8000% $1,659 This policy, including all endorsements, Is hereby countersigned by 12115=14 —De-- Service Office: Bryden ✓L Sullivan Ins Agcy of Dennis Inc 54 Third Avenue PO Box Burtirgton MA 01803 So Dennis,sMM A 02660 WC 00 00 Ot A (7-11) kichrdee coPYriahW melariel of the National Comca on Compenuaon lnsu , i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY C S MA DATE PERMIT# JOBSTTEADDRESS 3 Lgwix ogy gL✓v• OWNERS NAME Tosr" P1&j&e GOWNER ADDRESS I TEl FAXO 1PRINTR OCCUPANCYTYPE COMMERCIAL❑' EDUCATIONAL'❑ • RESIDENTIAL® CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO❑ APPLIANCES I FLOORS BSM 1 2 3 4 5 1 6 7 8 9 1 10 1 11 1 12 13 14 BOILER BOOSTER WOMEN CONVERSION BURNER COOK STOVE WINES DIRECT VENT HEATER DRYER -FREPLAGE— — — — — -- — FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOFTOP UNIT Means TEST UNI WCATED U WA R BUILDING =U96 T INSURANCF have a current Ilabir Insurance policy orb substantial eglihmi J `/ ;L Ch.142 • YES ❑ NO ❑ /' IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE LIABILITY INSURANCE POLICY❑ JJJ (YI/ BOND ❑ .V 1' OWNER'S INSURANCE WAIVER: I am aware that the BCenaee does not yaired by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit app6 .anent CHECK ONE ONLY: OWNER ❑ AGENT SIGNATURE OF OWNER OR AGENT \ / 1 hereby certify that all of the details and Information I have submitted or entered mgardng this application ere true and accurate to the best of my knowledge and that all pksnbing work and Installations performed under the penny Issued for this application will be In compilarce with a0 PeN ent provision of the Massachusetts State Pksnbing Code and Chapter 142 of the General Laws. +�/nnkt /J�iV.N. �f _ PLUMBER-GASFITTER NAME Andrew Lev LICENSE # PL15162(.ZGNATUBZ MPED MGF❑ JP❑+ JGF❑ LPGI❑ CORPORATION❑+ # 3184 PARTNERSHIP❑# LLC❑#� COMPANY NAM Harwich Port Hea6n & Coofin Inc ADDRESSI 461 Lower County Road CITY I Harwich Pat STATE Ma ZIP 02646 TEL 508.432-3959 FAX 50Sd32 6075 CE 50t1958d674 EMAILFandy@harMchportheafingandcoonng.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECT Yes No loi�3 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE; $ PERMITII PLAN REVIEW NOTES t The Commonwealth ofMassachuseffs Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass gov/dia WWorkers' Compensation Insurance Affidavit: Builders/Contnetors/Electziclans/Plmnbem TO BE FH.ED WrM THE PER3Er1TING AUMORM. AonlicautInformation Please"t Le0'bly Name (Bumtass/Orgminmon/tadiv;aun0: Harwich Port Healing & Cooling, Inc Address: 461 Lower County Road Harwich Port, Ma 02646 Phone #: 506-4323959 Are yea as mployer? Cheek The appmprinte hot: Type of project (required): 1.01 m a emplayerwim 75 eroployeer (tWi aoNorpea-tksey 7. Q New construction 2❑ I s s a role gogleformpetnaahip and haw no employees working faros in 9. © Remodeling Any sty [Na workers' comp• humz= re9oined.) ' _ 9. 9. Demolition 3.plam nhnmeownrdaing an wurkmyseM[Nowmkerecmn;x inewince mrprhnd) t 4.❑Iams6me ecrandwo'nbehifing rxmrecmrs to conduct an work an my properly. I will 10 Building addition Colors d tanconh mseitherhavewateWcooWmaetionkummceeeerole II.❑� Electrical repairs oradditions peprieton with no employem 12 Q Plumbing repairs or additions S.Q I am a gemrel omsarmradI hero hied the xubenmactme Wed an the Wiched sheet These 13.❑Roofrepairs nob-cmOncmn hart employees end bow wmken'camp insumcat 14. QOther WAC 6.❑ We are a emporati® ad its officers have ea ndsd their dghl at esmptim per MGL c. Ir; ll(All ad we hmns eonployem [No workers• camp. hrs ewceregomed.] 0Any1pphcse11 td=bbox#I mart alsotollommeuction below showmgdmirwod=eemapmmtimpaUcybafbmtiom t Homeowners who nobnotthis affidavit indatiog4my am doing all work ad then him outride conhacton met submit a new af7idsv tindiestrog soorh $Cmhsetera that check this box mart attrcbed an additional sheet showing the osme of fie sobemuacbm and seem whether or rat those mutt- have employees. If the mbemhaclnx have mplayw%may me[ pmvido Mw ems• gyp• polkynrmber. I ern an employer that frprovG6ngworkers' compensation tnsurancefor my ergployeet. Below Lr thepollcy andJob site Infor)"aion. . Insurance Company Name: NORGUARD INSURANCE COMPANY Policy # or Self-ins.Ile. #: HAWC642691 ExpirationDate: 09/01/2016 Job Site Address:.53 ZU ..a- to 'y 4 e CStyy/statemp: W,r Attack a copy of the workers' compensation po declaration page (showing the policy number sfid expiration date). Fafffure to secure coverage as required under MOL c.152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year impfimument, 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 oflavestigations of the DIA for insurance coverage verification. I do hereby cerafy under thepaWs andpenallla of iya jWry that the Information provided above is tree and correct Official use only. Do not write In this area, to be completed by dty or town oSZdaL City or Town: Permtt/L&ense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other ContactPerson: Phone arm Commonwealth of Official Use Only � Massachusetts Permit No. BIDE-16-002051 �-' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 1 Rev.1/07 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massa husetts Electrical Code (MECL 527 CMR 12 00 (PLEASE PRINT LYINK OR TYPEALL INF01UM170N) Date: 10/112015 City or Town of: YARMOUTH To the inspector of X'aes: By this application the undersigned gives notice ol his or her mtenbon Lo per orm Ene clectrical work described below. Location (Street & Number) 53 LEWIS BAY BLVD Owner or Tenant DAMICO JOSEPH A TRS Telephone No. Owner's Address Is this permit In conjunction witb a building permit' 1'es ❑ No O (Check Appropriate Box) Purpose of Building Utility Authorization No, Existing Service Amps Volts Overhead O Undgrd O No. of Meters New Service Amps volts Overhead O Undgrd O No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replacement tumace Completion ofthefollowinz table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of CeiL-Susp4Paddle) Fans No. of Total Transformers KVA No. of Laminaire Outlets No. of Plot Tubs Generators KVA No. of Luminaires Swimming Pool A�dve O 10 O No. of Emergency Lighting R r 'nit+ No. of Receptacle Outlets No, of Oil Burners FIRE ALARMS No. of Zones No. of Switch" No. of Gas Burners 1 No. of Detection and fnitiatinr Devireg No. of Ranges No. of Air Cond. Total m No. of Alerting Devk" No. of Waste Disposers Ilest Pump o"h: umber n. ToK% No. of Self -Contained Detection/Alertine Device+ No. of Dishwashers Space/Area Ileating KW Local O Municipal O Other. Conne Bon No. of Dryers HeatingAppliances KW Secure Systems:• N f vie or iv 1 n No. of Water KW Heaters; No. of No. of Si BallsOl Data Wiring: No f ie or F. uiv I n No. Hydromasssge Bathtubs No. of Motors Total HP Telecommonieations wiring: V of D vi or ulv I n OTHER: Aaarh addrno col detml r(desne4 or as regwred by the hupector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to start: Inspection to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO VERAGE: Unless waived by the owner, no peril for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has exhibited proof of same to the peril issuing office. CHECK ONE: INSURANCE O BOND O OTHER O (Specify:) f certify, under the palm and penahies ofperjury, that the lnformadon on this application Is true and cotrWide FIRM NAME: HARWICHPORT HEATING & COOLING INC Licensee: toter -exempt- m LIC. NO.: 17318 Bus. Tel. No.: Address: 461 LOWER COUNTY RD, HARWICHPORT MA 02646 AR. TeL No.: *Per M.G.L. c. 147, a. 57-61. security work requires Department of Public Safety "S" License: 014WER'S INSURANCE WAIVER: I am aware that the License does not have the liability insurance coverage normally required by law. But signature below. I hereby waive this requirement 1 am the (check one) O owner O owners agent Owner/Agent Signature Telephone No. RbAcLt:sc -r,�) (p/t3�t _ PERAftTFEE. SS0.00 � n t l co�mmonru alf,4ofcl7l14�Quie,.tfeEm7mmy //a use0* .[J�pa+ nfof YinJiro%af .�-�.�, BOARD OF FIRE PREVENTION REGULATIONS Checked lank - APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Aawedrmbepmftmedtaeoasasncew;milwmh acbmtwlumewcodeamc) 4279aWo (PLK=PBW NDX oRTYPRALL RM�T7 M Date: /O 7 1 •City or Town of. • To thelnspec o By9eisappliationtbo:mdacigmed ' . aedcoofhisorher gMtDpeflmngeelccWcelwmkdescn7:edbolaw L0=ffm(Sh &N®ber) -573 /G/inC Lt.4.i Q/.,Y% ' OwnworTemmt Owner's Address TelephonoNo. Is9i1eperailttu onwhhabn2db:gpe:mlt7 Yea ❑ No ((herkAppropdateBo:) rmpaaof g_ !sari/ /VTIf} IihvtyAudhorhatioaNTa Edsthr�Servka__ Ampa / vans Se ce —Amp / vo& Nomber of Feeders and Ampatity Loatlon and Natue of Proposed Mechical Worh: Overhead ❑ Vadgrd [] Na of Met= _ Overhead ❑ lWgrd ❑ Na of BW= N0. ofRecessedLmaL:abw & a Of `�.^.tr"�-.'..^ri (Paddle) Fsas mast a• - Tow No. ofLwmhsfro O No. of Hat Tabs era RVA Geaeabars HVA NO. ofLamht IM St►hnmh:gPool ova ❑ 'd a• eacy g MM&IInLb 0.ofRecephwleoaflds aofOff Bmaen ALARMS (Lofzmes N0.ofSwttchea aofGas Bmnera 0. a o•ofRinges - No cfAb•Oond. T.00"A Desks 0.cfAkrangDakm NO. ofWasbI)hposesa TAP er oas o. No. ofDbhwaaLees SpacdArem Hattng RW ebecUoo/ Devices cs10 cmm ❑ on, N0. of Dryers attagAppllanees 1�V a KW 0. 0. is Ballasts a of evtw m mt aft NaHydmmaasageBsthmbs No. Ofhfotm Total Hp NO. Of or eat „- �„_ - _ - FatimafedYeLie World (wd>�9m �OrmbPgjWknc Wadcrostart 10 °d$ p° 9) WV Inspections m bo regarded bi amw wM B=RnIa 10, andupea cooplea m. L% ORM(3i GE:���i7l,o�el�es�awaivedbyt tow=.noprmitibr&epedmanwadalactdcalwodrmaybmomlesa tieflctaseepmvldmpmofofn6n"Yk:amamcelncbidmg"wmpletedopexatlon"COVQageorlta8n Ld wetMmtbdsanccoveaagaislan=e,amdba affi.adproofofaemem9:epematisssinga> t318CZCOAI6 nom"CS IN BMW ❑ mHm 0 gyp ) ICY, �dcSrepah:sondpmalayofP Y, thai fo> on arws appAcaUan tvirueand complete FII2MNAME:•i�i1p,(iVf �`( i.J wit,; LIGNO.: L1�seC�NblZt:bU D,tslD.(r: �tmn GNO� AaPP a th TeLNo. Addrea: afar KGJ. a 147, s.17-61, somiffywodc All• TeL No bra! Pabao Sality "S"Lteensx LiaNa OWMM'SMSURANCKWAIV&R: IamawsmtbattbeLtc=wdosmarhamamfiabnhyb mamas my �! BY AV O1below.ILertbywaivethisxa�emeoi Iam1Le(checkoae mwaer owna's agmt �natr°° •TeiephamoNa_�_ PSEll111'gg� SJ�O.• 1 �\ The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www massgot'/dia Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumben. TO BE FILED WrrH THE PERMITTING AUTHORrry. Applicant Information Please Print Le 'blv Name (Basiness/Orgmimuodlndi idue1): HarvAch Port Heating & Cooling, Ina Address:461 Lower County Road r I,u p.Wr VVI{,w VzV An you an employee! Check the appropriate trot: Phone#:t"'o) %JZ-,3V0bP I.Q I w a employer with employees (full. Wor port-tio x- 2.❑ I am a eole propti iw wpmtmsWp aM hm m employm walmtg form in my capacity. [Noworkera' comp. taMreoce required.] 3.❑ I sm a homeowner doing ail work myself'. [No workers' Comp. vuurace Moira .] t 4.[JI an a homeowm and will be hiring ommaeton to Conduct all work on my properly. I w01 ensure that all Contractors either have workae' Compensation nmeerce or are mle proprietors with on employees. SE] I am a gmval contractor and I bare hired the ab-comnomn tined on the minded sheet Them sub-C000actm have employees and have workers' Comp. insurance.: 6.❑ We art a Corporation and 0s offices bare exercised their right of exemption per MGL c. IA I1(41 and we have on employees. [No weaker ' Comp. ban = e requiem] !Any opplians that checks box al must alm Col out the mctm below showing therworlrm ' Type of project (required): 7. New construction 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions 12.0 Plumbing repairs or additions 13.[:]Roof repairs 14. DOther HVAC nomeowoers win smmr Mu amaarn mmcamg they are aomg.a Mask and then htre outside contractors must submit a new affidavit indicating acts. tCaotracmn that chock this box must attached an additional .heel showing the name of the mb-contractors and state whether or not those entities hm employma If the sub-Contradan hove employam dry mat provide their workers' comp. policy mmler. lam an employer that tr providfng workers' compensation insarmtce for my employees. Below Is the policy and job site Information. Insurance Company Name: AmGuard Insurance Company Policy # or Self -ins. Lic. #: HAWC536127 Expiration Date: 09/01/2016 Job Site Address:�3 0001S &$/ 8L11Q City/Statcaip: Attach a copy of the workers' cmpensfition policy declaration page (showing the policy nmdber and expiration date)L Failure to secure coverage as required under MGL c.152,125A is a criminal violation punishable by a fine up to S I,5o0.00 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. ofperfury that the Information provWed above Is true (506) Oflldal use only. Do not write In this area, to be eompided by city or town ofJidaL City or Town: PermWLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone #: