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HomeMy WebLinkAboutBLDSM-23-001576 Fedex RECEIVED .- , 1 SHEET METAL PERMITE.----1SEP 1��7 441:14 Commonwealth of Massachusetts _ j _ BUILDING DEPARTMF N \,w f i Town of Yarmouth Building Department By -" 1146 Route 28, South Yarmouth, MA 02664-4492 Date: 9/22/2022 Permit #: j3l.Ay>roJ 2-t31LS 74 Estimated Job Cost: $ 450,000.00 Permit Fee: $ Plans Submitted: YES/0M) Plans Reviewed: YES/ NO Business License # 174 Application License# Business Information Property Owner/lob Location Information Name: Rusty's Inc. Name: FEDEX Renovations C/O Turtle Rock LLC Street: 222 Mid-Tech Drive Street: 225 white's Path City/Town: West Yarmouth, MA 02673 City/Town: South Yarmouth, MA 02664 Telephone: 508-775-1303 Telephone: 508-375-0005 Photo I.D. required/ Copy of Photo I.D. attached: oato` NO Staff Initial: 1-1 /1441D unrestricted license J-2/ M-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 x Educational Institutional Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. x Number of stories: I. Sheet metal work to be completed: New work x Renovation: x HVAC: x Metal Watershed Roofing: Kitchen Exhaust System: Metal Chimney/Vents: Air Balancing: Provide detailed description of work to be done: Two ducted heating and cooling systems Two computer room cooling systems Three ducted makeup air systems Replace nine roof exhaust fans INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes x No If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy x 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 here- _x i hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installation 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. Inspections shall be called for prior to insulation installation. Duct inspection required prior to insulation installation: Yes No x Progress Inspections Date: Comments: Final Inspections Date: Comments: Type of license: By: X._._. Master ( eL Title: Master-Restricted. '1` Signature of Licensee 'I` City/Town: Journeyperson Permit#: Journeyperson--Restricted License Number: 1291 Fee: $ v:i Check at www.mass.gov/dpl t- J1)—. 'I` Inspector ignature of Permit IN of Permit Approval , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations° ;: , �..., . 600 Washington Street Boston,MA 1I2111 . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plnmbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Rusty's Inc. Address: 222 Mid-Tech Drive City/State/Zip: West Yarmouth, MA 02673 Phone.#: 508-775-1303 , Are you an employer? Check the appropriate box: 'Type of project(required):, 1.© I am a employer with 42 4. [ I am a general contractor and I 6. ❑New construction . employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- listed on the'attached sheet 7, A Remodeling ship and have no employees These sub-contractors have g, ❑Demolition . Working for me in any capacity.acity, employees and have workers' $. 9. [ Building addition [No workers' comp, insurance comp. insurance. required.] 5. © We are a corporation and iic . 10.E Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their : 11,E Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[] Roof repairs insurance required.]t C. 152, §1(4),ane we have no employees. [Na workers' 13.❑ Other comp,insurance required.] *Any applicant that checks box#1 must also fi[l out the section below showing their workers'compensation policy information. , t Homeowners who submit this affidavit indicating they art 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 name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp,policy number. , i e' �i� ..r'zd rd • rt m..,,... -.�..-,n_ a"-r...'J U, ._ ,. .rn..._� --..'.«_ I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. , insurance Company Name: Merchants Mutual Insurance Company Policy# or Self-ins.Lic,It: WCA9099225 _ Expiration Date: 1/1/2023 - Job Site Address: 225 White's Path City/State/Zip: South Yarmouth,MA 02664 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 S250.00 a day against the violator. Be advised that a copy-of this statemnerit may be forwarded to the Office of 'oils of the DIA for insurance-cover# e verification. I do hereby cert1fj.'under the pains and penalties of perjury that the information provided above is true and correct.. f , . • `v, 1_, _ X L Da . 9/22/2022 . .. , Pbc3nc#: . , 508-775-1303 r Official use only. Do not write in this area,to be completed by city or town official ' t City or Town: Pertnit/License"# . Issuing Authority(circle one): 1 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: . , . Phone#: _ i Ir COMMONWEALTH OF MASSACHOSEUS DIVISION OF PROFESSIONAL LICENSURE SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE w! MASTER-UNRESTRICTED F a z MICHAEL J RODERICK" , 10 KETTLE DRUM LN 0 E SANDWICH,MA 02537-1701 z w J 1291 05/28/2022 867740 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER Fold,Then Detach Along All Perforations c COMMONWEALTH OF MASSACHUSETTS BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE BUSINESS S MICHAEL J RODERICK 1 y RUSTYS INC �`W 222 MID-TECH DRIVE z z la YARMOUTH,YARMOUTH,MA 02673 174 01/05/2023 967823 LICENSE NUMBER EXP D1 �,,', Y,'SERIAL NU. ASSACHUSE;T'Ts DRIVER'S LICENSE its ,' ' 45/30/2018 �' /2023 in 1b!4664 05/29/1965 situss , REST q,en , ' D: NONE NONE •' F + S'8 r /�,0 on,,t,.�.,+�r ,„ MICHAELJOSEPH r � F, 1014ETiLE DRUM LN ��` � :' EAST SANDWICH,MA 025537.1701 .,�B SEX M RUSR y_ 5o005301201 o 05/29/95