Fillable Sheet Metal Permit Application (Town of Belmont)

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Sheet Metal Permit Application (Town of Belmont)

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The Sheet Metal Permit Application (Town of Belmont) form is 4 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Town of Belmont

BROWSE TOWN OF BELMONT (MA) FORMS

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Commonwealth of Massachusetts

Sheet Metal Permit

Date: ________________ Permit #_________________

Estimated Job Cost: $________________ Permit Fee: $_______________

Plans Submitted: YES ____ NO ____ Plans Reviewed: YES ____ NO ____

Business License # ___________________ Applicant License # ____________________

Business Information: Property Owner / Job Location Information:

Name: ______________________________ Name: ______________________________

Street: ______________________________ Street: ______________________________

City/Town: __________________________ City/Town: __________________________

Telephone: __________________________ Telephone: __________________________

Photo I.D. required / Copy of Photo I.D. attached: YES ____ NO ____ ________________

Staff Initial

J-1 / M-1-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 ____ Educational ____

Institutional ____ Other ____

Square Footage: under 10,000 sq. ft. ____ over 10,000 sq. ft. ____ Number of Stories: _____

Sheet metal work to be completed: New Work: ____ Renovation: ____

HVAC ____ Metal Watershed Roofing ____ Kitchen Exhaust System ____

Metal Chimney / Vents ____ Air Balancing ____

Provide detailed description of work to be done:

______________________________________________________________________________

INSURANCE COVERAGE:

I have a current liability 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 are 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

_____________ ____________________________________________________________________

By ______________________________

Title _____________________________

City/Town ________________________

Permit # __________________________

Fee $ ____________________________

__________________________________

Inspector Signature of Permit Approval

Type of License:

Master

Master-Restricted

Journeyperson

Journeyperson-Restricted

_______________

____________________________________________

Signature of Licensee

License Number: __________________

Check at www.mass.gov/dpl

Rev. 1/17/2019

TOWN OF BELMONT

OFFICE OF COMMUNITY DEVELOPMENT

19 Moore Street

P. O. BOX 56

BELMONT, MASSACHUSETTS 02478-0900

Telephone: (617) 993-2664 Fax: (617) 993-2651

DEBRIS FORM

Will there be a dumpster on site? □YES

□NO

Debris will be removed daily by trailer □

In accordance with the provisions of MGL c 40, S 54, a condition of issuance of a BUILDING PERMIT is that

the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal as defined by

MGL c 111, S 150A. The debris will be disposed of at:

Name of Facility

________________________________

Signature of Permit Applicant

________________________________

Date

CONTACT THE BELMONT BOARD OF HEALTH FOR FURTHER INSTRUCTIONS & REGULATIONS

617-993-2720

WARNING: This document merely certifies that the above referenced building complies with applicable provisions of the State

Building Code. No opinion is expressed or warranty given is to any potential health hazard not addressed by the State Building Code

including, but not limited to, the presence of radon, lead paint, asbestos, and urea formaldehyde.

 

TheCommonwealthofMassachusetts

DepartmentofIndustrialAccidents

1CongressStreet,Suite100

Boston,MA02114‐2017

www.mass.gov/dia



Workers’CompensationInsuranceAffidavit:Builders/Contractors/Electricians/Plumbers.



TOBEFILEDWITHTHEPERMITTINGAUTHORITY.





ApplicantInformation

Name

(Business/Organizational/Individual)

:________________________________________________________________________________________

Address:___________________________________________________________________City:_________________________________________

State:______________________________Zip:___________________Phone#:______________________________________________________

Areyouanemployer?Checktheappropriate box: Typeofproject(required):



1. Iamanemployerwithemployees(fulland/orparttime)*





7.Newconstruction

2. Iamasoleproprietororpartnershipandhavenoemployeesworkingformeinany

capacity.[Noworkers’comp.insurancerequired.]

8.Remodeling



9.Demolition



3. Iamahomeownerdoingallworkmyself.[Noworkers’comp.insurancerequired]†



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proprietorswithnoemployees.

11.Electricalrepairsoradditions



12.Plumbingrepairsoradditions



5. IamageneralcontractorandIhavehiredthesub‐contractorslistedontheattached

sheet.Thesesub‐contractorshaveemployeesandhaveworkers’comp.insurance.±

13.RoofRepairs

6. WeareacorporationanditsofficershaveexercisedtheirrightofexemptionperMGL.

c.152,§1(4),andwehavenoemployees.[Noworkers’comp. insurancerequired.]

14.Other

*Anyapplicantthatchecksbox#1mustalsofilloutthesectionbelowshowingtheirworkers’compensationpolicyinformation.

†Homeownerswh osubmit thisaﬃdavitindicangtheyaredoingallworkandthenhireoutsidecontractorsmustsubmitanewaffidavitindicatingsuch.

±Contractorsthatcheckthisboxmustattach

anadditionalsheetshowingthename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jobsiteinformation.

InsuranceCompanyName:__________________________________________________________________________________________________

Policy#orSelf‐ins.Lic.#:_______________________________________________ExpirationDate:______________________________________

JobSiteAddress:__________________________________________________________________________________________________________

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thepainsandpenaltiesofperjurythattheinformationprovidedaboveistrueandcorrect,andthatclicking

this

checkboxandtypingmynameinthefieldbelowwillactasmysignature.

Name:__________________________________________________Date:___________________________________________________________

Phone#:________________________________________________Email:__________________________________________________________





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Sheet Metal Permit Application (Town of Belmont)

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Completed 15 July 2020

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