Fillable Sheet-metal-permit-application - SM permit # 1

Fill Online, Printable, Fillable, Blank Sheet-metal-permit-application - SM permit # 1 Form

Use Fill to complete blank online TOWN OF HOPEDALE (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Sheet-metal-permit-application - SM permit # 1

On average this form takes 28 minutes to complete

The Sheet-metal-permit-application - SM permit # 1 form is 4 pages long and contains:

  • 2 signatures
  • 29 check-boxes
  • 91 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Hopedale

BROWSE TOWN OF HOPEDALE (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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
click to sign
signature
click to edit
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_________________________________________________ _
Address:__________________________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
†
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 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: 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 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 of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: ___________________________________ Permit/License #_________________________________
Issuing Authority (check one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing
Inspector 6. Other ______________________________
Contact Person:_________________________________________ Phone #:_________________________________
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10. Electrical repairs or additions
11. Plumbing repairs or additions
12. Roof repairs
13. Other____________________
1. I am a employer with _________
employees (full and/or part-time).*
2. I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers’ comp. insurance
required.]
3. I am a homeowner doing all work
myself. [No workers’ comp.
insurance required.]
†
Are you an employer? Check the appropriate box:
4. 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.
‡
5. 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.]
click to sign
signature
click to edit
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-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 burn 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
Department of Industrial Accidents
Office of Investigations
Lafayette City Center, 2 Avenue de Lafayette
Boston, MA 02111-1750
Tel. (617) 727-4900 or 1-877-MASSAFE
Fax (617) 727-7749
www.mass.gov/dia
Revised 7-2019
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Sheet-metal-permit-application - SM permit 1

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document