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HomeMy WebLinkAbout2010 MECHANICAL PERMITS N-Z - NICKERSON RD - PERMLi://(A Map #: C Lot #: •. Unit #: Street#: street Name: /1/76 C /e50/1/ Rn rreet Urnt #: %f 0 Oepartment:d«,Iti�I ()€ etyrnent Type: (PL ) (PJOt) (Perin) F TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: i\1 `ckec-scr a1 Owner of Record: ; > kt�s- Assessors Map # S O Lot # gt245 Type of Occupancy: I-es; New: Renovation: Replacement: j Plans Submitted: Yes No Installing Company Name: CZna -t1-1.l j(,, 4-171-610-01(' 1m,�c Company Street Address: 9 jJ, rMa& ;S-tree,) City: AAul, Zip: di zv. Company Phone Number: -7r Estimated Cost: $ ik Indicate total number of units in the applicable box below Family 1N/I 1 &2 Basement 1St Floor 2nd Floor 3rd Floor Roof -0 c Air Handling Units X Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners X Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement $ LL -J,. — 2nd Floor J 3rd Floor Roof* c ' 2 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: = , f..2r Cairn. `ssr, 19'k sycl y?il I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the MassachusetjState Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of xington:,m AVAZ!,. 'in to IstA e 1 (U.) .,\ . i irv, ws ie (S 13 'wVa Print Name: Type of License: License #: Perm ee: Issued By : Revised 12/31/09 This Section for Offical Us O y Receipt #: 7f0O Date Received: 2 /0 Approved Date: ",/� / adul. Ito Received by: fic Permit Number: (0 Ito ■ The (nation weatai of 114assochuseas Deparanee of Industrial Accidents elffice of investigationy 600 fri-ishington Sa:e0 .1.71q0n JIA (72 I 11 W."'S',4?:0•3,,/diez Workers Compensation haltrance Affidavit: BuilderEtContractorsiElectriciansininnkrs ••---••• •._ - - • . • •-•-••• 1lJeijlV Map f EAPt Addr Pot 'nit 1\1.i arn (E'0sirieSsIC,:g v A ' 0 Sj . : k- Are you an employer? Cheek the appropriate boyt Type of project (required): 1. El 1 am a employer v.ith `ti 4. 0 1 am a general contractor and i employees (fiill ancVor part-tim 2. L...1 I am a sole proprietor or partne ship and have no employees working for me in any capacit [No workers' comp. insurance required.] 1 am a homeowner doing all we myself. [No workers' comp. insurance required.) t rk have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers' comp. insurance.1 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.] 6. New construction 7. Remodeling 8. Demolition 9, El Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.12 Other c--ee *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. ICentfactors 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. am an employer that is providing workers' compensation insurance for my employees, Below is the policy and job site information, c"-v■-rr's.G.,,,e..e. -4- 0-) insurance Company Name: 61 SW-iv,. Lw .11 axpiroion Doe:. ; ; City/Staiouap:._ L.C5211t4,11{A, — - Attach a copy ei the- wet*crr,' tot pen.sation policy declaration page (showing the policy number and expiration date), .'ailistre, O scome coves ovei.c r )et.kuirod under Secticrn 25A of M e 152 er lead to the inipojlim criAairipj ren2,11-k, ct fine' 'IF to '1,500.0.0 alido 1 impriLonmeni, es well as ivii o&Jlier in the Ibrm of a S'I'OP WOR If 0.1-z-DER and a 1'n-if- & op to $250,00 i" day af---kin n:: filo '43e101 Be advised that a copy of this statement map 1 fer,\7:rded to the (ff. c.c. of investigations of the DIA for insurance coverage veriticticif-r. do hereby ° utv'er the pa fru and perialfiet eirerjury that the information provided above i true wind jilt' 4 S.xria are: Phone It: 3- _ Data: _6/2 Ytt 0 "tidal use only. Do not write in this area, to be c npleted by dry or town officiaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone TI f tr?rroatio ar Jns1rueiions clapti.rd leqUifieS Ve3TS' ,,"i.,d-n- eplte _-'1.11‘.:023.A' to this statdle„ clefiJaGd. .jinOth.':._1. cf.,ritract 'LL... P r( partnerOlip, association, cortioratien. or others legal entity, e any tvc c. moye of the foyegoing etgaged L at. kill: 1i illaUdijag tiro legal 3..evre,seintatives of F. de.-CT-ESed elsnploye,r., Ci titer teceivf t. ea trustee. of an individual, partnership; ass.ec-iiation. or other jogai entity, c:norpluidg employees. ...4oitvever the. ritat of a. dwelling hous.e bwoirig riot molt tha.n ariartaienis arid who resides tuttetirn or the toctupatif of tie .Nho cmplc:,:fs pons Erocb the,:;.io shall ficA tiaaaitssi ofsucli elitipUtt EC- (J-1 sgenc E:11.5'M ;Its- ei a license, or permit to operate s business or re; consti net buildings in the ceqamoriwealtn, tor an' applicant .1.the has not produced acceptable evidence oi eempliauce with the insursuce coverage required." Additionally,14GL 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 insurarice. Limited Liability Cornpanies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not requited 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 dale 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 Deparbuent at the nuniber listed below, Self-insmed contpanies, should enter their s,elf-Mstnance license marine' on the appropitate City ur Town OffieWs Pledsc saw e that the affidavit is complete and printed kgibly. The D ryotnent hat provide4 a space a the bottom .“ffidavit. fot yoo le fill out in the, eve at d investigatior hats to ttontact you regarding the, applicant. Phrt,sol,-t, suit- to fin 13.!dfse nont=h,ii. 1:ri, addition Fdi -- f'201:q1-1..d pl °,pplicatioDs ill oily 1.3.(zo Okily aubmit affidavit (;111s tJ p,dbCy illibildatiOD (if nec estu-oiy) aud under "Job Site Addl. ess" the applicant should writ, "01 locations in eom7 of the, affidavit that haF been QfiiC 11 r stamped or marlied by the city et: tovrn int,y be nievided to the appitoani plogf fiat void rfivit i on filc.: fool e, p adis i lic;ei_tc,e,F.. A bc„. fined (-,..to Where- a herne owner cititen is Obi2initig r lic.:4-,trIFt: pti mit no lot,tr--,c n. tnEi/Iff:SF (XI . Cid?. lif.:CL'F,e- je 'e etc) ibis Tbe Ofiict cd Inveeigations tvould in thank you 7;-:1-I your c.eopf.naricur and !ihould yeru hatk%st any questious, ple,ase dO C. hesitate, to VU of a call< Depattnent's address; telerthrute, and fax, rutinber, cornmormeizithi of 1A.4ss4cints,etts Department of:Industrial Accidents Office of inve.qigattorts: 600 Washington Street Boston, MA 02111 Revised 11-22-06 TeL # 617-727-4900 ext 406 or 1-877 SAFE Fax 11 617,727-7749- www.ITIRFS, gov/di • .14 „7//td:- Map #: Lot*: Unit #: Street #: Street Name: Street Uletu : .esszammsaa• ..te••. ..�- Permit*: Depa tr ati% Document Type: (Plit / VV S TOWN OF LEXINGTON Community Development Building Division The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts State Building Code For One- and Two- Family Dwellings 7th Edition APPLICATION FOR: ROOFING, SIDING, SITE INFORMATION: WINDOWS, DOORS_ Permit #/;113/0 Date issued:%/ /7 /U Work approved by: Property Address: Assessors Map /Parcel # Historic District: Yes/ No Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Phone # 1- 888 -559 -0909 Yes Roofing 5900: (Note: Roofmg is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Proposed material: Existing material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Nunr$er of replacement doors: 3 Estimated cost of work and material excluding electrical cost: 7t a. l ©O PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (print d): Signature: h, Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SE ICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lakeville MA 02347 Signature: R A- C,,,,° Phone # 508- 583 -3999 ✓ Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Address: Expiration Date Si(nature: Phone # Received by /date: V )1) )7) )4 Fee: Receipt #: '9,61L) Issued By: ta,r_ Map #: Lot#: Unit #: Street*: Street name:. Street Umt*: Permit*: Department; Document Tye: ,_ f F1'. TOWN OF LEXINGTON Community Development Building Division < „_ 5 MOAN i»s ryc.. ■ , ; _- b t ,' e4, ,-co The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts State Building Code For One - and Two- Family Dwellings 7th Edition APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS SITE INFORMATION: ERV ES: Permit #,/23- /3d/ Date issued:_�!� Work approved by: Property Address: V-3 '2.. Y.o kh S(r�A - License Number 76563 Historic District: Yes/ No Assessors Map /Parcel # 7 j o2.9 Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Phone # 1- 888 -559 -0909 Yes Roofing 5900: (Note: Roofing is not permitted over more than one (1) existing layer. If two layers of roofmg exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Proposed material: Existing material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 2 Estimated cost of work and material excluding electrical cost: f /`-I 0 0 PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (printed): , Signature: / V Phone # 781- 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION ERV ES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lakeville, MA 02347 Signature: R //,M, Phone # 508 -583 -3999 Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Expiration Date Address: Signature: Phone # Received by /date: \0\r() Fee: 3D Receipt #: ZO013 Issued By: 2 Map #: Lot #: Unit #: Street #: Street Name: Street U,nft #: Perrcit.#: =.` Departs at: Budding Document Typo: (Plan) CPI%) TOWN OF LEXINGTON Community Development Building Division 0 ° a a r,` =m 4£X Vs MOgN, ins iii of t,� 4PPtt 19 N X10, ro The Commonwealth of Massachusetts T �° State Board of Regulations and Standards Massachusetts �. s _- a State Building Code For One- and Two - Family Dwellings 7th Edition APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS SITE INFORMATION: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Permit # 45"3"--T3 Date issued: /l Work approved by: Property Address: 1 Y1, 1Aav ' • Historic District: Yes / No Assessors Map /Parcel # ''J S -2 Expiration Date Provide name of Waste/Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Phone # 1- 888 -559 -0909 Yes Roofing 5900: (Note: Roofing is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Existing material: Proposed material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 3 Estimated cost of work and material excluding electrical cost: a,1oo Received by /date: daV )1\0) /i) Fee: te Receipt #: c9 Issued By: .80-49,gov0A}, PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (print d): Signature: N. Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SER ICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lakeville, MA 02347 Signature: �,t„ "- v a Phone # 508- 583 -3999 Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Expiration Date Address: Signature: Phone # Received by /date: daV )1\0) /i) Fee: te Receipt #: c9 Issued By: .80-49,gov0A}, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Li Arc 1 I kTt . C1 64% (.i. tl✓ G Address: 2i `t itiPtt,A/c7 S15" —1v (it -Q City /State /Zip: fit) g iZ i l) G ett,AY L�R f Mil Phone #: 5-06 ' & Fr3 ' 3 991 Are you an employer? Check the appropriate box: LEI I am a employer with 9.3~ 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub - contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.1 required.] 5. ❑ We, are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.0 Other bote. ��p�l•- *My 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 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: F IT te- 11 eX 5 N SV kA&'C.t. C� . Policy # or Self -ins. Lic. #: W eA 2-0 0 31 / 4 Expiration Date: 6 _ D ^ ao f ) Job Site Address: La/iv6Y- NotesAvG i ' l' S ) t Lew5 City/State /Zip: L5X// U , 07" 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. ✓ 1 L✓0 °'--vt W Date: ti s /I? gO( f! Signature: Phone #: s- 5s'3 3451? Official use only. 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 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 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 600 Washington Street Boston, MA 02111 Revised 4 -24 -07 Tel. # 617-727-4900 ext 406 or 1- 877 - MASSAFE Fax # 617 -727 -7749 www.mass.gov /dia ACORD. CERTIFICATE OF LIABILITY INSURANCE /1 0 ) 06 1/2o TYPE OF INSURANCE PRODUCER (978)392 -4567 FAX (978)392 -9696 E. J. Wells Insurance Agency, Inc. Regency Park 238 Littleton Road Westford, MA 01886 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT FICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Vareika Construction Co., Inc. 219 Walnut Street Suite B W. Bridgewater, MA 02379 INSURER A: Union Insurance (Acadia Group) GENERAL X INSURERS: Acadia Insurance CPA 0092564 -17 INSURER C: Firemens Insurance Company 06/20/2011 INSURER D: $ 1,000,000 INSURER E: $ 250000 r COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR A'L NODSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM /DDY) N POLICY EXPIRATION DATE IMM/DDNY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CPA 0092564 -17 06/20/2010 06/20/2011 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PRFMISFS (Ea orrurence) $ 250000 r CLAIMS MADE I X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,00C GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY X 78-- LOC A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS MAA 0092568-17 06/20/2010 06/20/2011 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ B EXCESS/UMBRELLA T1 LIABILITY OCCUR J CLAIMS MADE DEDUCTIBLE RETENTION $ CUA0121032 -16 06/20/2010 06/20/2011 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below WCA 0112029 -17 06/20/2010 06/20/2011 X TORY MILT 1 O E R E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500, 000 A OTHER Stored Materials CPA0092564 -17 06/20/2010 06/20/2011 $200,000 any one job site $200,000 temp off premises $200,000 property in transit DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION Insured's Copy SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Paul Coffey /NAM ACORD 25 (2001/08) ©ACORD CORPORATION 1988 J,47) 7)Le_eze__ /P/W Map #: Lot #: Unit #: Street#: Street Name: ;rreet [Jntt#: 7 7 3 /01/6(/, 57— j"rnlit #: Department: Building, 1)1- vitment Type:. (P/ in) (Plot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT FEE: $12 per one thousand valuation or done in conjunction with a Building Permit any portion thereof Property Address: 3 A J of Owner of Record: pk Assessors Map # ( Lot # 0.947 Type of Occupancy: R. cs, f_pv7`i New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name:EG' Company Street Address: ,,,ioc, City: ko e,>// Company Phone Number: 2 7-t217 s, 5-9c/6 Estimated Cost: $ /'i Indicate total number of units in the applicable box below Zip: p1,5 INII:::y Basement 1 g u - N 3rd Floor 1 Roof 0 Air Handling Units t Hydro Air: Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces - Oil Generators Other: Basic Building Code Commercial Basement g u - 2nd Floor 3rd Floor Roof 0 c 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexi,•jj,n: Signature: Type of License: License #: Permit fee: Issued By : 0 be This Section for Offical Use Only Receipt # , L Revised 12/31/09 Date Received: 6 proved Date: LI / f /D /0 Received by: Permit Number: t(7 _Ssp jixA ./2(_,Loo Ae_ed- 71 Map #: Lat #: Unit #: Street #: r A street Name: G'/ =greet Unit#: - rnlit #: (Department: B «ildin Document Type: (Pf tm) ( Piot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: r 1 I u..1.< 0 r Owner of Record: D L 1" k 5+ e Assessors Map # 3.3 Lot # Type of Occupancy: S: ,� ) New: ✓Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: Company Street Address: Company Phone Number: fe 47_ ( )Lt L i C City: `Z l er.i S -3I- 27 —: )St- Zip: 0 1 ( , ) , _ Estimated Cost: $ v ' U Indicate total number of units in the applicable box below 1 &2 Family Basement 0 ra 2nd Floor 3rd Floor Roof 2 Air Handling Units. Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners / Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Permit fee: I Receipt #: Basic Building Code Commercial Basement 1St Floor 2nd Floor 3rd Floor t, 0 0 ix Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: This Section for Offical Use Only Date Received: I Received by: Describe Project: "Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexin on's Noise By -Law: cer.b_I A/c - i =tome, D��ttess A /c. � '1 P. I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: S t. Ff- iZOS s P 31A 10E; re, C51 45C Print Name: Type of License: License #: Issued By : proved Date: 6 110 ttc 6H (0 /V7 Revised 12/31/09 Permit Number: 10 —5-51 jitx) l_tee4 Ae_eze_ \_//6c-d__/ Map #: Lot #: Unit #: Street#: 3 5 r2- street Name: �/R =t eet Unnt #• /0 —// 3 5 }department: Building 0- ,dUtment Tyne :_ iNtt l) (Plot) f TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # C 0 — 7c6 Cl U-i5 NO Property Address: 2C Opt /cG,i( 4'?, Owner of Record:4 N )1_r UniJ1-1 X-0 Assessors Map # 33 Lot # /02/ Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: 4 i- — ..r� Company Street Address: -7 1„._e �..� „ S j. City: Zip: o)-4G6 Company Phone Number: 9 7'5 L Cicj.» 6.1)),c- Estimated Cost: $ l)O Indicate total number of units in the applicable box below Basic Building Code Commercial c a) E a) co as 0 0 u- `0 0 U- C 0 0 u- C,) 0 c 2 (9 Generators Draft Inducers Oil fired Equip Kitchen Vent & Eaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: r. 11.1,5 ,,, c. r/t— (. ✓art -v.- I 'hl P c,,o,5. d 47a I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insurance Affidavit required for all mechanical submissions Signature: Cho,c / I (Ar- Print Name: trigs, Type of License: 000. lob )3 License #: Th�iss Section for Offical Use Only ) Permit fee: ; 1 Receipt #: g91S Issued By Revised 8/4/10 AC Date Received: 7,024011 Received by: Approved Dateve/021� Permit or AlteratiNuml�e; JC 2' 1 &2 Family Basement °o Li 2nd Floor 3rd Floor Roof Ground* Air Handling /Hydro Units Evaporative & Refrigeration Coolers i I Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air ventilation Fans Energy Recovery Ventilators Furnaces- Oil Other: Basic Building Code Commercial c a) E a) co as 0 0 u- `0 0 U- C 0 0 u- C,) 0 c 2 (9 Generators Draft Inducers Oil fired Equip Kitchen Vent & Eaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: r. 11.1,5 ,,, c. r/t— (. ✓art -v.- I 'hl P c,,o,5. d 47a I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insurance Affidavit required for all mechanical submissions Signature: Cho,c / I (Ar- Print Name: trigs, Type of License: 000. lob )3 License #: Th�iss Section for Offical Use Only ) Permit fee: ; 1 Receipt #: g91S Issued By Revised 8/4/10 AC Date Received: 7,024011 Received by: Approved Dateve/021� Permit or AlteratiNuml�e; JC 2' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Afjt r& (- e`" `y._ A- /C Tr, Address: 72 L // City /State /Zip: 4L,Iouro 114 01 Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part - time).* have hired the sub - contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.t 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.] 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.] t Type of project (required): 6. ❑ New construction 7. ` Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other *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 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: Z Jl_4 1c.z4' City /State /Zip: Y,''V•N 1MJ4 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 fme 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 fme 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. Si a Phone #: Date: Ii/ /l ( /0 Official use only. 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 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 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 Depaitment 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 600 Washington Street Boston, MA 02111 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617-727-7749 www.mass.gov /dia jjtx. ,dle_ /A,,t- Map #: 7 a Lot #: Unit #: Street#: street Name: /7/)C • 5r •reet Unit #: '".rnitt #: Department :3�talcin Document Type: (P! n ) (Ploi rrtnlT TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a' Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: #00r /" %° Owner of Record: Assessors Map # ' 7,2 Lot # New: Renovation: Replacement: Installing Company Name: I r Company Street Address: 1,40"-el:‘," Company Phone Number: /P A Z Type of Occupancy: piPh--/P Plans Submitted: Yes t7- No /7-e./117, l� City: -G h i1 Zip: e92- 4' 72 Estimated Cost: $ te Indicate total number of units in the applicable box below Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil c' E a) 0 0 U- 0" 0 0 0 0 0 c 2 Generators Other: Basic Building Code Commercial Basement o 2nd Floor 3rd Floor Roof .Kpunoao Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: f-4 Signature: Print Name: Type of License: License #: Permit fee: 9 4 Revised 12/31/09 This Section for Offical Use O Receipt #: 1.pO -/ y Date Received: ..47je,y Approved Date: Received by: Permit Number: L0 7 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov /dia Workers' Compensation Insurance Affidavit Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Leeibly Name ( Business /Organization/Individual): 4! 44 7 ,C-l7 c G 'y // O jj°° Address: l� ���d City /State /Zip: 'etii/', //0 riPhone #: (e/ ?/ S" r ? Are you an employer ?Check the appropriate box: 1. ❑ I am a employer with 4• ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub- contractors listed on the attached sheet. These sub - contractors have employees and have workers' . ['Wmp. insurance.* e area 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.] 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.] t Type of project (required): 6. ew construction 7. Eiliemodeling 8. ❑ Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *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 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: e-(' i j City /State/Zip: Imo, 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. P-4 Date: S 2 it // Signature: Phone #: 7) Official use only. 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 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 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 600 Washington Street Boston, MA 02111 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 www.mass.gov /dia )ear_ Map*: Lot*: Unit*: Street #: Street Name: Street U tut #: Permit*: DepaTtneft: Document Type: .Mali CPiot) 4! TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PE T 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781-861-2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: PG Owner of Record: brawn Assessors Map # PC Lot # 6 Type of Occupancy: g as (J__Qv.\ --Q. New: Renovation: Replacement: ;X Plans Submitted: Yes No X Installing Company Name: CQVI -frcK \ 6_61)yri + 1-71- eov4ini r. Company Street Address: 'J 1'vi p1r - City: w oku<<n Company Phone Number: 7S /- 7.3: hP e Zip: 6 i �d J Estimated Cost: $ ? k Indicate total number of units in the applicable box below 1 & 2 Family Basement °o LT.. o° ii- N 3rd Floor Roof Ground* Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil �( Generators Other: Basic Building Code Commercial Basement 151 Floor o u. N 3rd Floor y0 ix 0 2 CD Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be,required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: repIAC -k.1 FLAnn CA fz + ft. I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations erformed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts tate wilding Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of gto Signa Permit ee: 1'tv Issued By: Revised 12/31/09 11 clip? L, QC) ) Yv1 cv5 Arec- Print Name: Type of License: isl3-7 License #: This Section for Offical Usp Only Date Received: ,61000 roved Dat • a /0 Receipt #: 9c� Received by: Permit Number. /y#. 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Map # Lot # 600 Washington Street Address: Boston, MA 02111 Permit # www.mass.gov /din Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Ce r+ca t (? jyj' i + 14 ea.-t' pn (lj , �1 C Address: �j 9 nl or-i-�l N►a�1 � S�e�� City /State/Zip: VU 0 1)1 , M 71- a ( 80 I Phone #: -7$1- 933 - 8 a 81 Are you an employer? Check the appropriate box: 1. ® I am a employer with ASS 4. 0 I am a general contractor and I 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.] t have hired the sub - contractors listed on the attached sheet. These sub- contractors have employees and have workers' comp. insurance.: 5. [J 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.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12. ❑ Roof repairs 13.E2' O t h e r i g e i a l t r y P n- r& cc *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 tContractors 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. /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. #: G- LOB I -L r1 Sik&A NCE NETWd K) TNc. a.5-600, 9 653 Expiration Date: I /3 / 2 C' I/ Job Site Address: �� P u. ��-(� a e ►� at City/State/Zip: 1_ -p,rr I .-7,4-4,14) 191. 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 uil er the pains and penalties ofperjury that the information provided above is true and correct. Sias .1.►► Phone #: r I 933 8,9- ?g Date: 1].) /3)/0 Official use only. 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 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 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 a ' • ro ' riate 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 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 600 Washington Street Boston, MA 02111 T`el: # 61 7- 727 4900 ext 406 or 1 -$77- MASSAFE Fax # 617 -727 -7749 www.mass.gav /dia Revised 11 -22 -06 4 ,1:hA 7/t? \AL-4/ Map #: • Lot #: Unit #: Street#: street Nam: street Unit #: Department: BE��Ictn a Document Type :_ (PL.n) ("Plot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work aithorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: l' / ka.re ,/- Owner of Record: (4.10/FA2QJ Assessors Map # 6-6 Lot # G18B Type of Occupancy: New Renovation: Replacement: /./ Plans Submitted: Yes No e---" - Installing Company Name Ai4 c f ,,,00 UgG Company Street Address: re, p99i5 // A'e' City: G ®we // Zip: 0196-01 Company Phone Number: rtx - p3 sPsr919 Estimated Cost: $ ' ©d Indicate total number of units in the applicable box below Family Nil 1 & 2 Basement 1 _ °o u. 2nd Floor 3`d Floor Roof 2 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 1 ti i% T 2nd Floor 3`d Floor Roof c ' 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: gnature: / 2 /t,fre1 ,.f%r Print Name: f/u9G Type of License: 401.® /1,3 6'7 License #: Permit fee: 60.cO Issued By Revised 12/31/09 Receipt #: This Section for Offical Us 0 l 36 t (ta Date Received: 3/ Received by: O Approved Date: / i 0 Permit Number: to jitx.A die4 /lam luuL- %c G 1/1(--d A-e./ Map #: Lot #: Unit #: Street#: Street Name: .;Feet Unit #: ',trnnit #: ��� r 7 Department: B «aiding Document Type: tPi n) (Plot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 75 fci( M Owner of Record , •�' 1 ''rte Assessors ap ## Type of Occupancy: New Renovation: Replacement Plans Submitted: Yes Installing Company Name: ) rrk i Company Street Address: S coJ o h i'c, City: € 401 (6) Zip: Q3 Company Phone Number )36 a - ®d Estimated Cost: $ Indicate total number of units in the applicable box below Air Handling Units N E m 0 0 0 U N 0 0 u- M 0 0 V c 2 0 Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 1S` Floor 2nd Floor $ cM Rook" 0 z U Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Pon, 1 INS44 irtti O11i��.aVIA V rt y t ►1 d g s t 0 41' Describe Project *Note: If any equipment is being placed outside of the{ootprint d the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: gnature: 1f4() Petit A/r Print Name: Type of License: Go License #: This Section for Offical Use Onl Permit fee: 3C U© Revised 12/31/09 Date Received: Approved Date: Permit Numbe PRODUCER E A Stevens Co Inc 389 Main Street Malden MA 02148 ISSUE DATE 07/30/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE COMPANY A Travelers Property Casualty Co of America COMPANY B LETTER INSURED BM Demolition LLC 18 Benton Rd Medford MA 02155 COMPANY C+ LETTER COMPANY LETTER COMPANY LETTER AMA THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS D E CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM /DD/YY) POLICY EXPIRATION DATE (MM /DD/YY) LIMITS GENERAL LIABILITY U COMMERCIAL GENERAL LIABILITY U CLAIMS MADE 0 OCCUR. 0 OWNER'S & CONTRACTOR'S PROT. GENERAL AGGREGATE $ PRODUCTS - COMP /OP AGG. $ PERSONAL & ADV. INJURY $ EACH OCCURRENCE $ FIRE DAMAGE (Any One Fire) $ MED. EXPENSE (Any one person $ AUTOMOBILE LIABILITY ANY AUTO 0 ALL OWNED AUTOS 0 SCHEDULED AUTOS U HIRED AUTOS U NON -OWNED AUTOS U GARAGE LIABILITY U COMBINED SINGLE LIMIT $ BODILY INJURY (Per Person) $ BODILY INJURY (Per Accident) $ PROPERTY DAMAGE $ EXCESS LIABILITY 0 UMBRELLA FORM 0 OTHER THAN UMBRELLA FORM EACH OCCURRENCE $ AGGREGATE $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY To be determined 07/21/10 07/2/11 STATUTORY LIMITS X EACH ACCIDENT $100,000 DISEASE - POLICY LIMIT $500,000 DISEASE -EACH EMPLOYEE $100,000 OTHER The owner, partner or member of an LLC is not included for workers compensation coverage. TOWN BUILDING DEPARTMENT ATTN: INSPECTION DEPARTMENT 1625 MASSACHUSETTS AVENUE LEXINGTON MA 02420 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Cind Marowitz/Assistant Operations Manager The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information ` Please Print Legibly Name ( Business /Organization/Individual): Address: a 4/9e AIQ,ZGt.a )rd City /State /Zip: Phone #: Are you an employer? Check the appropriate box: 1.1"1 amt a employer with 4. I am a general contractor and I employees (full and/or part- time).* have hired the sub- contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub - contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance,t required.] 5. 0 We are a corporation and its 3.0 I am a homeowner doing all work officers have exercised their right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] myself. [No workers' comp. Type of project (required): 6. ❑ New construction 7. 0 Remodeling 8. '0 Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *My 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 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. Lie. #: i 'I69 Expiration Date: a'/ 6 l Job Site Address: - — l 0 [ c ,c a s /q � City /State /Zip: - , !i/I 1 01 Attach a copy of the workers' compensation policy declaration page (showing the policy number add 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 certi Signature: Phone #: under the pains and penalties of perjury that the information provided above is true and correct. -e % Z`( cc ° e)- Date: g /c',l 6 7f( (Q3— Official use only. 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 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 defmed as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defmed 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 bum 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 600 Washington Street Boston, MA 02111 Revised 4 -24 -07 Tel. # 617 -727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617 -727 -7749 www.mass.gov /dia J',AA Map #: 9 Lot #: Unit #: Street #: 'treet Name: 'Tieet Una#: -'trelit #: Oepartment: Bi riding, i)o urpent Tyke ( E�. i1 1F�r�t`f TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: AAA (y Actd Act Owner of Record: FF /e y Assessors Map # 3 Lot # /G Type of Occupancy: r" dcr New: Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: 1- [■f�_ Company Street Address: q` ,/■,/, )140A Sty - City: Woi3ut lt1 Zip: v/ Company Phone Number: 1`I- 933 -6 -P<i' Estimated Cost: $ Xv Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement 0 2nd Floor 3rd Floor Roof c 0 Air Handling Units X Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners X Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Basic Building Code Commercial Basement 1St Floor 2nd Floor 3rd Floor Roof* c o 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the ,Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: j ?rCtiae Print Name: Type of License: Is-f3'7 License #: Perm s fee. 9 oD Issued By : Revised 12/31/09 Receipt #: This Section for Offical Use Only Date Received: %147440/(� Received by: Approved Date: IA akeyo Permit Number: m The Commonwealth of Massachusetts Department of Industrial Accidents Office of )nvestigations Map # Lot # 600 Washington Street Address: Boston, MA O2ijj Permit # Workers' Compensation insurance Affidavit: Builders/Contractors/Eleetricians/Piumbtrs Amy:cant Information_L_ PleaLe Print LegALly Name (Business/OrcanizariontIndividual): p A ddress:_ y/State„Vin: ; Phone 4: Are you an employer? Check the appropriate box: 1. E I am a employer with employees (full and/or part-time).* 2. D I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. Li 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.T 5. Li 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.] Type of project (required): 6. 0 New construction 7. Li Remodeling 8. Li Demolition 9. D Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.D Roof repairs I 3. IS Other get &Dz. 4- *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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: G Lc13 P, IN 5U PftJC E tJ iJCtR K Policy or Self-ins. Lie, ,r; () :DO /..:4 9 6 3 6 Expiration Date: I L ,/ 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 MGE c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisomne,nt, 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. .1 do her;eby certify ignature: r the pains and penalties of perjury that the information provided above is true and correct Date: Phone I Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and instructions Tviassachusetts General Laws. chapter 1.52 requires all employers to provide, workers' compensation for their employees. Pursitant to this statute, ar employee is defined as "..„every person in the service of another under any contrar of bin, express or implied oral or w-iitten." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or mom of the foregoing engaged in a "pint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal nntity, employing employees, -However the owner of dwelling house having net more than three apartments and who resides the,rein, er the occupant of the rjv dill heUS:. Of ar,o,th,i,„ \v1-; o c-rdi)loys pei sons lo do maintenartee, cOnStIOCtien ei epaii '00-T0 00 Slieb dWenirip houn . or nit the F.:Join:ids bAciipg appartenoni theretc, shall not because- of such employment be deemed to be an employe:J." MGL chaplet 152, §2.5(;(6) also states that "ever y sae ok local het:rising a gene simh withhold Mc- iFsuarle* renewal of a license or permit to operate n 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 fax 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 ap tropriate 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 foi you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please bG. Flint°. fill Ti 3 the permit/license irtimber which will be used as r reference number. In addition, an applic,ant that most submit multiple permit/license applications in any giver; year, need only submit one affidavit indicating current policy inforwtion (if necessary) and under lob Site Address" the applicant should write "all locations in (city or lown).' A oopy of the affidavit that has been officially stamped or marked by the city or town may be- provided to the applicant as prod that r valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner oi citizen is obtaining a license or permit not related to any business or commercial venture dng license or permit rc burn leaves ctc,) said person is NOT required to coninlete this affidavit The Office of Investigations would like to thank you iu advance, for your co per ation and should yen have any question, please do not hesitate to give us a call, The Department's address, telephone and fax number: Revised 11-22-06 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877 Fax II 617-727-7749 wwwmass.gov/clia ENTERED: MAR TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 'vlassachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x-211 Fax 78i-861-2780 Dale: Type Occupancy: I 2011' Renni - . /9y Describe type Of work and focatlan. if any setbacks Air Handling Units Heating Zones Evaaorativ)e Coolers Neat Pumps Range Hods Fiefs eratibn Units Sprinkler konn, Sprinkler leads _Sprinkier Mlose Conn Ventilatiorr -F- lersll~ ulmaces1G as/ Owner's Name_ Installing Compa ny i ame: l yJj Phone: Company Street Address: " it s C.; ��r? 7 yr„Yor` / 7 e�c7- -7,30'13 ---- 5 - -�--r �, - - ! c Ems= ��IS� Indicaile total number of units to the applicable box below ti ess P. i . Generators; No Vent HI_ ters Steam Kettles Duct Coils - Describe to rdi y egu)men( is being placed outside of the footprint of the building- describe Vocation and indicate P perty line. A land survey may required. Roof top units.may require a Structural Engineer's review: New work ❑ Replacement :* Renovation ❑ Plans Submitted' (] certify that I helve the authority to make the forE aPptCalion is trfre and accurate to the best of m' under the permit issued for this application will t; Mechanical Code, and alt tawybytayryregulatioi 0 Print N n nose, information and belief, and that all mechanical work and installations performed in compliance with all pertinent provisions of the Massachusetts State Building Code, the ICC s-at the Town of Lexington: rr;e: / teaSje Type of License: license a: Ins urance'ori' FiGi: 1ili: Fk: For Office Use O ni em Fee: -b 1:2/5 Receipt iii .1 Dale. Issued: 02010 c a) aar rn to o 1'1 z" 3'd Fire Suppression Draft Inducers Kitchen 'Equipment Pool Heater Pumps Radiant Heat ~� Incinerators Steam Generators Baseboard Heat Radiators Kickseace Heaters Hydro Air Systems Direct Vent Fireplace Roof Top Units Central Air Conditioners Describe to rdi y egu)men( is being placed outside of the footprint of the building- describe Vocation and indicate P perty line. A land survey may required. Roof top units.may require a Structural Engineer's review: New work ❑ Replacement :* Renovation ❑ Plans Submitted' (] certify that I helve the authority to make the forE aPptCalion is trfre and accurate to the best of m' under the permit issued for this application will t; Mechanical Code, and alt tawybytayryregulatioi 0 Print N n nose, information and belief, and that all mechanical work and installations performed in compliance with all pertinent provisions of the Massachusetts State Building Code, the ICC s-at the Town of Lexington: rr;e: / teaSje Type of License: license a: Ins urance'ori' FiGi: 1ili: Fk: For Office Use O ni em Fee: -b 1:2/5 Receipt iii .1 Dale. Issued: 02010 \74,c-d._/ Map #: Lot #: Unit #: Street#: Street Name: ;Treet Unit #: '<'.rnll t #: Department: BEtilding Doeltment Type:_ (Pitm) (P!oCPer TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 9j4,0/2_04 '%\ i Owner of Record:/, Assessors Map # 0- Lot # j 3 Type of Occupancy: ( J a6/ New: Renovation: Replacement: V Plans Submitted: Yes Installing Company Name: ena(ae.)(Y2Q.42s Company Street Address : j ,f,q e," Cr City: 779-0,(10/1/01- Zip: 6272 Company Phone Number: oZte %65/7 Estimated Cost: $ IMO Indicate total number of units in the applicable box below Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: a) E a) RS cc 0 0 u. 0 N L 0 0 u_ o`c) 0 0 tY C 0 Basic Building Code Commercial Basement 1st Floor 2 "a Floor 3rd Floor Roof 0 0 (.'D Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof'. Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all, of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexin•ton: To- am� Cox oti/ Prins e kQFr;� � der co 5a Type qr License: Licens Permit fee: Issued By Receipt #: This Section for Offical Use my Date Received: 0-01 roved Date: ?it 00,6 (ctortitoptti Received by: Revised 12/31/09 JitixA Map #: Lot #: Unit #: Street#: 3 street Name: 1;T eet Unit#: '?rmit Oepartment:3 «ilc)i n ()c wuurnent Type: (Y[u) (Plot ) (Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: . /ter 4iv S Assessors Map # 4" Lot # 93 Type of Occupancy: /esapytce New: Renovation: Replacement: X(" Plans Submitted: Yes No X Owner of Record: Drc L. i% 2e Installing Company Name: C Cc:1,10 + e�r1 �t n c Company Street Address: pAue/42 ct City: i e>r r7-7 Company Phone Number: 7i/ - y33-,2(5 Zip: ofids Estimated Cost: $ 16, crow Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement 1st Floor 2nd Floor 3rd Floor Roof c o 6 Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners / Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Ft,,,,-,„,,,,...R, -- Gas / Basic Building Code Commercial Basement 1st Floor 2nd Floor 3rd Floor Roor 0 ' 0 6 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: �'R-f ��� 4� Pr, e*nrl, I certify that I have - : thority to make the foregoing application and that all of the information I have submitted (or entered) in the above a • • ation is . ue and accurate to the best of my knowledge, information and belief, and that all mechanical work and 'stallati ns • rformed nder the permit issued for this application will be in compliance with all pertinent provisions of the chose s e Build' g Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of on: Permit fe /2 - Issued By : Revised 12/31/09 01) Cla -skr- (S13a Print Name: Type of License: License #: This Section for Offical Use Only Receipt #:.,ls 5 y6 Date Received: 6 73/( pproved Date: S Received by: /AS az. Permit Number: t © — 31X Workers' Compensatio A ®' licant Information The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass,gov/dia Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Please Print Le b' Map # Lot # Address: Permit # Name ( Business /Organization/individual): Address: t City /State /Zip: (11 Are you an employer? Check the appropriate box: I. Iamaemployerwith B5 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 refired.] 3.0 I am a homeowner doing ail work myself. [No workers' comp. insurance required.] t Phone #: `7 b / _ i 3 3 - 4. 0 1 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.t 5. 0 We are a corporation and its officers have exercised their right of exemption per MGI c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. [Q Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.5i1 Other t<r, p / -1 t fru P_ *Any applicant that checks box 41 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 name of the sub - contractors and state whether or not those entities have employees. lithe sub - contractors have employees, they must provide their workers' comp. policy number am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ld1_ AL, Trisu ANC NETWORK) Policy # or Self -ins. Lie. # �} t- tt ,2 9 h 3 b Expiration Date: l 1 / 3 c I.L b t c Job Site Address: 2 (by c City /State /Zip: L2 i k5{7 i r, 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 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. Ido`hereb nder the pains and penalties of perjury that the information provided above is true and correct. Date: `i(2, 7/10 Phone #: 1- 933-$8 Offaclal use only. Do not write in this area, to be completed by city or town offcia� 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 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 that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone numbers) 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 elf-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 an please do not hesitate to give us a call. The Department's address, telephone and fax number: The Common Revised 11 -22 -06 should you have any questions, 0�ce` taf I 600 Washington Street Boston, MA 02111 Tel. # 61 - ?27-4 ext 406 or -$7.1 Fax # 617 -727 -7749 .mass.govIdia COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE IN • = S REGISTERED AS A PLUMBING CORP ISSUES THIS LICENSE TO MICHAEL BERNASCONI CENTRAL COOLING & HEATING IN 68 MOUNTAIN RD 1mi BURLINGTON MA 01803-4741 2806 05/01/10 429954 LICENSE NO. EXPIRATION DATE SERIAL NO COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE • IT: - ' LICENSED AS A MASTER PLUMBER ISSUES THIS LICENSE TO MICHAEL C BERNASCONI 68 MOUNTAIN RD BURLINGTON MA 0 18 0 3-4 74 I 15137 LICENSE NO. 05/01/10 451380 EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE IN PLUMBERS AND GASFITTERS LICENSED AS A JOURNEYMAN PLUMBER ISSUES THIS LICENSE TO g g, ct MICHAEL C BERNASCONI 68 MOUNTAIN ROAD BURL INGTON 26474 LICENSE NO MA 0 1 80 3-4 741 05/01/10 451381 EXPIRATION DATE SERIAL NO. Map #: • Lot #: Unit #: Street #1 street Name: J`" P (9Nb :T;eet Unit#: ermit #: Department: Building Document Type:. (i'L n) (Plot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 16 O'er /06)4 j Owner of Record: Lu r a f Dtreef .1..'k- Assessors Map # Lot # '& Type of Occupancy: /2e/ids,/ c� New: Renovation: Replacement: k Plans Submitted: Yes No x Installing Company Name: (� Coe,„) � env}, v7,5 , Company Street Address: 7 /Jr) , arn SF City: vb ,,., Company Phone Number: --71-/ -733 Pe Zip: ©J Fi Estimated Cost: $ Indicate total number of units in the applicable box below Family A i 182 Basement 0 o 2nd Floor 3rd Floor Roof Ground* Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: n,t,,,s F ,,,,„. a X 1V add Basic Building Code Commercial Basement o IL h 2nd Floor 3rd Floor L Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: i ac.i123., 1 r Pte A- / G I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusett te Building Code, the International Mechanical Code, and all Taws /bylaws /regulations of the Town of Lq ingt Signature: jf11KC' t'z)J Chi Print Name: nnoc 4-e_— Type of License: IC[3 71%1 License #: This S ly Rece' #• -� 02 Section for Offical U n Date Received: 7 / /o Permit ee: a Issued By : Approved Date: ?lb 1(0 Revised 12/31/09 Received by: Permit Number: I ®r 7oc I.Vorf4Lers tortipention NLID.e (17-,esiness/OigarnzationfirdiA:id-, The Camino ttweolth of Massochuseta' Departmenf of Mdiistriat A ce-idenk gifice („tf Mveakations' Map # Let (00 Washinpoh ,Sireef Addresv. Boston,. J4 02111 Permit in:an.(7e: Affidavit BtlildersiContr a etorsillectricians/Plumtlers • . . • .. . e_t? rinItspAlgy, • Are yin au employeil Check the appropriate box: Type of project (re d qu re ): . 1( 1 am a erriployei with (. employees (full and/or part-time).' 2. Li I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] I am a homeowner doing all w ork myself. [No workers' comp. insurance required.] t 1 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.1 5, 0 We are a corporation and its officers have exercised their right of exemption per MGT., e. 152, §1(4), and we have no employees. [No workers' comp. insurance required.) 6. 0 New construction 7. ED Remodeling . Li Demolition 9. Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other (c *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 1 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 employee,s, they must provide their workers' comp. policy number. 1 am an employer that is providing workers' compensation insurance for my employees. Beim' is the policy and job site *Pi 07 ?Pi' alien Insurance Company Name: Pc lin,' ,fif- or Self: .101, Site A dc-ti dc_cerijoil Attach a copy of the workers' compensation policy declaration page (showing the policy number and expir alien dale), ure tf- LoYezt-Ige ieguircd mioe: SeGtiGu 25A OfMGi 2 ear: lead to the imp:-.ft.iticr, of erimin.al pcn2ltie cf fine up to i,5OO.00 and/o3 can- peer imprisonment; as well us, p;,nalties in the RAM el a STOP WORK ORDER and a fine of up to s250.00 day f••,_ailst, via,ter, Be, advised that a„ copy ef this statement nary hr foi vv.Eitel to the Office of Mcestications or the D 4surance coveiage venilication. I IP} 1,..efab7v certi " er e pains and penalties of perjury am' the infotinafion provided eibove is ir e and correct: TANI . . -1) L, :".`)? Expiration city/State,I7Jp: rnatuie. / Date: 7c) Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person:______ Phone #: In ynation. an instructions stesaclutsetts CrencinlIA.ws eltinurter red:oil-es ornployers to provide woilteis' compensation. for. then: emplo.yees, nuirsthint to Ibis sh],:h.tte, an ekniploye,--: stefitiecl rr ..oreer:t Etr,rhiroe: of undnr atty. s:..Dnto-vtrt. of exprets cq: 6. oml et written.' An employer: is 6e- b`,73..e.d "111.individtud„ partnership, assoeiatioli corporation or other legal entity, Or any two ot mot:e of the foregoing engaged. in .,:jf;oirit enterprise, as including flie legal leprosentatives of a deceased einpioyes, or the receives o trustee of au. indivi6m-4, partnership, Crtht03 c otlitA, legs) emify, employing employee-c. However tne owner of a eeeVatilig he.11Se haVirig ri.et ;ipatt-Merit,S. N,1110 the,yoip:, C: t6 OeCtipant of the h01,1-Se, e01.0 pelSi.):OF 'ie. 60 MaTinier&41:e.",,e, ek,'IlarDe;Orei 03- ViSek aLE houne inn g)-0"Oride e1,103.y.aleilt dee.Ma t0 employeL.' lnesu hcensiq ago: lth.c w:to,bolti the 6 9wieu i-ch-iewal of a license or permit to opel aie r buFineEs of tc zorpst: not buildings in the oRrkmenwealth for ally applicant who has not produced acceptable evidence of compliance with the insurance. coverage required." Additionally, 1%/161, 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-instnance license nturioer on the appropriate City et Town Officids Please be sw:e 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 ns, thr eVent the Othcc ol Ice-CS tipti.0115 has cc oorant you regarding. the applicanc . j'icaso tC rite HP I- the :nem:ill/lie erehr rcunber vrItriehtvill he used a iefetenee lortubeu, ii- PC.,:dillie,11 applic:fint multiple pesruRililentsso itpplicatirees any gives., policy imfbrniLtiori if hecetsany) and wider "ob Site Acldress" the applicant should write "all locations Ln (city lownsn' J copy the affidavit that ha been officially stamped er imrked by the dty or town may be pi ovided to the applicr'sri CC re, eof firmi a :valid aihdheit is on P fey tote- e pesmits ere. liceraser., 35.CAV14,fidaVit must be filled out each yezlr, bele: c home ev-no cc chigen it: obi-thy:dug C )ioem,.e.nr, pelmet not iciated to any business or coniwerciral venture, ;cc-r;6 Irmlir etc.) Enid NOT rehuirecl to completer this ofiidnvit. Mc Office of Investigations woillel like to lila:pit :ere- in advance for your cooperation and slid-did you hca ny giu.,,,stitim=„ please do DOt hesitate to give us a,. cal Department's address, teletohone and fax nu/fiber°. The Cormonwealth of Musachusetts Department ofindustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Revised 11-22-06 TeL # 617-727-4900 ext. 406 or 1-877-MASSAFE Fax 617-727-7749 www.lnass.govidiE: Map #: Lot #: Unit #: Street #: Street Name: Street kj,riu#: Permit#-: 10— I'5N 1zepa tment: Document Tyrille:410 C -bi �i n TOWN OF LEXINGTON LEXiNGTO = Community Development Z V a Building Division ; - 4 V, MORy !ns t _- i ,91L∎ Y 1 T A The Commonwealth of Massachusetts _= , State Board of Regulations and Standards Massachusetts =` ; State Building Code For One and Two Family Dwellings a^ 7th Edition N APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS Mailing Address: 1 Countryside Village Lexington, MA 02420 SITE INFORMATION: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Permit # /I-/ 1 Date issued: // A Work approved by: Expiration Date 12/18/2011 Property Address: ,5 j,L)a �q Historic District: Yes / No Registered Home Improvement Contractor: Company Name: Assessors Map /Parcel # ©� gD Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Phone # 1- 888 - 559 -0909 Yes Roofing 5900: (Note: Roofmg is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Proposed material: Existing material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 3 Estimated cost of work and material excluding electrical cost: <$a/ /oo PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 -861 -0900 Authorized Agent: Name (print d): Signature: h. Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SE ICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lakeville 4 ' 02347 Signature: rt, Phone # 508- 583 -3999 Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Address: Expiration Date Signature: Phone # Receive by /d te: /7 6/6 Fee: Receipt #: ;290 fr' Issued By: Jhy) d-eg4 Map #: f? Lot #: Unit #: Street#: 'treet Name: •rreet Unit #: '77 Oepartment: ancumettt Type: (PEi..n) (Piot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: g 4K P e d s f Owner of Record; Assessors Map # e y Lot # 57 Type of Occupancy :_ New: Renovation: ' Replacement: Plans Submitted: Yes Installing Company Name: C A e lm r f-v rd t l v i J5 r'4 Company Street Address: 3( F ®r e vat a5 e City: 1 y vv )7-(-0/ d Zip: 0 f d 8 Company Phone Number: '7 78- ,2_73- o t e Estimated Cost: $ /QQQ Indicate total number of units in the applicable box below &2 amily Air Handling Units' Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators 0 E m 0 0 ur to- Y 0 0 LL (.4 0 0 u_ 9 0; 0 LL c 0 Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o v. 1 2nd Floor 3rd Floor Roof" c o Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool f Heater Process. Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: K i. k S/1RG C /7cfi, Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: Div ,'lorgsi. Plc /ntd&er not Name: Type of License: • ion License #: Permit fee: Issued By : Rece. This Section for Offical Us Oily Date Received: 67g pproved Date: Revised 12/31/09 Received by: i- Permit Number: Map #: Lot#: Unit #: Street #: Street Name: Street Pern6#: _ 1` Depa t nt: Bu tdanz Document Type: ` ,f CPI t TOWN OF LEXINGTON Community Development Building Division Building uS M0„A, O tiop 77s ` a'i ; .,�w'���' , q x \p The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts a State Building Code For One- and Two - Family Dwellings 7'h Edition ',:- Zzvr APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika SITE INFORMATION: Not Applicable: License Number 76563 Permit #1.a Date issued: // / Work approved by: Signature: re, Phone # 508 -583 -3999 ( Property Address: O 3 ' 0 ' Historic District: Yes/ No Assessors Map /Parcel # ? / 8'y A Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Yes Phone # 1- 888 -559 -0909 Roofing 5900: (Note: Roofing is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Existing material: Proposed material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 3 Estimated cost of work and material excluding electrical cost: a/ /00 PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (print�ed); Signature: I`- V � Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 . CONSTRUCTION SE ICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. La eville, MA 02347 Signature: re, Phone # 508 -583 -3999 ( r' . Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Expiration Date Address: Qianat,rrE- Phone # Receive !1 by /date: n P Receipt #: 29"? Issued By: Map #: 6 6 Lot #: 6 c Unit #: Street#: Q Street Name: C /,4e =reet Unmt #: ' ,trmmt #: /0 Q� }department: B «ulciin t)ceument Type.: (Plan) (FlotD erm?) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861- 2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: /0 Y a --6 Owner of Record: Assessors Map # c (, Lot # 6;? A-1 Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes No Installing Company NameConstrcaction Specialtie3 .O. Bux 53 Company Street Address: Stoneham, MA 02180 City: Zip: Estimated Cost: $ 1 c; P/%) m Company Phone Number: 7- 6 6 5.---cf c°l l C Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement ° u. H ° C N ° u_ 9 co Roof c 2 0 Air Handling Units Draft Inducers Oil fired Equip Hydro Air. Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil LAll 0 Vi-l0 5 c_t'ii FIg . Generators M. A 0 `55,OCpA F-i RED+' Other: Basic Building Code Commercial Basement o i w •- o u. C N o D M Roof I Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: LAll 0 Vi-l0 5 c_t'ii FIg . M. A 0 `55,OCpA F-i RED+' Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law:* I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws/regulations of the Town of Lexington: SignatJre: "r( M ,fi( to C.-5j3 77 Print Name: Type of License: License #: Permit fee: S This Section for Offical Use Onl Receipt #: 0/74) (, Issued By : Revised 12/31/09 .#4 Date Received: 7/0 /L) Approved Dat . Permit Number: l Received by: r.amc: cr Is•oti: • •' ' • • ..■ ti11011 'C,0%.7•11'iullIngron Strut 11.01ker:.r...C.,)vvihrdirpn./nrirovIer ,VI:•n•r • • COnStrUCtidri**4#14I1J:2CIDLY P.O. Box 53 Phonc Storie :I i:ocncosvocr per fornainc al4 yoork mysclf. r:1 to!: proprietor and 11•3 VC no one workinc in any caNcity. It...' . ._ 1 0.:n In employer prvvidinc %votker$' 4intp4rtsation for nty c.mployccz wol Line Company manic: Phonc aly: 1:::•..nn.:c Company: , :.01: proprietor, Cenci contractor, or 119p1COWnCr (circic onc) and ttavc tared t!t: contractors who :Lave the rollowinc workers' cornp4,:nsation policy: Company name: Co::Ipany addr: :n.:;:r7,:r:c Company: Policy: . . Cc Construction Specialties Stoneham. MA 02180 • covipany: LiAil OA) t7U C— "006, —? 5-2.) 3 Phone q(7: St:1;c: Policy: Phone 707-45---Leq(cD 3".11tIorta1 sliects if necessary. 0 -..-• to s,:cure coverage aS required under Section 2$A of ?..191..152 can Icad to the implcmcntation of 4 p:nalties of a tine up to S15C0.00 and / or one ycari' Impri.:onmcnt 1.s Ivell as civil penaltics form a "STOP \von): ORDER 'and 114C of S100.00 a daY acaing mc. undcatand tlot a copy et II::: :tat; mem r.uy forwarded to the OflicCOr Invaticaiion of thc DIA Icy Covcra cc ‘.erification., isfrc!). Cc, wider the paint MU/pt./Mille I r.:,..v.urc of application: 1';:m tvt • Datc: (71(0 Phon)( —.86..._c—L1ki/ 0 :101 ■■TilC Oti: VC3 ^ 1• In COmplckd tly city or 10`All Cfr:7:.11. • • • • C rtnrIf •. • . • :lc, • ),.4 of:AA "7_ Pt 9d4tfe_ Map #: Lot #: Unit #: Street##: L street Name: WjG it-frnewp :Meet Unit #: Department: 13 tt 11d1_ Qc 1!ment Type: (PLin. P (Perm), TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a BuildingPermit FEE: $12 per one thousand valuation or any portion thereof Property Address: f (o caner of Record: Assessors Map # 6•() Lot # Type of Occupancy: RcLscAnficti New: Renovation: Replacement: Plans Submitted: Yes /No r Installing Company Name: Constrt,Q P.O [c: Company Street Address: Storieh .rbi. it d t Ff G City: Zip: Company Phone Number: ? 7 _ ip 6 t-{ L' (0 Estimated Cost: $ /CVOR-a- Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement l 00 u °o u- 2 N o° u p M Roof c = o 0 Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit . Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators CP 0 3 via c. Pm Other: Basic Building Code Commercial Basement I `o Le. `o 3rd Floor Roof* I o Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: CP 0 3 via c. Pm Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexin tg o`; Signatu (4„ -- -.. C 5s3 License #: Print Name: Type of License: This Section for Offical Use 0 Permit fee: 3).00 Revised 12/31/09 Receipt #: X317 Date Received: af!' 7 Y Approved Date: ct /30 lt,.� Received by: 4c._, Issued By Permit Number: to (013 4 4 C( /,"%‘..,4414/0m, • , Coa.7.11'athlrtReon Stele , • 111411. (... 7.Con ipei1431ron•le;ri1ov,ee Constructidri 12 linu c..uctEst.Y P.O. Box 53 aeS 4.-2v(-66 Lckir 9 4 I it% hocuowncr pc-ffor Mint 1.4 yvork•mysclf. I J r : 2 lo!: proprietor And K Q one Ivorkinc in Any cap.acity. I Al employer prvvidinc ‘%otkers' ornpz.ru-aLion for my employee:. Ivo; kin on s Cc r.arne: ConTany: Phone CIty: Sca::: Policy: proprietor, cencral contractor, or 119 rncow1cr (circic onc) and %we hired th: eontra::crs 1; !ow who have the follov%inc workers' cornr9suation policy: C'or.1;\any name: Phone addre,•s• CO Inpanr: q(Y: Polity: State: ' Ranl.:: Construction Specialties . 7 (37 —_ 4 5--I—Le Li ( (i ,...:::,„:::,. a 2.!rez.:: Stoneham. MA 02180 . city str-• ________ • "".......__ !,....-.•.::::::c Company; 42hJA ____________ji 64) 1--fizp__, PolicY: / • 6U C- 001-7 t21)::.;:- /A)S.. C-0 -- A.;:ac!1 A.:.1•itiortal sheets if necessary. . '5/.( IC) — g'-( .) I. coverage AS required under Section 25A of M91..152 can lcad to tlic implementation of .4. c: '::::i.-41 ;tic s of z ftne up to 5-1,5C0.00 and / or one yeari' .impris,onmen( as well as civil renalf.ies 'in ... t:.-., form a "STOP WORK, ORDER" 'aM 1 fis3C of S100.00 a daY azaing mc..I undcrsund du( a copy cf (nen( cuy In forwarded to the OrficC of Invc.sticationof the DIA for Covemte verification< : ..d., i::-.-(!). 1.71,./ey. Ihe pains 'allies Y... i r.:•..1: urc c( 1 pplie-a ti on: • ".--z..--)........ / f (tit F-( AlA : • D3(c: cr (61- 17 0 PhoT( — 5---k-(y/ 0 (2.) not wr'ite in Otis a:ca - to In completed by city or to,.vn cf1:7:3! • ____ Permit i• JILx-Y) tar_ da+eo Map #: 5 1 Lot #: Unit #: Street #: Street Name: %Z OZ—P-6- D =TAeet Unit #: '?rnlit #: /0 -- (3-, :department: i;3«il�i t)omment Tvpe:_ (P ittn) (P TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781-861-2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: Fr CO7 Owner of Record: Assessors Map # Lot # !—� Type of Occupancy: re 1/ Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: )% %ly 1A7ee l e Company Street Address: VY 1,-051 lL-41'7 Company Phone Number: 6 D3 F- 3 5'5, Estimated Cost: $ 2 o, ®0 0- Indicate total number of units in the applicable box below w'J/ Zip: Did 71 Family IN 4/i I 1 &2 Basement l 0 r ° N 3rd Floor o m o 0 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners `- Ventilation Fans Energy Recovery Ventilators Furnaces - Oil Generators Other: Basic Building Code Commercial Basement 1st Floor $ u.. N o tr) Roof Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that 1 have the authority to make the foregoing application and that all of the information l have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be, in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signature: ad i 2 n y Print Name: Type of License: License #: Permit fee: 60 This Section for Offical Use Only Receipt #:�j /Lfr� Issued By : ..)46 Revised 12/31/09 - a Date Received: --� Received by: 4, Approved Date: er12 Permit Number: f 24(E yp The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 WWW.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Levbly Name ( Business /Organization/Individual). jL � r s -� Address: V5/ 0.4 4.7 rCl- City /State /Zip: Sr 47 )-✓)/ '3b 7, Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 2. 121 am a sole proprietor or partner- listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.+ 5. 0 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.] 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.] t Type of project (required): 6. 1:144ew construction 7. ❑ Remodeling 8. ❑ Demolition 9. 0 Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *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 fme 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 fme 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: P Phone #: 64.7 v 5 Date: - t� Official use only. 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 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 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 600 Washington Street Boston, MA 02111 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 www.mass.gov /dia i.,/,/tA d-l-e-4 1/1<-4-/ Map #: Lot # :_ ..__L Unit #: Street#: ,ltreet Name: / '0 S 1 .T e�et Unit r: ,t rniit #: / ® s_ /e /, }department: i3 �R ldin Document Type: (Plan) (Plot (Perrot TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: I ( �.bss +' Owner ofRecord: we (aicA_ Assessors Map # 9 Lot # /5 9 Type of Occupancy: 12CS New: Renovation: Replacement: / Plans Submitted: Yes No Installing Company Name: Company Street Address: Company Phone Number: .-5450th /u gh b y ems! f,_ �-- 'c • BOX N City: LNIkiil Zip: c.)l &) Estimated Cost: $ 020 £: 7$ cleg 3737 Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement 1st Floor 0 u- N 0 u: M Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: '-&)i ler -Oa Basic Building Code Commercial Basement 1st Floor 6 cc.. N 3rd Floor o o: Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexingtgn: Signature: Print Name: 14CII- Type of Licensd: I`ce47/ License #: Permit fee: This Receipt 6S5 Sc ction for Offical Use On y Date Received: ./, /O Received by Revised 12/31/09 CL Jiix ‘leigo ‘24 Map #: Lot #: Unit #: Street #: street Name: =Treet Unit #: 'erne t ##: / © — 720 Department: B«31<i ikcutment Type: (PL.n) (Plot (Perm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: A"'`) 4, d 4',; Owner of Record: , 7 /cy, L Assessors Map # 0 Lot # 39 Type of Occupancy: A ■ -' /74- New: V Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: /v. •4-'. T. rA • ,N C Company Street Address: /4 Ss`f /ire �,l ar City: C,> as ur#/ ` Zip: 0/ gd Company Phone Number: 20/ - 933 — 6 3 S7 Estimated Cost: $ /0/dot) — Indicate total number of units in the applicable box below Family i‘i 1& 2 Basement 0 0 u_ tz 0 0 LI N `o o u co Roof a c CD Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps / V Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement $ Li n. o 0 LI N 00 LI a M Roof* Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: .5 e 777 rd ) Gale 114 C d %ter -ICS I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the To 1 C.� Lexington ��4) 1 AfIG'' / (4/`�)"cc-ta 02-x—' - /02 7 76' 1 License #: Print Name: Type of License: Permit fee: ice. p Issued By : This Section for Offical U, e • Receipt #: 1 Date Received: 1 Received by AIN Revised 12/31/09 77 Approved Date: ,v Permit Number: ®^ ? N.E.T.R. Inc. 165 -A New Boston St . Woburn, MA. 01801 781 - 933- NETR(6387)- FAX# 781 - 933 -4727 WWW.NETRINC.COM ALEXANDRE WAHL 5 ROWLAND AVE LEXINGTON, MA July 06, 2010 Proposal DAIKIN INSTALL 7804- 114882 FRANK F 8/5/2010 ALEXANDER WAHL 5 ROWLAND AVE LEXINGTON, MA We Hereby Submit Specifications And Estimates For: MASTER BEDROOM, BEDROOM TWO, LIVING ROOM, FAMILY ROOM AREA Install 1- Daikin 4MXS32GVJU 4 ZONE HEATING & COOLING outdoor unit. With four matching indoor units. Indoor Units to be installed in the following areas >Master bedroom would be 1- FDXSO9DVJU Ducted unit installed in the attic space with two supply registers and one return register in the space as shown on drawings. >Bedroom two would be 1- FDXSO9DVJU Ducted unit installed in the attic space with two supply registers and one return register in the space as shown on drawings. >Main living area would be 1- FTXSI8HVJU Wall mounted unit installed on the wall to the right of the window on a backer board to build out the wall to accommodate the indoor unit size.(This unit is larger than the living room unit it is 43 inches long vs. the 30 inch unit in the living room) >Living room area would be 1- CTXSO9HVJU Wall mounted unit installed on the wall to the left of the fireplace Outdoor unit will be installed on the left side of the house near the chimney on the corner. Unit installation to include the following All refrigerant piping. (Will be installed on the left side of the home) All drain piping. Evacuation of refrigerant piping. Mounting of remote controllers .(Upstairs units would be wall mounted hard wired thermostats and the down stairs units would be hand held remote controllers with 24 hour daily timers only on both controls) D/C communication cables. Interconnecting electrical wiring from outdoor unit to indoor unit. Appropriate line hide needed in choice or color. (white,ivory,brown) Installation of electrical disconnect switch. Outdoor unit prefab cast pad. Charging unit with Freon . Mechanical and electrical permits Startup and checking all operations of unit system. ELECTRICAL POWER WIRING: All power wiring is included in this cost. WARRANTY: One year labor on complete system. Five years on all parts for indoor and outdoor units Seven years on compressor only no labor ty Exclusions : Mechanical drawings if required by town. TOTAL COST :$10,000.00 DOLLARS 10000.00 Subtotal Total 10000.00 $10,000.00 All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon delays beyond our control. Purchaser agrees to pay all costs of collection, including attorneys fees. This proposal may be withdrawn by us if not accepted by the above due date . Customer acknowledges that from time to time, Contractor may offer discounts as a promotional device. Promotions, of any kind, will not affect this agreement in any manner. This offer shall not be valid with any other offer. N.E.T.R.Inc reserves the right to remove equipment from the site due to non payment after fourteen working days. Authorized Acceptance Signature Signature Date rDAIKIN AC absolute comfort Job Name: Purchaser: ufti -Split Submittal Data: TWSO9GVJU / CTXS'12GVJU Wall Mount Indoor Units XSI5DVJU IFTXS 78DVJU Wall Mount Indoor Units X QyJUtFDXSI2DVJU Slim Duct Indoor Units Location: Engineer: Submitted To: Submitted By: Unit Designation: Schedule #: For: ❑ Reference Date: Model No.: ❑ Approval ❑ Construction Capacities & Efficiencies: CTXS09112GVJU=[" t FTXS15/18DVJ4 System Combined with Nominal Cooling Capacity EER SEER Nominal Heating Capacity COP Low Heating Capacity COP HSPF Btu /hr 95F Btu/hr 47F Btu /hr 17F 4MXS32GVJU ..- Non Ducted Indoor Unit 30,600 10.3 _ 17.6 32,000 3.40 22,200 2.30 9.30 Ducted Indoor Unit 29,000 8.4 13.3 30,400 , 3.00 21,000 2.10 7.9 Mixed Ducted and Non Ducted Indoor Unit _ 29,800 9.35 15.25 31,200 3.20 21,600 2.20 8.6 [: t �suawuu inaoor unit: Power Supply (V /Ph /Hz) from 4MXS Cooling Airflow Rate (H /M /L) Heating Airflow Rate (H /M /L) Running Current (Rated) Cool / Heat Weight Sound Pressure Level at 3.3ft (H /M /L) 208-230/1/60 388/335/283 cfm 400/357/314 cfm 0.18 Amps / 0.20 Amps 20 Ibs 44/40/35 dB(A) FTXSI5DVJU Indoor Unit: Power Supply (V /Ph /Hz) from 4MXS 208 - 230/1/60 Cooling Airflow Rate (H /M /L) 519/436/353 cfm Heating Airflow Rate (H /M /L) 515/476/402 cfm Running Current (Rated) 0.18 Amps Weight 26.5 Ibs Sound Pressure Level at 3.3ft (H /M /L) 45/31/36 dB(A) FDXSO9DVJU Indoor Unit: Power Supply (V /PH /Hz) from 4MXS 208 - 230/1/60 Cooling Airflow Rate (H /M /L) 305/280/260 cfm Heating Airflow Rate (H /M /L) 305/280/260 cfm Running Current (Rated) 0.52 Amps Weight 47 lbs Sound Pressure Level at 3.3 ft (H/M/L) 35/33/31 dB(A) 4MXS32GVJU Outdoor Unit: Power Supply (V /PH /Hz) 208 - 230/1/60 Cooling Operating Range 14 °F - 115 °F DB Heating Operating Range 5 °F WB - 59.9 °F WB 5 °F DB - 72 °F DB Minimum Circuit Amps (MCA) 18 Amps Maximum Fuse Amps (MFA) 20 Amps Maximum Starting Current 13.8 Amps Running Current (Cooling /Heating) See Combination Data Weight 168 Ibs Sound Pressure Level at 3.3 it (Heating) 54 dB(A) Options: Air Purifying Filter with Photo - catalytic Deodorizing Centralized Control /Unified On- Off /Scheduled Timer XSI2GVJU Indoor Unit: Power Supply (V /Ph /Hz) from 4MXS Cooling Airflow Rate (H /M /L) Heating Airflow Rate (H/M/L) Running Current (Rated) Cool / Heat Weight Sound Pressure Level at 3.3ft (H /M /L) FTXSI8DVJU Indoor Unit: Power Supply1V /Ph /Hz) from 4MXS Cooling Airflow Rate (H /M /L) Heating Airflow Rate (H /M /L) Running Current (Rated) Cool / Heat Weight Sound Pressure Level at 3.3ft (H /M /L) 1 -4101 208-230/1/60 388/335/283 cfm 400/357/314 cfm 0.18 Amps / 0.20 Amps 20 Ibs 45/41/36 dB(A) 208-230/1/60 549/476/402 cfm 609/529/448 cfm 0.18 Amps 26.5 Ibs 45/41/36 dB(A) FDXSI2DVJU Indoor Unit: Power Supply (V /PH /Hz) from 4MXS Cooling Airflow Rate (H /M /L) Heating Airflow Rate (H /M /L) Running Current (Rated) Weight Sound Pressure Level at 3.3 ft (H/M/L) 208 - 230/1/60 305/280/260 cfm 305/280/260 cfm 0.52 Amps 47 lbs 35/33/31 dB(A) System Piping: Maximum Height Difference 49.2 ft Maximum Length (Per Unit) 230 ft (82 ft) Minimum Piping Length 9.8 ft Liquid Piping Connection 1OD) (1)1/4" x4 Gas Piping Connection (OD) X3/8" x1, 41/2" x1, 0/8" x2 Condensate Drain Piping Connection (OD) 01° Standard Features: U.S. Compressor Limited Warranty 7 years U.S. Parts Limited Warranty 5 years U.S. Limited Labor Warranty 1 year Wireless Remote Control Standard Daikin AC (Americas), Inc. • 1645 Wallace Drive - Suite 110 • Carrollton, TX 75006 SDS 4MXS32GVJU with CTXS09 /12G, FDXS09 /12D & FTXS15/18D 5 -08 www.daikinac.com (Daikin's products are subject to continuous improvements. Daikin reserves the right to modify product design, specifications and information in this data sheet without notice and without incurring any obligations) Vluiti-Split Submittal Data: CTXSO9GVJU /CTXSI2GVJU Wall Mount Indoor Units F1'XS15DVJU /FTXS18DVJU Wall Mount Indoor Units DXSO9DVJU/ FDXSI2DVJU Slim Duct Indoor Units 4MXS32GVJU Outdoor Unit VoAIKIN AC® absolute comfort 4MXS32GVJU 35-7/16 condensing Unit Dimensions: 4-CUTS FOR ANCHOR BOLTS (5412) MINIMUM SPACE FOR AR PASSAGE WALL HEIGHT ON AIR OUTLET SIDE LESS THAN 47 -V4 N 1.34 14 -1316 RA MR-HOSE FOR CONNECTION NAME PLATE AS STOP VALVE 5- TERMINAL STRIP WITH GROUND TERMINAL LIQUID STOP VALVE L OUTDOOR AIR TFERMISTOR IRE INTERCONNECTING PIPING AND WRING MET UNIT : INCH « ROOMA» GAS PIPE N3e SINGLE UNION) LOUD PPE (41/4 SINGLE UNION) at ROOM B. GAS PIPE (41• SINGLE UNION) UOUD PPE (nn SINGLE U/ON) ROOMCs GAS PIPE BUS SINGLE UNION) UOUIO PPE (11/4 SINGLE UNION) «RCOM Do GAS PIPE LOAD 5)001 UNION) (41/4 SINGLE UNION) Indoor Fan Unit Dimensions: CTXS09 /12GVJU - 0.75 /1.0 -Ton Wall Mount Type Indoor Unit THE MARK (') SHOWS PIPING DIRECTION LEFT ROM FRONT GRILLE FIXING SCREW (NSIDE) FLAPS 0ANAL 1RANSMITTER 24116 11/16 INV WIRELESS REMOTE CONTROLLER (ARC433A53) inscwo INSTALLATION PLATE 0- 7/16(240) OPERATION LAMP SIGNAL RECEIVER INDOOR UNIT ONOFF SWITCH RTELLIG 41 EYE SENSOR ROOM TEMP. THERMISTOR(NSIDE) TIMER LAMP HOME LEAVE LAMP MINA - 15/16(50) (SPACE FOR MAINTENANCE) AR FLAW(NDOOR) (FOR PERFORMNNCEANO MAINTENANCE) MN. 1 -15/1 (SPACE FOR MAINTENANCE) REQUIRED SPACE HORIZONTAL BLADE BLADE ANGLES (AUTOMATIC) COOL6 3 HEATING DRY i I5• C « 4 s. SS 15•v 25' S ,/ 5S 36' 55 55. VERTICAL BLADE(AUTOMATIC) MODEL NAME PLATE TERMINAL BLOCK WITH GROUND TERMINAL (INSIDE) OAS PIPE S48C ff DRAIN GORE FOR VPI2 (THE LENGTH OF PPE OUTSIDE OON.IECTING PART THE UNIT: ABOUT 1340)) ID. 0(16 UOUID PIPE 1/4CuT OA. 11/16 (THE LENGTH OF PIPE OUTSIDE THE HOSE LENGTH OF THE UNIT ABOUT 10-30) OUTSIDE THE UNIT. 316/15(705) ABOUT 174 /16 2 -7 /16(626) WALL ROLE FOR EMBEDDED PIPING 42-0 /16 HOLE STANDARD LOCATIONS OF WALL HOLES 2 WALL HOLE 3 4 -0'16 HOLE 3D048 Daikin AC (Americas), Inc. • 1645 Wallace Drive — Suite 110 • Carrollton, TX 75006 SDS 4MXS32GVJU with CTXS09 /12G, FDXS09 /12D & FTXS15 /18D 5 -08 www.daikinac.com (Daikin's products are subject to continuous improvements. Daikin reserves the right to modify product design, specifications and information in this data sheet without notice and without incumng any obligations) y DAIKIPJ AC® absolute comfort Multi-Split Submittal Data: CTXS09GVJU /C7-XSI2GVJU Wall Mount Indoor Units FTXSI5DVJU /FTxSI8DVJU Wall Mount Indoor Units DXSO9DVJU / FDXSI2DVJU Slim Duct Indoor Units 4MXS32GVJU Outdoor Unit Coil Unit Dimensions: FTXS15 /18DVJU - 1.25/1.5 -Ton Wall Mount Type Indoor Unit C> AIR FLOW(1NpoOR) (FOR PER MANGE AND MAIMENANA:E) THE MARK (`) SHOWS PIPING DIRECTION FRONT GRILLE FIXING SCREWS FLAPS !INSIDE) SIGNAL TRANSMITTER 2d1 s 111,j� 7 HORQOMAL BLADE (AUTOMATIC) aggil 7 tiii WIRELESS REMOTE CONTROLLER (ARC433A53) CDOUNG 10 �� 40• 10'� 4d 55" 55. (SPACE FOR MANTENANCE) MIN. 1 - 1516(50) INCLUDING (INSTALLATION PLATE 0 -7/1 . 24 OPERATION LAMP SIGNAL RECEIVER 8 NDOOR UNIT O$L/OFFRS SWITCH RCOM TE MP.THE INIOSTOR (INSIDE) INTELLIGENT EYE SENSOR TIMER LAMP HOME LEAVE LAMP BLADE ANGLES HEATNG (FTX -0ONLY) 1b•( 15• �7 DRY FAN VERTICAL B LADE(AUTOMATIC) MODEL NAME PLATE TERM% BLOCK NTH GROUND TEAMI (INSIDE) MIN. 1- 15118(50) (SPACE FOR MAINTENANCE) REQUIRED SPACE S D. 4- 0 2 GAS PPEf12CuT (THE LENGTH OF PIPE OUTSIDE THE UNIT: ABOUT 13-3/8) DRAIN HOSE FOR VP13 (CONNECTING PART ID.5/18, 0011 /16) (THE HOSE LENGTH OF UOUID PIPE f1MCuT OUTSIDE THE UNIT: (THE LENGTH OF PIPE OUTSIDE ABOUT 174/16) THE UNIT: ABOUT 16-345) 41-5/1 . 1050 (98. -) 5 c �..` HO • FOR STANDARD LOCATIONS OF WALL HOLES 55. 55' 43.145 HOLE FDXS09 /12DVJU - 0.75 /1.0 -Ton Slim Duct Built In Type Indoor Unit 27-/16 12 OR IS-3%09_ Jut(13.M? 3D047161C U & P31SH 10 -11H6 1. SY6 HOLE 5 4A .SERVICE SPACE„ (ALL 20 -18 Z5USPEN51CFROLT WIGAN) SUSPENSIONS:LT 2634 4- M8 -M10 Od A NEEI6SRBOfE60N/RXIER (1RC4333863) NOTE) 1. N CASE OF BACK - SUCTION. MOUNT CHAMBER COVER TO BOTTOM SIDE OF THE UNIT INCASE CF BOTTOM - SUCTION. MOUNT CHAMBER COVER TO BACK SIDE OF THE UNR. 2. LOCATION OF UNIT S NAME PLATE :CONTROL BOX COVER 3. MOUNT THE NR FLIER AT THE SUCTION SIDE. ( SOLE CT MOPE. ORP4FTHOD(GRAVITY METHOD)) IT CAN NOT BE EQUIPPED WITH NR FILTER(ACCESSORY) WHEN 00(I ECTNG DUCT TO SUCTION SCE. 4. PIPE SPECIFICATION «IN CASE OF BOTTOM - SUCTION. • N CASE OF BACK - SUCTION» 10 PROTECTION NET 0 NR FILTBi/jACCESSORY) 8 SUSPENSION BRACIET 7 PCVER81NP0 00NNEIION 6 MREFO GNERMENNECI7N 5 CONTROL BOX 4 oaumosExcEssorm LG. 431/32(OUTLET) 3 SOCKET FOR ORAN VP20(01/41- 1l3211.0.02632) 2 OAS PIPE CONNECTION 43496 u RE OOMECTCN) 1 UCUD PPEOOINECIION 41A(PLARE CONNECTION) MIMI HAKE DESCRIPTION 30052092A Daikin AC (Americas), Inc. • 1645 Wallace Drive — Suite 110 • Carrollton, TX 75006 SDS 4MXS32GVJU with CTXS09 /12G, FDXS09 /12D & FTXS15/18D 5 -08 www.daikinac.com (Daikin's products are subject to continuous improvements. Daikin reserves the right to modify product design, specifications and information in this data sheet without notice and without incurring any obligations) VDA IKINAC absolute comfort'' Job Name: Location: iubmittai Data: BRC944B2 A & RA -Multi Wired Controller Purchaser: Engineer: Submitted To: Submitted By: Unit Designation: Schedule #: For: ❑ Reference Date: Model No.: ❑ Approval ❑ Construction For use with the following Daikin RA & RA -Multi Indoor Models: FDXS Slim Duct & CTXS / FTXS Wall Mount For use with the following Daikin RA & RA -Multi Outdoor Models: RX Std. Efficiency, RXS High Efficiency, 2MXS & 4MXS FEATURES / BENEFITS • Includes 8m (26ft) of cable • Built in one time or daily timer functionality with up to 2 timer actions per day • LCD lets you display set point temperature in either °F or °C units in 1 degree increments • Monitors room temperature and preset temperature by microcomputer and can select cool or heat operation modes automatically based on the set -point requirement • Selectable auto / cool / heat / dry operation modes with adjustable temperature and airflow rates • Approximately two hour battery backup • Required remote control adapter PCB included • Controller can be used in conjunction with the factory supplied standard wireless remote controller Remote Controller Functions OPERATION Start / Stop Operation Mode Temperature Setting 64 °F — 90 °F Set Point Range Fan Speed Airflow Direction MONITORING Status Operation Mode Temperature Setting Fan Speed Airflow Direction SCHEDULING One Time Timer Daily Timer 000r tlleed CORD OUTLET ROLE CABLE SPECIFICATIONS TYPE 4 -wire sheathed vinyl cable TOTAL LENGTH BRCW901A08 — Approx. 8m (26ft) Daikin AC (Americas), Inc. ♦ 1645 Wallace Drive — Suite 110 ♦ Carrollton, TX 75006 SDS BRC94482 10.08 www.daikinac.com (Dailo'n's products are subject to continuous improvements. Daikin reserves the right to modify product design, specifications and information in this data sheet without notice and without incurring any obligations) VDAIKIN AC® Job Name: Purchaser: absolute comfort mittal Data: ARC433A53 Wireless Remote Controller For:usewith FTXS75, 18, 24, and CTXS09 units) Location: Engineer: Submitted To: Submitted By: Unit Designation: Schedule #: For: ❑ Reference Date: Model No.: ❑ Approval ❑ Construction FEATURES / BENEFITS Self- Diagnosis with Digital Display Shows when something has gone off - track, for fast, easy maintenance Home Leave Operation Keeps the room from becoming too hot or too cold, even when the room is vacant Night Set Mode Senses nighttime and gently raises or lowers the temperature just before the air conditioner stops Intelligent Eye Senses human movement and saves energy when the room is vacant Wide Angle Louvers Provides the widest airflow possible, no matter where the unit is located 1. Signal transmitter; • h sends signals to the indoor unit. 2. Display: • It displays the current settings. 3. NOME LEAVE button: HONE LEAVE operation 4. POWERFUL button: (Maximum operation) POWERFUL operation 5. TEMPERATURE adjustment buttons: • It changes the temperature setting. 6.ON/OFF button; • Press This button once to start operation. Press on again to stop h. 7. NODE selector button: • h selects the Operation mode. (AUTO/DRY/COO LME ATIFAN) 6. SILENT button: OUTDOOR UNIT SILENT operation 9. FAN setting button: • It selects the airflow rate setting. 10. SENSOR button: INTELLIGENT EYE operation 11. SWING button: • Rap (Horizontal blade) 12. SWING button: • Lowder (Vertical blades) 13. ON TIMER button: 14. OFF TMER button: 15. TRIER Setting button: • 11 changes the lama setting. 16. TIMER CANCEL button: • II cancels the timer setting. 17. CLOCK button Daikin AC (Americas), Inc. • 1645 Wallace Drive — Suite 110 ♦ Carrollton, TX 75006 SDS ARC433A53 04 -07 www.daikinac.com (Daikin's products are subject to oontinuous improvements. Daikin reserves the right to modify product design, specifications and information in this data sheet without notice and without incurring any obligations) • • ICYNENE INSULATION ALL EXTERIOR WALLS & ROOF AS NEW CONSTRUCTION PERMITS. ... . .. v , .. . 1/2" PLYWOOD FLOORING (IF EXPOSED - \ JOISTS) FOR STORAGE. ACCESS DOOR WITH HAFELE #161.15.613 FLUSH HANDLE & BALL CATCH SWITCH •--„,„. LOWER HALF 6',6'(WNi-)V3 UUEEN-901 CEILING SLOPE II LINEN CLOSET BUILT -IN TO COVER EXPOSED AREA FROM DEMO NEW CA T& PLASTER CEILING NG SLOPE RECONFIGURE EXISTING CLOSET TE /DATA HOMERUNTO CONNECTION IN BASEMENT 2x6 STUD WALL WITH R19 MIN. INSULATION. EXT. SHEATHING, SIDING DORMERS 6-6" 0 1 1 ?1 ,vas& y �l1EtS�%S L 6Y fapit Utit� r 1 r DESIGN INTENT: ALL REPLACEMENT WINDOWS TO BE INSTALLED BELOW EXISTING HEADERS, TYP. WHERE APPLICABLE, NEW SILL FRAMING OR ROUGH OPENING SIZES SHOULD BE ADJUSTED ACCORDINGLY FRONT YARD SETBACK LINE ra 2`BLUESTONE SLABS a -2. -v PATCH PAVED .<4.,ZAA i--/-e4 //te,t- iL— Map#: Lot #: Unit #: Street##: street Name: .Treet Unit r: Jttrnn t #: 2. Department: Buildin Dociilnent Type: 11P[_.al (i lc (Fer 1 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: ).1 5q.LJjt & f oh av Owner of Record: 4/..e xc d4,2, Petmet5yu k Assessors Map # 55 Lot # 8 Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes Installing Company Name: pr eyt j e r c,7- I / O. Company Street Address: ! 7 ( City: Worfev`Lv k Zip: Q (). off Company Phone Number: (Q (7-- L{ 7 '7'/ Indicate total number of units in the applicable box below Estimated Cost: $ Gtr Air Handling Units' 1 &2 Family Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners E 0 0 o E w L u. U.) ro' O p Ca C Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o o u_ ,- 0 u- cos, ' 3'd Floor Roof 0 Generators Draft inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. Aland survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that 1 have the authority to make the foregoing application and that all of the information 1 have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexi gton: j Signature: rl 61,66Ac etas G ri Print Name: Type of License: 0.2.?*2.7 09 License #: This Section for Offical Use Only Date Received: ' (O /8/ O Permit fee: in. Issued By: 1 Receipt #: a'$6 1 Received by: $ Approved Date: Jg Permit Number: Revised 12/31/09 fk. 6 giro Map #: • Lott: Unit #: Street#: 'treet Name: AZ.D1P 0 ;T,eet Unit #. -'4•trmit 4: Oepartment: €3 t t ilciin . - - 5 - i):,1m-nent Type: (PLm) (Plot TOWN OF LEXINGTON BUILDING/INSPECTION DEPARTMENT RECEIPT Date Name Building at Building Permit Electrical Permit Plumbing Permit Gas Permit Mechanical Permit Micro Film Fee Accessory Apartment Certificates of: Use /Occupancy NOTE THIS "IS NOT A PERMIT PERMIT FEES ARE NON- REFUNDABLE TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 2 9 3 /zcku b P_au.d. Owner of Record: S a At 01.4-j /an Assessors Map # 0 Lot # i Type of Occupancy: r e cievt c-e-. New: Renovation: x Replacement: Plans Submitted: Yes No X Installing Company Name: Ce,n -4--c o„l Cc f , mn Company Street Address: i , map le s4, City: W v6u rn Zip: o i Po, Company Phone Number: --'j, - 933 — F 11846-' Estimated Cost: $ ® ,C Indicate total number of units in the applicable box below Family IN41, 2 Basement o° 2nd Floor o° 2 Roof c 2 Air Handling Units f Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners 2. Ventilation Fans Energy Recovery Ventilators Fumaces- Oil Generators Other: Basic Building Code Commercial Basement J o _LI N r 2nd Floor g M Roof` ' o 6 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: t ie Gt /P 's iv-A: al 2 G 1, -1:;11„ e 1-11-CAP Clue w;r • I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of ngt ture: Perm' fee: t.20 Issued By : MCA Ae 1Zsi ,.1 cCot.- 0A-445 -iec I5I37/19 Print Name: Type of License: License #: This Section for Offical Use Only Receipt #: - p t , Date Received: MO o % Approved Date: b `WO Revised 12/31/09 (C (SL/ Received by: Permit Number: tO -SST The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wWW.rnass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApplicanjInformation Please Print Legibly Name (Business/Organizatiorillndividual): Map #_ Lot # Address: Permit # Address: L\jd 7-1/1 .1(-1(..„ H' City/State/Zip: Phone. #: Are you an employer? Check the appropriate box: 1. I am a employer with 5 4. 0 I am a general conVactor and employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers' comp. insurance.t 5. D 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.] 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Type of project (required): 6. 0 New construction 7. D Remodeling 8. EI Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.2 Other irA A )r *My applicant that checks box #1 must also till 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 name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees, they must provide their worIcers comp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 6- Lc)13 5U9-IJCJ E: NE1-6,J6RK, INC. Policy # or Self-ins. Lic. #: 5 6 C.J cf 3 Job Site Address: ag s'adokecii4h Expiration Date: i 1 / City/State/Zip: Lex tv len 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 ofthe DIA for insurance cover e verification. I do hereby certift under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Phone #: 7 3-F-1 Date: Official use only. Do not write hz this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. 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, mai or \vritten." 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 foint 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. ilowever 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 03 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 ap kropriate 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 600 Washington Street Boston, MA 02111 Revised 11-22-06 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.govidia ,z4eg4 gL Map#: 3 Unit#: •Street#: - street Name: ;Treet Unit #: Oepartment: Docl!ment Type: (P fl) (P)of (Perm TOWN OF LEXINGTOAT APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781-861-2780 4,6\ ad3 Date Reoerved ' Type of Occupancy: it Basement , `Perrrrit Building Location: H sea q L o u_ �c''5 � oc b �. ruff s rat- 3/{ r Owner's Name: T L Permit R€'cei}a r' L Installing Company Name: c.2 iio _ / 4 P•. -. ..e. 1 - 7 S • Aro1 Company Street Address2, / ,, J� / b City: �/ j4,gl,J Zip:)/ _ / Indicate total number of units in the applicable box below V 0 it Basement L a L.,.. y '-- L o IL N L o u_ �c''5 � oc b �. t i � zO L C9 Air Handling Units E Permit R€'cei}a r' , ._ x Baseboard Heat Boilers /Furnaces /Gas /Oil Central Air Conditioners a- Direct Vent Fireplace Draft Inducers Range Hoods Duct Coils Refrigeration Units Evaporative Coolers Roof Top Units Fire Suppression Sprinkler Conn, Generators Sprinkler Heads Heat Pumps Sprinkler Hose Conn. Heating Zones Steam Generators Hydro Air Systems Steam Kettles Incinerators Ventilation Fans Kickspace Heaters Kitchen Equipment No Vent Heaters Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line A land survey may be required. Roof top units may require a Structure Eng'neer's review:' Equipment that is visible from a public way and within a Historic District wifl require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: New Work ❑ Replacement Renovation ❑ Plans Submitted: ❑ I certify that I have the authority to make the foregoing application and that ail of the information I have submitted (cr entered) in the above application is true and accurate to the best of my knowledge, Information and belief, and that at mechanical work and installations performed under the permit issued for this application will be in compliance with at pertinent provisions of the Massachusetts State Building Code, the ICC Mechanical Code, arlglI Iry /bylaws /regulations of the Town of Lexington: Signature: 7173 Print Name: *7/7 3 License*: Type of License: Basement Sgt Floor a t1 a N aoold a£ Roofs` c 0 &- Pool Heater Permit R€'cei}a r' Issued ._ x Process Piping Pumps Radiant Heat Radiators Range Hoods Refrigeration Units Roof Top Units Sprinkler Conn, Sprinkler Heads Sprinkler Hose Conn. Steam Generators Steam Kettles Ventilation Fans Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line A land survey may be required. Roof top units may require a Structure Eng'neer's review:' Equipment that is visible from a public way and within a Historic District wifl require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: New Work ❑ Replacement Renovation ❑ Plans Submitted: ❑ I certify that I have the authority to make the foregoing application and that ail of the information I have submitted (cr entered) in the above application is true and accurate to the best of my knowledge, Information and belief, and that at mechanical work and installations performed under the permit issued for this application will be in compliance with at pertinent provisions of the Massachusetts State Building Code, the ICC Mechanical Code, arlglI Iry /bylaws /regulations of the Town of Lexington: Signature: 7173 Print Name: *7/7 3 License*: Type of License: ZOO /ZOO 'd ZLEU 9L :90 OLOE /6Z /LO 960i;09b LBL say / 3NOZ 31VIII]3 : tuOJI For Office Use Only nsJra na on die ,4 1t lit Fax Permit R€'cei}a r' Issued ._ x ZOO /ZOO 'd ZLEU 9L :90 OLOE /6Z /LO 960i;09b LBL say / 3NOZ 31VIII]3 : tuOJI jitx d_fee,o NJAC—d_ Map #: • Lot #: Unit #: Street#: 2 Street Name: ; reet Unit #: _ '"rmit4: Department: BiuukIin % 1):1ri ment Type: (PL.n) (Pk (Perm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PE ' IT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: j ' kUd Q S Owner of Record: Sea \Per Cmr}-ruoliol Assessors Map # g5 Lot # it t-1.i3 Type of Occupancy: New: X Renovation: Replacement: Submitted: Yes No x Installing Company Name: &s;,/1 00 Cam\ ; r., �. 14 er> t hD ,s n c . Company Street Address: 4 , "i apse St ied City: v) ,,, /-7-) 474 Zip: p /gyp / Company Phone Number: 7S/ - 9,33— FdoC", Estimated Cost: $ 20 Indicate total number of units in the applicable box below 1 &2 Family Basement L 0 N L 0 E N L 0 -2 co Roof Ground" Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners 3 Ventilation Fans Energy Recovery Ventilators Central Air Conditioners Fumaces- 9r1- Gus / 2 Generators Other: s f a vz k --e Basic Building Code Commercial Basement g e_ N g L 2 N 3rd Floor 0 /y 11 Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A and survey may be, required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: 3--„f-/-(1 / 3 FLA ne,0 czd ce)„de>7ters / ff xS c /u: „fer, nv , . W I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations .erformed under the permit issued for this application will be in compliance with all pertinent provisions of the ssachusett- State ilding Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of e ingt Signature: At\ icl,,a2t C. Bwricsrmi Ytevi3 e� Print Name: Type of License: ISl License #: 7 Perm, fee: at�Q Issued . ' i' Revised 12/31/09 This Section for Offical Us O Recei S Date Received: ( /��' billopproved Date: ly Received by: it Peonit Number: LO — l 3. The Commonwealth of Massachusetts Department of Imlusbial Acddents Office of Investigations Map 1 Lot1 600 Washington Street Address: Boston, MA 02111 Permit* www.mass.gon/dia Workers' Compensation insurance Affidavit Bni iders/Contractors/Electricians/Plumbers *indicant information Please Print Legibly Name (BwinessiOrSanizeiolilindividual): Ce tjc Cn 0 1 ;4.1) -I- 4e ck,i- Trtc. Address: 9 Ma& &free+ City/State/Zip: (ARA urn ni A Oleo, Phone #: F 32 - ircx.Fe Are you an employer? Check the appropriate box: 1. I am a employer with 115- 4• 0 I am a general contractor and I employees (full and/or part-thne).* have hired die sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.* required.] 5. 0 We are a corporation and its 3.0 1 am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption per MGL insurance required.] * c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] E'4 Type of project (required): 6. IJ New construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other Any applicant that checb box #1 must also fill out the section below showing their wafters' compensadon policy infomation. t Homeowners who submit this affidavit indicating they are doing all work and thus lure outside contractors mist submit a new affidavit indicating such. tContractors that **this !mac must attached an addftional sheet showing the sauna of the sub-Contractors and state Whether Or not those entities have employees. If theaulkontractOrs have employees, they must pnriide their workers', comp. policy number. I ins an employer that is providing- worhers' compensadort insurance for my employees. Below L s the policy and job ske information. Insurance Company Name: .LbEfL IrUANCJE ertJJ K.) 1"NC. Policy # or Se.lf-ins. Lic. #: 606,29 6 36 Expiration Date: / / 3 5 /2.6/0 Job Site Address: 01(1 cle City/State/Zip: /exo-,,..9 i-en 4 Attach a copy of the workers' compensation polky declaration page (showing the Polk"' 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 InvcsliRatjong of the D Id. under the , , and penaltks of perjury that the information provided above is awe and correct _ ..1A.LLA tl 1/6 - Official use only. Do not write In this area to be completed by city or town offlclaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town aerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 0 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 employe 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 indii►idual, 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 - contractors) 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 adf- insurance license number on thenroriate 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 masked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for fudre 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 Office of Investigations would hike 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 Amts Office of Investigations 600 Washington Street Boston, MA 02111 Revised 11 -22 -06 Tel. # 617- 727 -4900 eaet 406 or 1-877-MASSAFE Fax # 617- 727 -7749 www.massgov /dia d.,(2,g4 741,t- \AL-d Map #: Lot #: Unit #: Street#: 5 2 ,- street Name: -5--)55/<76e//2-'4J6 greet Unit #: 1t;rmit #: • I Department: Bualciing, Document Type: WW1) (Plot) %ersaL TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avent Lexington, MA 02420 Ph. 781-862 -0500 x -21 c r:'_: 78t1,61-2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof ,32> ,J7�r1rrIjYY� Property Address: ,7 J. lie b t -,- ke( Owner of Record: 4.c. o Assessors lylap # CO Lot # / Type of Occupancy: New: / Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: Xrch1 / ?c F; v I /az , Company Street Address: mow. City: s feia Zip: 03S2 Estimated Cost: $ Vgoo Company Phone Number: (4; o.3) Indicate total number of units ir: 1 e applicable box below Basic Building Code Commercial 1 & 2 Family Basement , U :- 2nd Floor �i 0 °o cc Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners • Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators ')t`-‘or: Furnaces- Oil ,2 Ji�p)�e c/ -Ve,4- nets Generators ,/ielt.tu,s Other: Basic Building Code Commercial Basement] o LL y r- °o C N °o u 12 M N°o/ LL Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat • Hydro Air Systems Central Air Conditioners ')t`-‘or: vi ,2 Ji�p)�e c/ -Ve,4- nets ,/ielt.tu,s 6cn 4 /' 44 c» den! R! la; n b, 44furr PP t>y Describe Project: *Note: If any equipment is being placed outside of the footprint of a building, ind' ate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations perfor �� der the permit issued for this application will be in compliance with all pertinent provisions of the Massachus . f tat -.1�' dl Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexingto Sig :ture: Print Name: /VFW Type of License: f 3/ s�s`l License #: Permit fee:2� Issued By : Revised 12/31/09 This Section for C ffical Use Only 7 A7cVDate Reeeivt,'. fd Received by: proved Date1/ / Permit Number: - 9r3-- i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 4rGi. Me. f f /re / AL. Address: /5" La/oh/ I .fir City /State /Zip: E. Abtritp.5ficAfiL Nil Phone #: 1v P3 go'-2 - noaz Are y u an employer? Check the appropriate box: 1. am a employer with J rj 4. I am a general contractor and I employees (full and/or part- time).* have hired the sub- contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 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.] t These sub - contractors have employees and have workers' comp. insurance.: 5. 0 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.] Type of project (required): 6. ew construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *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 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: Pg,er /e �Gt r C G✓ Policy # or Self -ins. Lic. #:�/ Job Site Address: 0.26- .� /rbczrnLt Expiration Date: /a /30 he City /State /Zip: Lex/iv/0n/ 44,4 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 cert f under the pains and penalties of perjury that the information provided above is true and correct. Date: -1/4.5 -/ Signature: Phone #: [P�� 0z.D Official use only. 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 Contact Person: Phone #: A °® CERTIFICATE OF LIABILITY INSURANCE 7/14/2010 ("""") THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION O V? Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER The Driscoll Agency, Inc. 93 Longwater Circle P.O. Box 9120 Norwell MA 02061 CONTACT NAME: PHONE FAX (A/C No Ext1:781- 681 -6656 (A/c,No1:781- 681 -6686 E-MAIL DSS: jbd @driscollagency.com PRODUCER CUSTOMER ID P: 5702 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Architectural Fireplaces of New England, Inc. 15 Colonial Dr. East Hampstead NH 03826 INSURER A: Peerless Insurance Company 24198 INSURERB:The Employers' Fire Ins Co. INSURERC:ACE Property & Casualty Insurance 12/30/2009 INSURER 0 : EACH OCCURRENCE INSURER E : INSURER F : $100,000 COVERAGES CERTIFICATE NUMBER: 1927855359 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW 11A JE:BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONi71TION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCL AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR • TYPE OF INSURANCE INS SUBR POLICY NUMBER POLICY EFF IMM /DD/YYYY) POLICY EXP (MM/DD/YYY1f) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY X OCCUR CBP8365065 12/30/2009 12/30/2010 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $100,000 CLAIMS -MADE MED EXP (Any one person) $5,000 PERSONAL &ADVINJURY $1,000,000 GEN'L GENERAL AGGREGATE $2,000,000 AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC JECT PRODUCTS - COMP/OP AGG $2,000,000 $ B B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS FB1E08033 - MA Auto 7530190680003 - NH Auto 12/30/2009 12/30/2009 12/30/2010 12/30/2010 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) $ X X Coll w/ Waiver Ded $500 Comp Ded $500 A x UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE CJ 8669202 12/30/2009 12/30/2010 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DEDUCTIBLE RETENTION $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A NWC C45865873 12/30/2009 12/30/2010 X WCSTAT- OTH- TORY LIMIUTS ER E.L. EACH ACCIDENT $1,000,000 Y E.L. DISEASE - EA EMPLOYEE $1,000,000 below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Notice of cancellation provision is 30 days, except 10 days applies for non - payment df premium. CERTIFICATE HOLDER CANCELLATION 30 Town of Lexington, MA 1625 Massachusetts Avenue Lexington MA 02420 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 'JClIdYS/t ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD sr d_tezi Map#: Lat #: Unit #: Street#: Street Name: 51 I &/ ®(/ LS -i=reet Unit #: '"rant #: Department: Biti4iing ancitment Type:, (Ply. ) (Plot) l TO OF LEXINGTON APPLICATION FOR MEC • NICAL PE " T 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: .2 ct Sh ec 60,rn e i-dcl(k Owner of Record: Ra M o h 4,c) Assessors Map # L40 Lot # t 6 ( Type of Occupancy: resit 4- c New: Renovation: Replacement: )( Plans Submitted: Yes No k Installing Company Name: Cer .3-r) Cobi , /40 -,;id Company Street Address: 9 /Norm Marie 5-4. City: Gd4LA Zip: Company Phone Number: -7 r -g3j_ 8".48? Estimated Cost: $ // k Indicate total number of units in the applicable box below 1 & 2 Family Basement _o° " _ °° u_ N 3rd Floor Roof Ground* Basic Building Code Commercial E N m ° — o° II N o° M o ° a `_ 0 Air Handling Units Generators Hydro Air Unit Draft Inducers Oil fired Equip Evaporative Coolers Kitchen Vent & Exhaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Refrigeration Units Roof Top Units Central Air Conditioners Radiant Heat Ventilation Fans Hydro Air Systems Energy Recovery Ventilators Central Air Conditioners Furnaces- Oil Other: Generators Other: g4i /cr a, / X Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be, required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installation perform . under the permit issued for this application will be in compliance with all pertinent provisions of the ssachusetts tate Buildi g Code, the International Mechanical Code, and all Taws /bylaws /regulations of the Town of in9to Print Name: user 15 137 Type of License: License #: Permi fee: 1,,3e1 Issued Receipt This Section for Offical Use On)y Date Received: t 24.8-10 proved Date: Revised 12/31/09 0-61/1 o Received by: Permit Number: 10 h (� $ The Commonwealth ofMassachasetts Department of Industrial Acddents Office of Imwstigations Map # Lot* 600 Washington Street Address: Boston, MA 02111 Penult* www.mass.govidia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/organization/individual): re if, i-c?, C(10 1 j 0) 4- e ch3 rtC. Address: 9 rpii &free+- CitY/State/ZiP: Walurri, ryi est80 / Phone #: -7 F / 32 - ircA.AS> Are you an employer? Check the appropriate box: 1. NI I am a employer with 4. 0 I am a general contractor and I employees (full and/or part-lime).* 2.0 I toni a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself [No workers' comp. insurance required.] t have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have worlcers' comp. insurance.: 5. 0 We am 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.] Type of project (required): 6. 0 New construction 7 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Phimbing repairs or additions 12.0 Roof repairs 13.0 Other 4...v/ac e F!4f,la(u *Any applicant that checks box #1 oust ako fill out the section below showing their workers' compensalion policy information. t Homeownas who submit this affidavit indicating they are doing all wort and then hire outside contractors must submit a new affidavit indicating such. *Contractors thatcheekthis box must attached m additional sheet showing the name of the sub-Comma:es and state Whether or not those entities have employees. If thelulkontractors have employees, they must proilde their works' comp. policy nuinber. • I atm in employer dtat is providing workers' compensadon insurance for my employees. Below 15 the policy taut job site information. Insurance Company Name: GLbBfL IN SUR Pits,' CE IJTIJJ02KJ 2NC. Policy # or seif-ins. #: 5-6 Da .29634 Job Site Address: k 4-ei et 0 ( Art, I 6 (z, Expiration Date: 11 /3 0 / o City/State/Zip: L. exnly /nig 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 of the DIA for *i .1.)k — I do hereby cede under the pains and ',NNW'S of perjury that the information provided above is true and correct. Signagget, Ditty: Li z Phone #: 18i - 933 -P-re Official use only. 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. Bungling Department 3. City/Town aerk 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. Puusuant 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 anployer,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 oft 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 necesiary, 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 Accident& 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 : , ' ; ' : to 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 m fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sine to fill in the permit/license number which will be used as a reference number. In addition, an applicant that rust 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 pets 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 (ie. a dog license or permit to bum 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 Acts Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877 MASSAFE Fax # 617- 727 -7749 w w.mass.gov /dia Revised 11 -22-06 COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE - BOARD OF IN PLUMBERS AND GASFITTERS LICENRRME,48tRyiWYMAN PLUMBER MICHAEL C BERNASCONI 58 ALBATROSS RD QUINCY MA 02169-2658 • 1 LICENSE NO. EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE - BOARD OF IN PLUMBERS AND GASFITTERS Lic Eng) AsAttpeorcfLUMBER MICHAEL C BERNASCONI 58 ALBATROSS RD QUINCY MA 02169-2658 UCENSE NO. EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE - BOARD OF BOARD OF SHEET METAL WORKERS AS A MASTER-UNRESTRICTED ISSUES THE ABOVE LICENSE TO: MICHAEL C BERNASCONI 58 ALBATROSS RD QUINCY MA 02169-2658 7 36 7 LICENSE NO. EXPIRATION DATE SERIAL NO. • 0 c Map #: Lat #: Unit*: Street #: Street Name: Stree j j: tt #: Peru#: - \'3\ Department: Builitinz Document Type: (MD PlOt) TigernaL TOWN OF LEXINGTON Community Development Building Division uS MOgN P` Ors �c The Commonwealth of Massachusetts = State Board of Regulations and Standards Massachusetts i State Building Code For One- and Two - Family Dwellings 7'h Edition ° ° �`s =_ 3 <, Lfi # £IN T a^ APPLICATION FOR: ROOFING, SIDING, Not Applicable: WINDOWS, DOORS SITE INFORMATION: Address: 86 Bedford St. Lakeville A 02347 Signature:,* . ° Phone # 508- 583 -3999 Registered Home Improvement Contractor: Company Name: Permit # / ' 3/5 Date issued: ii / 7, Work approved by: Property Address: _A / d. / ' Historic District: Yes/ No Assessors Map /Parcel # 2.5 / . Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Phone # 1- 888 -559 -0909 Yes Roofing 5900: (Note: Roofmg is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofmg shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Proposed material: Existing material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 3 Estimated cost of work and material excluding electrical cost: PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 -861 -0900 Authorized Agent: Name (print d): , / Signature: lk, u Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SER ICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lakeville A 02347 Signature:,* . ° Phone # 508- 583 -3999 Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Address: Expiration Date Signature: Phone # Receive by /date: Oh") Fee: Receipt #: -9o1 Issued By: .1*AaAA•t.. die-4 /21,66d_ Map #: c Lot #: % 6 Unit #: Street#: 7 0 street Name: �2 /NCB Sr- ;Trees Unit #: 'ttrniit #: }department: Building, 702 --q6- z)c nment Type: t PL2 n) (Plot) (Perno r APP.L.'„C.:ATI(..)N FOR NIEC.7.:AIN.',.C.AL 1625 Masons Avenue, Lexington, MA 02420 N' 78 -862-0500 x-211 Fax: 7 I-861-2780 iNNN \ %We: N-01, \ . ■N ta• jk FEE: $12 .x.r eae d:eman;: vabladea ar dv makA: thdmof • .s. II'=:.' A-N.,- : k' " ....- . N,.,. , k\ N , \, ; e'N •-.,:•.•.. s ..'.....•; k4.S:k k.): ,;.; os: , ,;. \-. ,,,, k a ,-, ' ,.A..1wr 01: COI" 0: ••M`,. •,...>:::.: A:,,,.,-,,,,,,,-.,:-..,,,,,,--..;-, k.4.--..6--, -:-..t. •:,>\\::::: ..:, i .,,.... .a. - " of ,e , 0.v" ko"...kkS ,..Akb.kkkk .....:... : tted Yes mstatom:, k„..ompam: Name: ■A„-, ,,,,,,,,,,, ,I„ ,,,,,,,, ----------- ---------------------------- , ompan , A A 41; Sr et k-• 0 • Ctv , $ ,,,, , \ , Estimated Cost: / hidteate totat aubt her of onits ta tne apptieabb box be;ow ., ,': \- I S 2 \ .:•• Famiy \ \ Air Handiftd Units Hytbo Air Lt Evaporative Coders --- ,,,,,,, ,,,,,,, ,,,,,,, • Heat Pumps Range HooOtt Vented :o Extenor 7..7; Retrigaration Units Contra: Air Cond:nonera Vanti:adon Fans • Baec ik;H:::'ng Code Commero:a A;ANIA,, kbohen Vent & ExhauSI Eatt:p:fient Heater Prooese P:p:ng Roof Top :inns Rad:ant Haat s$ ;"0 ••••• •2;" • •`;', ,,,, ,,,,,,,,, ■■■■■■■■■■ ,,,,, ,,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Ottter.: • se: Deacri„be Project: 'Note: :f any eqa:pmant is- Point; pd outside of the footphnt of tha btd:cate setbacks to propeby ane, A :and survey may he roou:red. Roof top unbs may :'eau:re ;`,3truotura: Engineer's \\\\\ ;hat is vis:b:a from a outtk way and w:thbt a Histono w::: reu:re onor approvai of he stodo Districts Comm:ss:on. A:: equ:pment nt sub:act to Lex:noton's Nobte oernfy that have :he aathohty to make the foreoinc: appkahon and tnat a:: of the :of:MT:at:on have ttabmintd for entered) in the aboya appkahon is: true and acourate to the bast of my know:edde, :nnbmanon and be:ief, and that a:: i-nechanica: and inata;:at:ons, Derformad under :ha -termit:ssued for th:s apoktation wi:: tta n oomoance oertinent ofov:sona of the Massachuselta S:ate Bui;dihq Code, ;he oo:::: Mechahice Cod end of the of •••• "•■• k.":kg:S•4kiteSISk: • NWM: Type L.:cat:se: &xliaa far Permit fee: Issued By f); 11,3 • •• • • Da I Approvod a.te: PQrna it Nutdder: Map #: Lot#: Unit #: Street #: Street Name: Street t:,nft # :. - •� Permit#: t: Buatdcnz Document TYP '. PI t TOWN OF LEXINGTON Community Development Building Division a•JSi nsR, The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts State Building Code For One- and Two - Family Dwellings 7th Edition : a a -- 3 <Ex l, try '� N o . ; =w � � APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS SITE INFORMATION: License Number 76563 Expiration Date 12/18/2011 Permit # J %Date issued:__1�!,7`z Work approved by: Property Address�,_� i;/hei'i ,1/Q_ Assessors Map /Parcel # / 3 / yS Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Historic District: Yes/ No Expiration Date Signature: Phone # Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Phone # 1- 888 - 559 -0909 Yes Roofing 5900: (Note: Roofing is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Proposed material: Existing material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 3 Estimated cost of work and material excluding electrical cost: /o0 PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (print d): Si ature: ■ V. Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION S VICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lalseville, MA 02347 Signature: `� t J , Phone # 508 -583 -3999 Registered Home Improvement Contractor: Company Name: Not Applicable X Registration Number Address: Expiration Date Signature: Phone # Received by /date: I ( (1 / ol0 Fee: J lP Receipt #: 26d/ Issued By: _ j &ILicy) "IL die_4 7/te.t- tje. gyt- \A-ct/ Map #: • Lott Unit #: Street#: z . treet Name: 4I/e4 / 4-- e. =reet Unit #: Departrnent: Buildl� rim D-= emmeiit Type:. t Pt to j t Pio i Perm a TOWN OF LEXINGTON BUILDING/INSPECTION DEP Date r i Name it.)_) SU' Ojnc c c.rti'4? fY\:- . Building at Building Permit Electrical Permit Plumbing Permit Gas Permit Mechanical Permit Micro Film Fee Accessory Apartment Certificates of: Use/Occupancy Inspection Received by NOTE THIS IS NOT A PERMIT ' = PERMIT FEES ARE NON- REFUNDABLE TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: 812 per one thousand valuation or any portion thereof Property Address: Assessors Map # New: 6./ Renovation: ,rcr/7 Lot # Owner of Record: , v!v Type of Occupancy: S E J7I <— Replacement: Plans Submitted: Yes No 1 Installing Company Name: as-bcbc; Sh e4 ,N, t. k 1 i' c_ fO r3 ox 1143 Company Street Address: )-3 iryc t/ //d t (�� pity: �s � �, r t . Zip: 0 Company Phone Number: 9)9- 6' i) - 70 Vie` Estimated Cost: $ 3'1 tot (V') Indicate total number of units in the applicable box below Basic Building Code Commercial 1$2 Family Basement °o 2"d Floor 1 °o 2 M Roof Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners ''j Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces - Js 7q r' j / 1 Generators Other: Basic Building Code Commercial Basement J 1st Floor 2nd Floor o LL ch Roof v o e 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: , 5" C ; RC; Ca,8t✓xerf' cru?L1°l i i S' I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexinoton: Sature: e7-1-Cr { v Q , qN ;Cif 7 't-X, ' e int Name: Type of License: 37 9 0 License #: Permit fee: 1..4 R 6//q/ir0— This Section for Offical U e (only �� Date Received: �,�� /r e� Receipt #: Received by: %.... Anrarn.rtari Tl •mta• PorrratIkTurrrihar• LO —51.101- Ce„ f ,�GJ, /t,rr /s—' " PAp i' -tam Map #: Lot #: Unit #: Street#: Street Name: T ?� ;g-ti n'VE Treet Unit #: '"runt t ##: Oepartment:3E�tici(nk Document Type: (FEL-.nj (Plot (Perri-1'7-Th TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address /6 7a d Owner of Record: = , t Type of Occupancy: !h'` Assessors Map # New Renovation: Replacement: Plans Submitted: Yes Installing Company Name: Company Street Address: Company Phone Number: Construction Specialties,: P.0 Box 53 Stoneham, MA 02180 Indicate total number of units in the applicable box below Zip: Estimated Cost: $ ittOOPL P 1 P Basic Building Code Commercial 1 & `2 Family Basement 0 r 0 N oo v M Roof c U` Air Handling Units • Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators m 055 A Other: Basic Building Code Commercial Basement I o U- u o u- o N 3`d Floor Roof* ° 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: m 055 A ✓✓ Describe Project: *Note: If any equipment is being placed outside of ththorint of the building, indi a setb cks'to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law:' I certify that I have the authority to make the foregoing application and that all of the information l have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all Taws /bylaws /regulations` of the Town of Lexington: Signature: ("4 F (,4.)A) Print Name: Type of License: C- 53-3177 License #: Permit fee: 3-w Issued By Revised 12/31/09 This Section for Offical Use Only Recei • Date Received: 6/4,i/C240 Received by: CO pproved Date: ,/l e) Permit Number: 0 _ `7 .4. rrticar.: r.amc: 1.C.73:ion of welt: rite: 1 ant homeowncr pea forminc al1work'mysclf. I r:1 ro!: proprietor and have no 4 one orkinc in any capacity. •' ‘s cmploycr prvvid:rsc ‘sorkers' 62mperts.ation for my employec.s wor Uric on Co 2:pany r-amc: Phonc • „ Ira.ahlngron .S'rre c '''‘v"41'.COhip.cc14$1Thn•lcsivervocr .4,17;44 r.N 'it COrlStrUCtidINWIrr LEC1D1,1' P.O. Box 53 vg Phone 4 .!r s : _,__••••••• Company; 1::1 :■)!:: proprietor, ccncral contractor, or liqmcowncr (circic one) and 1'.c hircd contra...:ters t..eiow who lure the followinc workcrs' compd...mation policy: Company narnc: • ddrcss: Company: • qtY: Policy: Phoric ,? Statc: r cor.,,,,..,..irly rta in c : Construction Sp.ecialties . . ({,k4 (c ('...,,;..1,...,, 3.Lkcf..:: oionenamt MA 02180 ' city _____ State: ____ _ ■•••••■••■•,.....1.1. OM. •••■■••••• Company: 4 ‘t_ ()421tT______ I_1._c),0 Eig,Policy: . W C- 00? — 5-2)5- 3 . 1A)s.. c__o , .A.;:ac.•!1 ortal shots ir nccr-ssary. 4: .51(09 — 8-1,1(0 5urc covcrlec a$ rt quircd under Scion 25A oiMPL 152 can !cad to the implcmcntation a 4 . ., c::::..i.-..21 p:naltics of a futc up to S-1,500.00 and / or one yeari' irnprif.onment as well as chit c•Inalties in . 0-. for STOP WORK ORDER" 'and a age a S100.00 a cL3Y a mc. ea taing '1 undtand that 3 copy cf ff. . , .!...; atzincnt r.uy be forwardcd to the 0Mcc of Inrosti&ation of thc DIA for Covcracc vcrifiemtion., 2., )::•P( !). cc, rib, 1..fl/( Ihe pains (11nd )( naltic i r----,,, of spplkacion: Phonc2g- c—k-( Vl (...!,) not write in l!'j S VC 3 ^ t 1-0: complock: by city or town cfr:•:i3! :1* • • • • • • •• • • • • • n• • •■■• Pcn:( D-.+(• JjuLA Me_ diza NYAL-d/ Map #: Lot #: Unit #: Street#: 'treet Name: -greet Unit #: - rnhit #: 9 aE,4 /#(2. Department: Building Document Type! (P b:.n ) (PlotC (Fermi TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE $12 per one thousand valuation or any portion thereof Property Address; %' /��'�'Z, /9 ,;'`? Owner of Record: Assessors Map # Lot # Type of Occupancy: 4-5/P4:71/439 L New: Renovation: V Replacement: Plans Submitted: Yes No -1e, US i/,riee Company Street Address: yG 2 etta4/� 4/ City: Ss/f Jam'' Zip: Do2a G G Company Phone Number: G / 2/¢ 78/ Estimated Cost: $ )''a. e o Indicate total number of units in the applicable box below Installing Company Name: /3,e1,4? fit/ 0 0 as 0 0 LL 0 N 0 0 LT. 0 0 LL C 2 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: /OW/ d'pz I7 Basic. Building Code Commercial E 0 Cl) m o u_ s �- 0 u- 0 c., 0 `u- - co o o c 0 L (9. Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment 's being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District wil require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law;_ y- /0/14 s /'E!/ iPi9'/l/ 4/6",c ,moo ✓Nc/ig 7; a .t/ I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws/regulations of the Town of Lexington: Signature: Print Name: Type of License: License #: Permit fee: 30, cx? I Receipt# Issued By : Revised Revised 12/31/09 This Section for Offical U O ly Date Received: 7f(7 Ac 7 /moo Received by: emit Number: °-1:h d-46° 1�. NYAL-d__/ Map #: Lot #: Unit #: Street##: street Name: €reet Unit #: 'erelit #: 7 -A- Department: Building Document Type: (P& n) (Plot) A TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: g Tzick e - ili/e Owner of Record: yYn __ (� /�q! d q;_yy► Assessors Map # 13 Lot # (9.06- Type of Occupancy: ter, S New: Renovation: Replacement: 1/ Plans Submitted: Yes Installing Company Name: a , jA Company Street Address:3 -er Ave City: k o 10 ry1 Company Phone Number: 7 /— 96.57-01 7 Estimated Cost: $ WO ,OD Indicate total number of units in the applicable box below No Zip: C Basic Building Code Commercial 1& 2 IVIFmhly Basement 0 L 0 U _a " Roof c 0 Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units / Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o y u o u- V C N 3rd Floor Roof* 0 0 6 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is e and accurate to the best of my knowledge, information and belief, and that all mechanical work and installati s pe ..�. f 'under the permit issued for this application will be in compliance with all pertinent provisions of the Massachus B��ding ..de, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexingt Print Name: Type of License: License #: This Section for Offical Us Oily Date Received: 5-0V �� Permit fee: (Q� Receipt #: $ Received by: t -_ —/ Issued By : pproved Date: S , / Permit Number: tp #3c .S 3-- / O Revised 12/31/09 ,111/LA ida7 Map #: Lot #: Unit #: Street It: O __a _Q._ -6. ie- 'treet =reet Unit #: '".Tnhit #: Oepartment: Building Document Type: (pt:tny (PI TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 2�� Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # // NO Property Property Address: Owner of Record: /10 -gwl qt N tiel Assessors Map #-5 Lot #W Type of Occupancy: kC Sida/ New: / Renovation: Replacement: Plans Submitted: Yes No V Installing Company Name: ?72?tt PP.i�( ent/c - f % /Nr / �C - Company Street Address:3 L /20ctfl , /�i�i, City: khiregfri (Ct- 4 Zip ai 31/ Company Phone Number: 47t37f's)3 Estimated Cost: $54 Y(' Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement 0 r 2nd Floor 3rd Floor 0 3 Air Handling /Hydro Units f Draft Inducers Oil fired Equip Evaporative & Refrigeration Coolers Kitchen Vent & Eaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Central Air Conditioners Roof Top Units Combustion Air Nentilation Fans Radiant Heat Energy Recovery Ventilators Hydro Air Systems Furnaces- Oil Central Air Conditioners Other: Other: Basic Building Code Commercial Basement $ Li N °o u_ C N °o L V M Roof Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Eaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insurance ffidavit re ' ° • for all mechanical submissions ignatu B et- nj skv r s Wiz,/ Here/ c'f S - vn ea 2g6 Print me: Type of License: License #: Permit fee. Issued By : 018 Revised 8/4/10 AC This Section for Offical Use Only Receipt #: (960 Date Received: 440 Approved � d6 / ,iD Received by: Permit or Alteration 1u • /0207 J_,/ I./AA G/zleo nrt �rstuC- 73 ,� Map #: Lot #: Unit #: Street#: 'treet Name; ;Treet Unit #: `",rnhi t #: Department:3�i�lci (Pin)_ (Flo z� 3 (TheAtrnent Type: TOWN OF LEXINGTON Permit Number APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781 -861 -2780 Tyler Rd. Owner's Name:Alan Gradzinsky Building Location: 31 Map # Lot # New: Renovation: Installing Company Name: Company Street Address: Company Phone Number: Type of Occupancy: Residence Replacement: Plans Submitted: Yes No xx Federal Heating & Engineering Co., Inc. 160 Cross St City: Winchester Zip01890 781-721-2468 Indicate total number of units in the applicable box below M GQ N co 0 0 u_ 0 0 CC N 0 0 LL 0 0 0 0 Air Handling Units Heating Zones Evaporative Coolers Heat Pumps Range Hoods Refrigeration Units Sprinkler Connection Sprinkler Heads Sprinkler Hose Conn. Ventilation Fans Boilers -Gas Boilers -Oil Furnaces -Gas Furnaces -Oil Process Piping Generators No Vent Heaters Steam Kettles Duct Coils Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington'bloise Bylaw: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Biding Code, the ICC M�! anical Ca� I laws /byla gulations of the Town of Lexington: Signature: Tom LaPointe Printed name: Universal Type of License 000164579 License # This Section for Official Use Only Permit fee: // Receipt #: // Date Received: 'Received by: �� Inspector: da r ( Approved Date: s f d/D Rev 5/ /1`2/09 AC 3 /' c 0 C E a) L 0 u_ L 0 LL L 0 4 c Fire Suppression Draft Inducers Kitchen Equipment Pool Heater Pumps Radiant Heat Radiant Heat Incinerators Steam Generators Baseboard Heat Radiators Kick -space Heaters Hydro Air Systems Direct Vent Fireplace Roof Top Units Central Air Conditioners t/ Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington'bloise Bylaw: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Biding Code, the ICC M�! anical Ca� I laws /byla gulations of the Town of Lexington: Signature: Tom LaPointe Printed name: Universal Type of License 000164579 License # This Section for Official Use Only Permit fee: // Receipt #: // Date Received: 'Received by: �� Inspector: da r ( Approved Date: s f d/D Rev 5/ /1`2/09 AC 3 /' c 0 J_Ju(A dee4 tjt_ Map #: Lot #: Unit #: Street#: Street Name: Teet Unit #: GtPt4n:rJ Oepartment: 3 EU it n . — 7 t 4 Document Type:, {PL n) (Pioi (Perm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 4 UpLApo Owner of Record: 3gYtn► ger Ack.viLs.y Assessors Map # 5.e.•2 Lot # 1 ) Type of Occupancy: j4>Fs l o t -} ,vlZ New Renovation: Replacement: ` Plans Submitted: Yes No \//.-. Installing Company Name: 1A lvk Company Street Address: l ` Akis City: - e., ►1n vl Zip /1i a( Company Phone Number: sp Gc�C Z) Estimated Cost: $ `eiri Le Indicate total number of units in the applicable box below 1 &2 Family 0 E 0 0 u- 0 LL C,), 0 0 c 0 Air Handling lint Hyd Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners, Ventilation Fans Energy Recovery Ventilators Furnaces- `rl s Generators Other: Basic Building Code Commercial Basement o u.. , r- 2nd Floor o 6 u- 13 M 0 (9 Generators Draft Inducers Oilfired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By- Law: I certify that t have the authority to make the foregoing application and that all of the information ,1 have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the etts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of LH14- )11,.‘ Print Name: Type of License: License #: This Section for Offical Us Only Permit fee: 4,7 UQ ( Receipt #:d75-75--- Date Received: 7 02a Issued By : Revised 12/31/09 . A ONO Received by: Appr ved D9ea0/07O/0 Permit Number: /a ^n�� The Commonwealth of Massachusetts Department of Industrial Accidents Office of 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Te`f Address: k ft4" S\- Olga City /State /Zip: R A-A lv \tctM , V4- Phone #: S-0 Are you an employer? Check the5ppropriate box: 1.M Iamaemplo e with 5 employees d/or part- time).* 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. 0 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. 0 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.] O Type of project (required): 6. 0 New construction 7. 1'4,1 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. 1` 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. Liic n c. #: Job. Site Address: 4 u Y L•" Kiv City /State /Zip: tar- t) iuizo M 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 forsnsura ce coverage verification. )f,ilioV fi . Q Co I .. 1-1 f I GI 1 41-4 0 \.V Expiration Date — 1 0 I do hereby certi Si : nature: Phone #: der e pains a es of p jury that the information provided above is true and correct. '111 AIMIMIKA‘ Date: 7 Z0 .-16 o � '? 7q- -dam Official use only. 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 Contact Person: Phone #: NY/I'L Map #: 3 3 Lot #: 4 Unit #: Street #: 4 street Name: 1/VA eH _ /= Tr ;Taeet Unit #: }Department: B El Document Type: (Ft !I'ejr) TOWN OF LEXINGTON EN TE:REa APPLICATION FOR MECHANICAL PE T 1625 Massachusetts Avenue. Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 1 5 2010 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 3y Wctcltus6�} fir v. Owner of Record: /Y1UrraaJrgn Assessors Map #j Lot # Oa Type of Occupancy: ess New: h Renovation: Replacement: Plans Submitted: Yes No X Installing Company Name: Cei,,�}co�1 Ccoh„.t };w� Company Street Address: qy N . p,oF )e S f . City: V\16 6�� Zip: 6 I R\ Company Phone Number: —73 j — C135 -�� Estimated. Cost: $ Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement L _o -, I-, 2nd Floor L _o LL 'O iq Roof } c L 2 U Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps f Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: l Basic Building Code Commercial Basement o u_ o u- N 3rd Floor Roof` o 2 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A and survey may be _required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: \JJ e G [e 1 r,• , n .S ,Q-; r" ii4 r7 )/e‘f W il, Uh. q in-704) ,1/441 P fI ' I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installatio . • ormed under the permit issued for this application will be in compliance with all pertinent provisions of the assachuset State = ilding Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of L - king . irY1 /1St qe rn asirk i i' its-i- tc r r t � 3'7 M Si s nature: Print Name: Type of License: License #: fee: /5 ifj is Section for Offical Us O ly Date Received: /4(//6 Receipt #:,:;;M-3_3 Received by: Issued By : Approved Date: Permit Numbei --� ,, /t/41/4 �o r�sz� Revised 12/31/09 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Yt1t'i'11s. na uss. goo /dill Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - _ _ __ Please Print Legibly Na1116 ( Business /Organ ianon/Irdividual): { 'v 1,— .)--(21_) 1ai , o.. a1 , L . 1 Yi C.. Map # Lcaf. Address: Pewit # Address:_ Ill �S`; icy /Slue /Zip: t \) Phone 4: 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.4 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.] *Any applicant that checks box t/1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who subupt this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such 3Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether ornot those entities have employees. lithe sub - contractors have employees, they must provide their workers' comp. policy number. Pam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: - L.ti 13 (.1 L _LW CE N E'1`" ,J d (/; Policy # or Self -ins. Lie. #: ? `� 006 ‘' ( 3 6 1.0 I am a employer with <85- employees (full and/or part-time).* 2.0 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.] t Type of project (required): 6, ;OA New construction 7. d Remodeling 8. ❑ Demolition 9. (] Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.3{ Other Expiration Dale: HI I c ! c- Lc, Job Site Address: 3V 1,0a pit ,v j # 7/' i€ City/State /Zip: G P° i Attach a copy of the workers' compensation policy declaration page (showing the policy number an expirat odate). Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the in osition of criminal penalties of a fine ups to $1,500.00 and/or one -year iimprisonment, 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 Inve tion of the DIA for insurance coverage verification. .1 do hereby IAA mature: ' paters and penalties of perjury that the information provided a bove is true and correct: 1..m Date: / / / 21/0 Phone #: IG'{ 933 - Fu Official use only. 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 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 }s defined 8s ...every person ill the service of another under any Contract of hire, eN res s or implied, oral OT 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 01 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 dl:'elhng house of another ne employs persons to do maintenance, construction or repair work on such dwelling house or on the g c!unds or buildin%, appurtenant thereto stall not because of such employment be deemed to be an employer," ?VIGL chapter 152, §25C(6) also states that "every state oi local licensing agency shalt withhold the issuance of renewal of a license or permit to operate a business or to construct buildings in the commouwealth 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 - contractors) 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 a • t ropriate line. City or Town OffiCiak 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 subunit multiple permit/license applications in any given year; need only submit one affidavit indicating cunelrt 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 e 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 m 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. - P The Department's address; telephone and fax number: Revised 11 -22 -06 The Commonwealth. of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617 - 727 -4900 ext 406 or 1 -477 MASSAFE Fax # 617 - 727 -7749 www.mass.govidia COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE - BOARD OF LI E PLUMBERS AND GASFITTERS t�5Ut5'tFiE ABOVE LICENSE7l�: MICHAEL C BERNASCONI 58 ALBATROSS RD QUINCY MA 02169 -2658 1 1 LICENSE NO. EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE - BOARD OF IN PLUMBERS AND GASFITTERS LICE FRASAttAl aRr.c'LUMBER MICHAEL C BERNASCONI 58 ALBATROSS RD MA 02169 -2658 QUINCY 1 1 LICENSE NO. EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE - BOARD OF BOARD OF SHEET METAL WORKERS AS A MASTER- UNRESTRICTED ISSUES THE ABOVE LICENSE TO: MICHAEL C BERNASCONI 58 ALBATROSS RD QUINCY MA 02169 -2658 73.2 LICENSE NO. EXPIRATION DATE SERIAL NO. 6 • JititA i_tee)J gyt- A76w_f_oL 4". Map #: Lat #: 3 5- Unit #: Street ft: O2 ° Street Name: i9 4-7W4/77 rreet Unit #: '?rmit #: Department: l cling, i)c cement Type: (PEN t) iFle ern1 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -21 1 Fax: 781- 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # NO Property Address: .2 0 ith /4.4 A,,,, s A Owner of Record: ,60r,A Assessors Map # -a Lot # 3 7 Type of Occupancy: A 2. New: Renovation: Replacement: v Plans Submitted: Yes i✓ No Installing Company Name: d/o m J 1 L // AA) v STe. - v r t C® , Company Street Address: / 7 C. c;L S s1, City: Ag Aid AI Zip: 0 2.15 5 Company Phone Number: 6/ 7— % q9 / 7Q. 3 Estimated Cost: $ 511S77, 0° Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement O n. _ °o u- 12 N _ °o u.. 12 M Roof Ground* Air Handling /Hydro Units Draft Inducers Oil fired Equip Evaporative & Refrigeration Coolers Kitchen Vent & Eaust Equipment Heat Pumps i✓ Pool Heater Range Hoods Vented to Exterior Process Piping Central Air Conditioners Roof Top Units Combustion Air Nentilation Fans Radiant Heat Energy Recovery Ventilators Hydro Air Systems Furnaces- Oil Central Air Conditioners Other: Other: Basic Building Code Commercial Basement] o 2nd Floor 1 3rd Floor 4- Ground* 1 Generators Draft Inducers Oil fired Equip Kitchen Vent & Eaust Equipment i✓ Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Workers'fCompensaf n Insurance Affidavit required for all mechanical submissions `- /c,) p7 D / e6 e^4 s Prin t me: Tvpe of License: /03//6 License #: Permit fee: Issued By : Receipt #:$ Revised 8/4/10 AC This S ection for Offical Use my Received by)1/7 A, Approved Date: / 27/16 Permit or Alteration Number: Date Received: //01. lb /oh o7 a� ��3 b (PF 17 Locust Street P.O. Box 239 Medford, MA 02155 781- 396 -5279 FAX 781 - 396 -0290 2251 Silas Deane Highway Rocky Hill, CT 06067 September 21, 2010 To Whom It May Concern, Medford Wellington proposes to install a new 14' type 2 exhaust hood, duct, fan and tempered make up air unit at Buca Di Beppo 20 Waltham St. Lexington MA. In addition, repairs to the existing type 1 exhaust hoods for the main cook line must be made to resolve clearance and accessibility discrepancies as reported to the Lexington Fire Department by Advanced Hood and Duct Cleaning. These repairs include installation of replacement duct as needed, access doors and two layers of 3m zero clearance fire wrap. Sincerely, Dylan Conn Special Project Supervisor Medford Wellington Service Co. Refrigeration - Air Conditioning - Sheet Metal - Electrical Sales & Service Since 1967 i ' L CERTIFICATE OF LIABILITY INSURANCE OP ID 73 MEDFO -1 DATE (MMIDD/YYYY) 09/21/10 PRODUCER TD Insurance, Inc. (MA) One Griffin Brook Dr Ste 100 Methuen MA 01844 -1865 Phone:978- 688 -4667 Fax:978- 682 -9037 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Medford Wellington Service Co. PO Box 239 Medford MA 02155 INSURER A ABC HA WC spa- iUSURED GROUP INSURER B: INSURER C: INSURER D'. INSURER E: COVERAGES THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD C NSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDDIYYYYI -POLICY EXPIRATION DATE (MMIDDIYYI'Y) LIMBS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ UAMAUE I V Kt N I Eu PREMISES (Ea occurence) $ CLAIMS MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L 7 AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY PRO- JECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) • BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS 1 UMBRELLA LIABILITY OCCUR [ I CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under SPECIAL PROVISIONS below ABCMA00502910 01/01/10 - 01/01/11 X WC SfAIU- 01H- TORY LIMITS ER E.L. EACH ACCIDENT $ 1000000 E.L. DISEASE - EA EMPLOYEE $ 100 0 0 0 0 E.L DISEASE - POLICY LIMIT $ 1000000 OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT f SPECIAL PROVISIONS Job: Buca Di Beppo, 20 Waltham Street, Lexington, MA •02420 CERTIFICATE HOLDER CANCELLATION Town of Lexington 1625 Massachusetts Avenue Lexington MA 02420 ACORD 25 (2009/01) TOWNLEX SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Jennifer Monkiewicz © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD fr No4 h 5-64, TcAlptAel mo44, As s...04p17 444 exis41.A1 gag MIA) 4 ee4 IG Pte4 teiqu Feop.,4 VuL > New .TY Pe ir fad To &Aloha, ti.ij hotd eXAtA434 i4/11-• aic,11 EXIS C 41.4.0 if) C-.C. i-4e- /A 1,t e_ Azwg \.7/6c -4/ (-0_/ Map #:' Lot #: 7 7 Unit #: Street#: dot 5_ l 'treet Name: V 4-T/-1/1-777 5'7 Tweet Unit #: }Department: B El II(ling t)oc.mpent Type: tPtap (not (Per6n1 TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: f k1 h U Owner of Record: ,CiG Ate(A) 9 Assessors Map # Lot # Type of Occupancy: SkttWL., New: Renovation: Replacement: i/ Plans Submitted: Yes Installing Company Name: Xi4O,(% v CO,OS Company Street Address4R7.7 silk,, '",QTCity: 72901170,,0j/s24 Zip:027 Company Phone Number: v2^Q g/1`r7 Estimated Cost: $ '1.f Indicate total number of units in the applicable box below Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners;; 0 0 u 0 u- 0 0 LL c) 0 0 a c 2 0 Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o u_ 15 o u- E (V ' $ U. P_ M 00 CC c e 1 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information 1 have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all Taws /bylaws/regulations of the Town of Lexingt•n: Pr darn e} l Ls 1 °)1) ReP9erdv cfy> C on /Kr 9 Type of L ,v ense: License #: Permit fee :` Issued By : . Receipt e Thi s S ti f r Off` I U O I s ec ion or ica y Date Received: $.41/77 Revised 12/31/09 Received by: ,proved Date: ( Permit Number: "alt_ d_ego Map #: • Lot #: Unit #: Street #: street Name: =fleet Unit #: '",rnli t #: Oepartment: B u i l!liil c 3- D- ,rurnent Type: (Ph-..n) (Plot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax 781 -861 -2780 This Application shall only be used if the work atthorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 3 0 tojec4b43n Owner of Record: ,,,, C 0PLe c. Assessors Map # Lot # 6 3 Type of Occupancy: nor,,5,nc1 6,,,,e New: Renovation: Replacement: VPlans Submitted: Yes INo Installing Company Name: De, Mel i-ieaivn n, Tic, Company Street Address: 3 t QsrJ. st,:48 City: /-wc;Iseyr .v, Zip: Gs)t9 Company Phone Number: 9711'- , -C2 -5r Estimated Cost: $ /2, OCC1 Indicate total number of units in the applicable box below 1 &2 Family M Basement l JO % ;g ti U. N 3rd Floor Roof v 0 Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil �^ Generators Other: Basic Building Code Commercial Basement ... u- r- o u- cv 3rd Floor Roof c ' C9' Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: walIGrt cw. 1 �^ uaet4 p o4'Sim Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that 1 have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massach tat Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexi 0 , on i Q1 tfr et 314/ 1 �_4 i, U4/e de AA x' to 'tla Type of Li nse: License #: ignature. Print Name: This Section for Offical Us 0 l �}C , Issued By : Date: 5. 010 Permit Number: 10 - Liov Revised 12/31/09 Permit fee: J Receipt Date Received: 5 Received by: The Commonwealth of Massachusetts Department of Industrial Accidents Office of 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Auplicant Information Please Print Legibly Name (Business /Organization/Individual): E' mph\ iztirk �tj ® yt4. CC SOC. Address: at afteg 4, City /State /Zip: 1-k ci5o<t Phone #: 9 )g'- 560- 92 - 9 Are you an employer? Check the appropriate box: 4. 0 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.) 1. t I am a employer with Z- employees (full and/or part- time). 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.2/Other wet( ,il, 1O \CC *My 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 Insurance Company Name: C l.s.a.1-4 Thy Mite Co wrty,v . V Policy # or Self -ins. Lic. #: We pfl? S3.3� Job Site Address: 3 (-13011-4001 S� Expiration Date: (32,//3/`% City/State/Zip: bee n M.4.. Attach a copy of the workers' compensation policy declaration page (showing the policy number an 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 Si Ph t the information provided above is true and correct Official use only. 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 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 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 600 Washington Street Boston, MA 0211.1 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 www.mass.gov /dia * &,/titA d-166' 7)1,6e4___ \AC-4__/ Map #: ' 7 Lot #: Unit #: Street#: street Name: /V4'1 =meet Unit #: 'ermi t ##: Department: B «u1dn, Document Type: (PLR) Mot) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 - 861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # N Property Address: 1 W4 i p pa. PA-0 Owner of Record: 04 hCe % M'1,E N Assessors Map # 37 Lot # 1 Type of Occupancy: [U SW. h`C %AI New: Renovation: Replacement: Plans Submitted: Yes No `-'' Installing Company Name: ED 61, - Vyvt -lo PLUS $ , r( Company Street Address: 2 , e.A.0 W.sJ St City: CZ/A, rem, hovi Zip: 01 S' Lo Company Phone Number: 4111 423— 1, c- Estimated Cost: $ 66 6a, dD Indicate total number of units in the applicable box below Family IN / I 1 & 2 Basement ° _o N " e- o 0 _ v_ C N 0 0 V M Roof Ground* Air Handling /Hydro Units Evaporative & Refrigeration Coolers Heat Pumps Range Hoods Vented to Exterior Central Air Conditioners Combustion Air Nentilation Fans Energy Recovery Ventilators Furnaces - Oil tes Q f [. 1 Other: Other: Basic Building Code Commercial Basement o Li. o u- N 3rd Floor oo 0 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & E gust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insurance Affidavit required for all mechanical submissions 992 ,t..A,y, iflAt 01 p1LM4taik.t" k? 1 0 o c Signature: Print Name: Type of License: License #: This Section for Offical Use Only Permit fee: W. Issued By : Revised 8/4/10 AC Receipt #: gdci 3/0 Date Received: q /3/rp A roved Date: i Permit or Alteration Number: Approved (3 1c t® '-160 Received by: 4_ JixA Map #: 1 Lot #: 7 3 2 Unit #: Street#: 2_ ' treet Name: 7 j/js/� 44 ;Treet Unit #: ®/3 Department: 1 ding Document Type :. (Pt m) (P1 Fer TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 -862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: /1/A,7.62 /9y e Owner of Record: 0 %. 1-k n 4.t Assessors Map # /4/ Lot # /_ Type of Occupancy: New: _ Renovation: Replacement: VPlans Submitted: Yes No Installing Company Name: S� 14,ner Company Street Address: l$$ G- cM5► ► S4 City: l etc .9..,k, =. VY►c� Zip:_ Company Phone Number: r? l 39 `'� - 3 � Estimated Cost: `$ top- Indicate total number of units in the applicable box below Family INT 1 &2 Basement . o N M Roof Ground* Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces - OiI Bc leti +% Generators Other: Basic Building Code Commercial Basement 0°o " LS °o u- N °o u= Eta) Roof* Ground* Generators Draft Inducers OiI fired Equip Kitchen Vent & Exhaust Equipment Pool' Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of cLicington: s ature: Print Name: Type of License: License #: This Section for Office! Ube Qnly Permit fee: 7a, Qo Receipt # t : 3 I Date Received: 3 /rlr Issued By :� ��, proved Date: 3 bl i( 0 kie- Revised 12 /31/09 Received by: Permit Number: tO — t3 JILIxA Me_ /0Le4 \i/Z-C4 Map #: 7 Lat #: 4 Unit #: Street#: / a street Name: .J t/ %� /. =T,eet Unit#: /d Department: B u lding I)cc tmnent Type_. (Nan) (Plot TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof r Coi9T F '11 Trt/St Property Address: ‘O W�► i ' -e2 7,4 Owner of Record: 3,4rnv L S Assessors Map # °? -1 Lot # 1. 3( ( Type of Occupancy: d.7 6 New: Renovation: Replacement: I Plans Submitted: Yes No Installing Company Name: V.-5. vo \i cn_ 1/1/1.-cc 1,1.4 t ^c ,9-( Company Street Address: tc 01,41,---6 400_ City: Zc,v -L Zip: i 4'6>C Company Phone Number: `lit -22-1 21{ctc -k Estimated Cost: $ Indicate total number of units in the applicable box below 7 1/I1&2 Family Basement I 0 u r 0 2 N 0 P Roof I Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pooh Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces - Oil 1--' Generators Other: Basic Building Code Commercial Basement `g 2"d Floor o co Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pooh Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note:, If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: OIL r= 7- V ( -e f I certify that 1 have the authority to make the foregoing application and that all of the information 1 have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Sig revii- (1b, Print Name: Type of License: 0 3 7 --r6 -s r-21 License #: Permit fee: (06-.0D Issued By Revised 12/31/09 This Section for Offical Use 71y Receipt #: g56,51 Date Received: �f 1121 1 Received by: >JC Permit Numbe Map #: Lot #: Unit #: Street #: p- 7 J �® ■••■■• Document Type (Plan) (Plot tc.Qi �r�i 7>te_eze___ Map #: / Lot #: Unit #: Street#: 3 9 Street Name: ald6D ;Treet Unit #: 'ermit##: f Department: Buildin {)cw ument Type: t Ptz n' (Plot) (Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 Mechanical Permits are inspected by the buildinginspector. The fee is the same as for a Building Permit FEE: $12 per one thousand Estimated Cost rounded up to nearest thousand. Minimum fee charged $30.00 Is this application in conjunction with a building permit? YES # Property Address: .3? 64%2 ' Ski Owner of Record: % X11-)7 ,,/ (ft5 ///9 Assessors Map # 5°\ Lot # Type of Occupancy: Si derfr7 g- L... New: Renovation: Replacement: Plans Submitted: Yes No X Installing Company Name: t 'pt4 Mecila el'Ce9- j1 S'6 4-7 C . Company Street Address: j C (e4 h S - City: ! ,$c Ton Zip: Da / g-' Company Phone Number: ° p y � � 7 — $�(� � -- C�7� � Estimated Cost: $ � COO, ° Indicate total number of units in the applicable box below Basic Building Code Commercial 1 & 2 Family Basement ° o u_ T.- r- ° o C N ° o `� V M Roof Ground* Air Handling /Hydro Units Draft Inducers Oil fired Equip Evaporative & Refrigeration Coolers Kitchen Vent & Ediaust Equipment Heat Pumps Pool Heater Range Hoods Vented to Exterior Process Piping Central Air Conditioners Roof Top Units Combustion Air Nentilation Fans Radiant Heat Energy Recovery Ventilators Hydro Air Systems Furnaces- Oil Central Air Conditioners Other: 5 go, Lie Other: Basic Building Code Commercial L Basement J o Li. c- 2nd Floor °o Li P_ M Roof ' LO C.5 Generators Draft Inducers Oil fired Equip Kitchen Vent & Ediaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: IAcTA -/I 6ne. t- i Tyr & Lev + one Lf0 6'rf10 ul �'t.- (I{ Ter I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Buildi Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexington: Workers' Compensation Insu once ffid • vit required for all mechanical submissions 7/! ZuG•. -- gnature: 75 p4 P. -fri(J e ' cot p?S. 37, Gi-5 ;7811 ,' /vii Print Name. Type of License: Licens #: This Section for Offical Use Only Permit fee: (; o_w Receipt #: <9,2r,5-00 Date Received: 2o!l L1�0 Received by: F}c. Issued By : Revised 8/4/10 A Approved Date: t0 2 /1 Permit or Alteration Number: /` t td - tl35 irk j {t7 /O The Commonwealth of Massachusetts --,� Department of Industrial Accidents Office of Investigations' 600 Washington Street !0 4 l+le l�Ilfif��9le11. -- ' Boston, MA 02111 www.mass.gov %dia orkers' Compensation Insurance Affidavit: Builders /ContractorstElectricians, Please Prin r SlY Applicant Information Name ( Business /Organization /Individual Address City /State /Zip; J. M. MECANICAL SERVICES INC. 172 ORLEANS STREET EAST BOSTON, MA 02128 Legibly Phone #: (617) 561 -4733 Are you an employer? Check the l .g) I am a employer with 7 employees (full and/or part-time).* ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capac. [No workers' comp. insuranc required.] 3. Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t appropriate box: 4. ❑ I am a general contractor and I have hired the sub - contractors listed on the attached sheet. These sub- contractors have ny. workers' comp. insurance. e 5 ❑ We are a corporation and its officers have exercised their 0 right of exemption per MGL c. 152, § 1(4), and we have no ployees. [No workers' camp. insurance required.] em Type of project (required): 6. ❑ New construction 7. ❑ Remodeling . 0 Demolition 9. ❑ Building additioi 0.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 2.0 Roo n Other Othertnstan Burnham 205 130,000 btu's Any applicant that checks box #1 must also €ill 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 their workers' comp. policy information. I am an employer that is providing workers information. insurance Company Name: A.I.M. MUTUAL INSURANCE COMPANIES Policy # or Self -ins. Lic. # WMZ 8006269 compensation insurancefor my employees B ow is the policy and job site Expiration Date: JULY 29, 2011 Sob Site Address: 39 WOODS STREET City /State/Zip LEXINGTON, MA 02421 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required fuze up to $1,500.00 and/or one -year i of up to $250.00 a day against the vio Investigations of the DIA for ins all under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a mprsonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ator_ Be advised that a copy of this statement may be forwarded to the Office of e coverage verification. I do hereby certifyr the Silature Phone #: d penalties;of pe rjury thai the information provided above is true and correct 4e ( 17) 561 -4733 Date: OCTOBER 12, 2010 (Vidal use only. Do not write ire this are C ty or Town: to be completed by city or to officio LEXINGTON, MA Issuing Authority (circle one): 1. Board of Health 2. Building Departmen 6.Othr` e Contact Person: PermitlL,icense # . City/Town Clerk ; 4. Electrical Inspector 5. Plumbing Inspects Phone jjAzaar.- ,////,_21 Map #: Lot #: Unit #: Street #: Street Name: \K\ od d Street li,ntt#: Permit#: t O - ��,�• Dep €tinent; �uatc� n Document Typo: (Plot) OVg 0 TOWN OF LEXINGTON Community Development = } Building Division ; .... ins 't' � wanir F. N4 ~O� " l; , , The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts State Building Code For One- and Two- Family Dwellings 76' Edition APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS SITE INFORMATION: Permit # /1-12 /Date issued: // /7 /L Work approved by: Property Address: 5Q U XOt( a y ' 2X Historic District: Yes/ No 1 i Assessors Map /Parcel # 59 44 9, Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Phone # 1 -888 -559 -0909 Yes Roofing 5900: (Note: Roofmg is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofing shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Location on roof Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Existing material: Proposed material: Door Replacement: (Note: Maximum U .44) Electrical Permit: Yes/No Number of replacement doors: 2 Estimated cost of work and material excluding electrical cost: / goo Received by /date: Fee: 3 Receipt #: Issued By: ciolgiLDA PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (printIe ):i Signature: I/ \. ( Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SERVI ES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lakeville MA 02347 ` Phone # 508- 583 -3999 Signature: >k c,,. Registered Home Improvement ontractor: Company Name: Not Applicable X Registration Number Expiration Date Address: c;cmat„re• Phone # Received by /date: Fee: 3 Receipt #: Issued By: ciolgiLDA • 0 ,//td "ar Map #: Lat #: Unit #: Street #: Street Name: Street 011111010201.. Street �i itt #: Permit*: - Department: 2 110 -W>; Docut t Type; (I 0 MOftk '775 Commonwealth of Massachusetts TOWN OF LEXINGTON Qv Community Development a ` Building Division ; sr APRIL x,N �r ' State Board of Regulations and Standards Massachusetts =u State Building Code For One- and Two - Family Dwellings a^ 7`h Edition APPLICATION FOR: ROOFING, SIDING, WINDOWS, DOORS SITE INFORMATION: Permit # 1,4-',, Date issued:__ /___fL Work approved by: Property Address: 8 r ■ 1, Historic District: Yes/ No Assessors Map /Parcel # 5 4, 5 6 B Provide name of Waste /Rubbish hauler All State Waste Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Phone # 1- 888 -559 -0909 Yes Roofing 5900: (Note: Roofmg is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofmg shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Existing material: Proposed material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 2 Estimated cost of work and material excluding electrical cost: PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781- 861 -0900 Authorized Agent: Name (print d): Signature: ► ( Phone # 781 - 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 . CONSTRUCTIO SER ICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. Lakeville MA 02347 Phone # 508 583 -3999 • - Signature: a„,� Not Applicable X Registration Number Registered Home Improvement Contractor: Company Name: Expiration Date Address: [,- ___ _...__. Phnne # Received by /date: \-2i)d Fee: Receipt #: Issued By: ("4 egt..11 z/L-aar- Map #: Lot #: Unit*: Street #: Street Name: Street #: waisssmorm. Permit*: DepTtc t:: Buttaina Document Type: (Fin) (Pldt) IIMMICONCIMWM • TOWN OF LEXINGTON Community Development Building Division The Commonwealth of Massachusetts State Board of Regulations and Standards Massachusetts State Building Code For One- and Two - Family Dwellings 7`" Edition APPLICATION FOR: ROOFING, SITE INFORMATION: SIDING, Property Address: Assessors Map/Parcel # 9 $Cc WINDOWS, DOORS Permit # - / /41Date issued: Work approved by: Historic District: Yes / No Provide name of Waste /Rubbish hauler All State Waste Phone # 1- 888 -559 -0909 Address: 67 Perkins Ave. Brockton, MA 02302 Is this hauler currently permitted through the Health Department? Yes Roofing 5900: (Note: Roofmg is not permitted over more than one (1) existing layer. If two layers of roofing exist, then roof must be stripped before re- roofing.) Roofmg shall be installed according to manufacturing recommendations. Proposed work: Strip and re -roof Re -roof over existing single course Number of squares Location on roof Does this involve replacement of sheathing? Yes/No Number of existing layers of roofing? Siding 5700: (Note: Electrical Permit required with application) Proposed work: Strip & re -side Re -side over existing Existing material: Proposed material: Electrical Permit: Yes/No Door Replacement: (Note: Maximum U .44) Number of replacement doors: 3 Estimated cost of work and material excluding electrical cost: aI I 0 Received by /date: de/)i))7 )v Fee: Lcr Receipt #: aciv»3 Issued By: .1"Aciool_raketti- PROPERTY OWNERSHIP /AUTHORIZED AGENT: Owner of Record: Name (printed) Lexington Housing Authority Mailing Address: 1 Countryside Village Lexington, MA 02420 Signature Phone # 781 - 861 -0900 Authorized Agent: Name (print d): Signature: . Phone # 781- 861 -0900 Mailing Address: 1 Countryside Village Lexington, MA 02420 CONSTRUCTION SER ICES: Licensed Contractor: Vareika Construction Inc. Name (Printed): Robert Vareika Not Applicable: License Number 76563 Expiration Date 12/18/2011 Address: 86 Bedford St. keville MA 02347 Signature: (, ( " Phone # 508- 583 -3999 CAA,, Not Applicable X Registration Number Registered Home Improvement Contractor: Company Name: Expiration Date Address: no __,_____. Phone # Received by /date: de/)i))7 )v Fee: Lcr Receipt #: aciv»3 Issued By: .1"Aciool_raketti- &ix lea etc i- Map #: __ Lat #: Unit it: Street#: , 3 c _ -7 'treet Name: rb/l 2J ;T eet Unit #: 'ernlit #: Department: Building, Document Type: (Pt i ) (Plot) (Perm) s -' TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 ENTERED This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof 3c� u;c ocR S} Soo ! Li Property Address: \ b Owner of Record: Assessors Map # Lot # / C. Type of Occupancy: New: Renovation: Replacement: /' Plans Submitted: Yes No Installing Company Name: ,i- , Company Street Address: ?moo Ni.4 City: Company Phone Number: —, L> Z-C:? 7- tO Indicate total number of units in the applicable box below iz Zip: A 07A 14 Estimated Cost: $ „co () Basic Building Code Commercial 1 &2 Family Basement 1st Floor 2nd Floor °o b In 0 Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent &Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units . Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: Basic Building Code Commercial Basement `g u- 1,-,. - 2nd Floor $ _ u- b co Roof 1 o 2 Generators Draft Inducers Oil fired Equip Kitchen Vent &Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts CommissiorhAll equipment is subject to Lexington's Noise By -Law: ®�Q �� x Cho.. I certify that I have the authority to make the foregoing application and (hat all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexington: Signa , re: Print ame: Type of License: License #: Permit fee: 3 oO eipt #: 9 This Section for Offical Use O�'' ly I Date Received: t /ro Received by: ,9 Approved Date: Permit Number: da L � as 11%/� Revised 12/31/09 q 4 a • Map #: Lot #: Unit #: Street#: ,_ r street Name: Z.-0 4 3 4/3 r:eet Unit #: —13 Oepartment: B It ilcling Document Type: (PL:—.an) (Plr, r rrnr TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Pe FEE: $12 per one thousand 'valuation any portion t ereof 3 20 Property Address: 3y7 p ©) s: Owner of Record: (11/1/t (e,/ [0 f7' /Lc Assessors Map # y Lot # IC Type of Occupancy: /6 .. C New: Renovation: Replacement: (Plans Submitted: Yes Installing Company Name: 4/J ,Jc r Company Street Address: 20 Stiff Ci Company Phone Number: f ?6 f - 20, 2/ Indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement o u - r 0 .N o D co Roof 1 Ground* Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces= Oil Generators Other: Basic Building Code Commercial Basement 1 1st Floor °o u- N °o- u_ co °o Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noisy By -Law: ir(A04't P/4 19 4/ /.?:.53,0,v,r5„/ -4 4Ze it/ (1,1/: teV095.? ,r,Z9 I certify that 1 have the authority to make the foregoing application and that all of the information l have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Building Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexi Permit fee: 30.0. JO Received by: Issued By Revised 12/31/09 uhi/ ,v Jac not Name. Type of License: This Section for Office' U1 e my Receipt #: p2 5'i,` 1 Date Received: 1 fi `. tD Approved Date: j, LO Permit Number: O916/99Yo 2e6gsy'AY License #: f Map #: Lot #: Unit #: Street #: :.tree=: Name. gisammnslaw Document Type: pt;tn The Commonwealth of Massachusetts Department of Industrial Accidents Office of 600 Washington Street Boston, MA 02111 www mass gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual Address: 2o ,57� City/State /Zi W;," ( (cr (% /,, Phone #: Are you an employer? Chec the appropriate box: 4. DI 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. 0 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.] 1, 0 I am a employer with yniployees (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.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 ltgof repairs 13. Other '/f 1/-4 C *My 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 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: II/'y/f $ Policy # or Self -ins. Job Site Addr 9/ x/431 7 Expiration Date: riZ -/ City/State/Zip: 1 X #45-I & /2 4 /Z/ Attach a copy of the wor ers ec aration 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 cer y a/der the peins aid pen 'es of perjury that the information provided above is true and correct. / s Date: %z — %Y-AV 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 (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 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 600 Washington Street Boston, MA 02111 Revised 4 -24 -07 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617 - 727 -7749 www.mass.gov /dia Map #: • Lot #: Unit #: Street#: 4 3 i Street Name: t' -' 3,-p Jj J� Btu 400 g=reet Unit #: rnll t #: Department: Building t)ot't ment Type: (PIin) (Pio .'CIi121 �_ .-n TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof 3 (d foC Property Address: 307 Wcz L. S�, viu d yo7 Owner of Record: (2a2fN re- !on ‘)/0.4-41"7-r. Assessors Map # New: Renovation: Lot # Type of Occupancy: Replacement: )X Plans Submitted: Yes No X r Installing Company Name: Co ,(/cc 1- -2 b ) �� 4 (2e- Lit-1 41 ' Company Street Address: 0,0 &) 3 it City: Chi) Zip:)f 7 Y2 Company Phone Number: 9 7 e - )6, - % Estimated Cost: $ total number of units in the applicable box below 1 & 2 Family Basement _ °o 5 °o u_ °0 " 0 o Ground* Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: �'' 4t -S cti 4/!//.-Ci.=. 1 Basic Building Code Commercial Basement o m g u- s N 3rd Floor Roof Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information 1 have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State : •' • i g Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Lexing� ure: Nifs re:Ird gio/g Print Name: Type of License: 9cc'7 License #: This S Qnly Permit fee: 30 . c 20 Receipt #: d,5-7 83 Section for Offical se Date Received: t G 10 IC mia� Rv • Arwsrrs.ra,1 rl�ra• /0 m Igo /10 Received by: '9c Aarrrit j rn,har• 10- 76 Map#: Lot #: Unti #: 4.11•11109.0■IMNIMM Street tt: 5 •• yousuourrNatecmia <61M11•1■1111•0 476' 7 Document -Pype: J,A.A ./f4e,a Map #: Lot #: Unit #: Street # Street Name: =Ereet Unit #: 3 o 7 000 � jgGp / Department: Building, Document Type: (BL.n) (Plot) :leerml_� TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof 307 . Ut: OQc9 Sfree 3 J I - .� , r-ise jQ Property Address: 1 K 7- 14 4. D .t2 ; e Owner of Record: KIT fl y. /), k loUb t Assessors Map # 21] Lot # l C Type of Occupancy: i fc r f� New: Renovation: Replacement: ,( Plans Submitted: Yes No Installing Company Name: 00 ive:42 a I �-�° =�t'�r � • %1 C . Y - Company Street Address: hi) NA( s- City: (c:" Eic 0 C2 Zip: 017 /2 Company Phone Number: c�c" p y ��% �' -- '��� ^ �� c��.,�- Estimated Cost: $� �rj'C,r' ° Indicate total number of units in the applicable box below Basic Building Code Commercial 1 8c 2 Family ,, m L °o LL , r- - o LT v N _ °o LI ,2 c. Roof 1 # c 2 0 Air Handling Units Draft Inducers Oil fired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Central Air Conditioners Energy Recovery Ventilators Other: Furnaces- Oil Generators Other: :ott, 00,/ , (1%,,../ r,- Basic Building Code Commercial Basement o LT r- °o u. V i• o° 1 O c+) 4- N8 re c it o L 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Builtjing Code, the International Mechanical Code, and all laws/bylaws /regulations of the Town of Le in ell 12 aht,,A,1,c(ar9-06 V7/ S Print Name: Type of License: . -tof License #: Use Date Received: 5170. This S ection for Offical U Permit fee: ,j, CO Receipt #:1 Too„n,l R,1 • $- /f`/ 10 A rvrtrn‘ ra.17o4o• y Received by: /9c D••rr, AT„ vet hor• 10 01 Ji 11/(A /dalt_ d_ee),J Map #: Lot #: Unit #: Street#: ' treet Name: •greet Una #: '<'.rnllt #: !Department: Building Docilmeft Type :_ (Plan) (PIoeC(:Perm 3,7 stesefk TOWN OF LEXINGTON Permit Numb APPLICATION FOR MECHANICAL PERMIT t .M� 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 Building Location: /3 =47igiPti Owner's Name: /477H-00 tvcx S Map # 7 ` Lot# K Type of Occupancy: Sii fvri,4 tr New: Renovation: Replacement°Plans Submitted: Yes No Installing Company Name P#4-08))460._ /- (EARAt -- ' ivy S E NC Company Street Address: D, iFoIP / S% City: L6wie ice, Zip: d iii Company Phone Number: c176-- (S ‘S-S` S VOA Indicate total number of units in the applicable box bel Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. Aland survey may be required. Roof top units may require a Structural Engineer's review, Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington'Noise By-Law: certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Buting Code, the ICC Mechanical and all laws/bylaws/regulations of the Town of Lexington: ignatur Perm fe : LI' Inspector: im MJ C�lLUNl+ License # Printed name: Type of License This Section for Official USe only Receipt #: 6 7J [ Date Received: Aeceived by: pproved Dat . Basement 1 St Floor 00 CZ N oo u- Roof Ground* Air Handling Units Heating Zones Evaporative Coolers Heat Pumps Range Hoods Refrigeration Units Sprinkler Connection Sprinkler Heads Sprinkler Hose Conn. Ventilation Faris Boilers -Gas Boilers -Oil Furnaces -Gas Furnaces -Oil Process Piping Generators No Vent Heaters Steam Kettles Duct Coils Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. Aland survey may be required. Roof top units may require a Structural Engineer's review, Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington'Noise By-Law: certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Buting Code, the ICC Mechanical and all laws/bylaws/regulations of the Town of Lexington: ignatur Perm fe : LI' Inspector: im MJ C�lLUNl+ License # Printed name: Type of License This Section for Official USe only Receipt #: 6 7J [ Date Received: Aeceived by: pproved Dat . Basement o- 0 2 "d Floor 3rd Floor/. 0 o Grounk Fire Suppression Draft Inducers Kitchen Equipment Pool Heater Pumps Radiant Heat Radiant Heat Incinerators Steam Generators Baseboard Heat Radiators Kick -space Heaters Hydro Air Systems Direct Vent Fireplace Roof Top Units Central Air Conditioners Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. Aland survey may be required. Roof top units may require a Structural Engineer's review, Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington'Noise By-Law: certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Buting Code, the ICC Mechanical and all laws/bylaws/regulations of the Town of Lexington: ignatur Perm fe : LI' Inspector: im MJ C�lLUNl+ License # Printed name: Type of License This Section for Official USe only Receipt #: 6 7J [ Date Received: Aeceived by: pproved Dat . Jitxy) me d.e4 "t fir _ Map #: 7 Lot #: Unit #: Street#: 3 C `j street Name: 1,(,/9/ j) ;greet Unit #: 3Ce Department: 1( Doom-Dent Type: (PL tn} ( Piot) (Perm) '* TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof 1 wood.si 30f Property Address: Assessors Map # / T Lot # 45W d- T e of Occupancy: New: Renov atiio-n(-: Replacement: t7 Plaps Submitted: Yes No Installing Company Name: VA)) 1,1,44 1, /' City: %10. Zip: Company Phone Number: f % - , }`� - 2e7/ stimated Cost: $ jQO. Owner of Record: ,/c 9 %i/4i 144.4 Company Street Address: Indicate total number of units in the applicable box below Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners. c E0 O L cis 0 O N` 0 O L O 0 C 2 U' Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement o 0 O u. 4 0 u- C 0` O 1,_ Roof 1 o 3 O Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: %e C41r' � c/L s 9. o`. t44 e.rt // tii Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By-Law: 1 certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massa usetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of Lexi )1/-ree- (' int ame: Type " o f License: Permit fee: 20,0) .,. ®, 0 J Issued By Revised 12/31/09 09/6/iiy02,K r Y7V License #: This Section for Offical Use On Receipt #:A7).$ Date Received: ; CI 2_01 rt p Approved Date: 6, 421 /lo Received by: L �% Permit Number: Co 681 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M4 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business / Organizatio div' ual): 1441/ (/ - G 74‘ Address: 20 City /State /Zip: Are you an employer? Check ''pp 1.0 1 am a employer with employees (full and/or part- time).* 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No rkers' comp. insurance ired.] am a homeowner doing all work myself. [No workers' comp. insurance required.] t a/520 Phone #: x/25 r -V " 207/ opriate 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. 0 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.] Type of project (required 6. 0 New construction 7. ❑ Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 1 L 0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *My 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 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' compens Lion insurance for my employees. Below is the policy and job site information. Insurance Company Name:�gp.F9 -S J ' /7% Policy # or Self -ins. Lic. # / $S %(a 2B #rOt /2,}3,Vfy'f f JO Expiration Date: Job Site Address: 1 /( ,q�°j/ � .1i f fi 1 City/State /Zip: ‘41,..}C, ®,fl `�T 02- 2/ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expira-t1 n date). Failure to secure coverage as required under Section 25A of MGL a 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 certi Signature: /er the p ins a penalties of perjury the information provided above is true and correct. /! /Y --C Date. 6eA/Z.-- 2 f 2 O /0 ?i`V- 702/ fficial use only. 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 Contact Person: Phone #: ,�j,/'tYJ if-6J A�X 77166,d___ Map #: Lot #: Unit #: Street#: street Name: Treet Unit #: 'ttrmit #: 3 Guy Oepartment: 3«3lci Doelkment Type: gip( alj P1oi (Perm TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781-862-0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in co ' . ctio FE o i ' thausagd valuation or any ton thereo 1 ith a Funding i'e. Property Address: Assessors Map # New: Renovation: Installing Company Name: Company Street Address: 0 Company Phone Number: er of Record: 2.9%J „i ilif4S Ty-pe of Occupancy: Replacement: Flans Submitted: Yes 1//),1,1 7:e4// • i? City-. 4ek, Zip: Zo>/ Estimated Cost: $ t1 d l/ No '2 - Indicate total number of units in the applicable box below E 0 0 ,tY) `0 0 ti e- 0 0 ii N 0 0 M o' 0 2 Air Handling =Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: Basic Building Code Commercial Basement lst Floor o 1.1_ a N_ 3`d Floor Roof 0 o is CD Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other. Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By- Law: certify that 1 have the authority to make the foregoing application and that all, of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massach setts State : uilding Code, the intematio - Mechanical Code, and all laws /bylaws /regulations of the Town of Lexing %n- This Section for Offical U e Only Permit fee: r ©4 I Receipt #: c9 77 1 Date Received: _ /2 Ai/ i v 4 Revised 12/31/09 Issued By : CIA If offi ,!/ow Yy y ?r License # Received by: Permit Number: to The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Affidavit: Builders/ Contractors /Electricians/Plumbers Please Print Le ib' rkers' Compensation Insuran :cant Information ne (Business /Organizatio address: d I'r' City /State /Zip: 4 Are you an employer? Check .h e , pp opr►at 1. ❑ I am a employer with 4, employees (full and/or part- time).* 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No rkers' comp. insurance ired.] am a homeowner doing all work myself. [No workers' comp. insurance required.] t e box: 0 1 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 .t We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §l(4), and we have no 1 e [No workers' Phone #: into oye s. Pomp, 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 additions) sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they roust provide their workers' comp. policy number. 517-- 2a7/ Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. ❑ Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13,0 Other ' _.. s tion insurance for my employees. Below is the policy and job site I am an employer that is providing workers ompens. information. Insurance Company Name: Policy # or Self -ins. Lic. #: , City /State /Zip: Job Site Address: Expiration Date: Attach a copy of the workers' compensation policy deelartion page (showing the policy number and expi e ►oil date). a Failure to secure coverage as required under' Section 25A. of MGL c. 52 can in the form mpoc -Ion of c it ORDER and a fine fine up to $1,500.00 and/or one -year imprisonment, as well civil penalties of up to $250.00 a day against the violator, Be advised a copy of this statement ma, _orwarde m the Office of Investigations of the DIA for insurance coverage veriftgg. znaltiess of perjr4ty'that the itforrrta rn ate: Atrue correct. //IL,. 2 Phone # fficial use only. Do not write in this csreu to ho ^'Joe City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building 6. Other Contact Person: µ c Jr town oj, L .n sitlikense # rtegesit 3. CityfTe ,,se Clerk 4. Elec` rical Inspector 5, Plliliiljing Inspector J- Map#: = 1 Lot #: Unit #: Street#: �_ 2_ .treet Name: r </" 9D `� / 3Z5 ;n-eet Unit r: c })epartment: Building i)ccutment Type: iPt .n) (Plot) TOWN OF LEXINGTON APPLICATION FOR MEC NICAL PE T 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781 -861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof f ir' . Pe;cc #30. od 307 tame sf Property Address: / _ k-�-4i' # 3 ,23 Owner of Record: 1S Assessors Map # 7t-( Lot # IC- Type of Occupancy: ter ieh ce. New: Renovation: Replacement: X Plans Submitted: Yes _ No -_ Installing Company Name: cc v 1- rc,..i Co0lih + 41rAfi49 ,titrC - Company Street Address: 9 M ma,* st City: u/d,6u/r7 Zip: d/Ri/ Company Phone Number: 77 / -2jj - X2 6f= Estimated Cost: $ 2 K Indicate total number of units in the applicable box below 1 & 2 Family Basement 1St Floor 2nd Floor LE a co Roof Ground* Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: p a a` a4), gaS Fo er..icE it Basic Building Code Commercial 1 Basement o LI N o O t � N 3rd Floor Roof` o 6 L Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may besequired. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: lat e a 1-e , y4 )c�c ri,� CAL f d. 94f FiA-rn ace c /Ac I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations •e med under the permit issued for this application will be in compliance with all pertinent provisions of the M chus ae B ilding Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of tort:- Signatu Print Name: VM.US4ec t St 3 Type of License: License #: Permit fe. 30.60 Issued By : This Section for Offical U eQnly Receipt #: a$-TS Date Received: (( /i7 to Received by: /c_ Approved Date: II Penult Number: � ��l� 7� Revised 12/31/09 fc t t (0- t32. The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): re t„ }fin 1 Co 01 i t,q +- r P cJ.'\' 1 C1 o� i I+RC.. Address: 9 N c1t-'H' nit rip )i &free+. cJ City /State/Zip: weI urn j al A 0,80 / Phone #: P / - 9 32 - 8' 8 Map # Lot # Address: Permit # Are you an employer? Check the appropriate box: 1. © I am a employer with 115— 4. I am a general contractor and I employees (full and/or part- time).* 2.0 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] have hired the sub- contractors listed on the attached sheet. These sub - contractors have employees and have workers' comp. insurance.t 5. 0 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.] Type of project (required): 6. 0 New construction 7: 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.12 other ,P�� /t. Fin,, G, p *My 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 than 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 sub - contractors have employees, they must provide their workers' comp. policy number. Ian an employer that is providing workers' compensation insurance for my employee& Below is the policy and job site information. Insurance .Company Name: G Lo $ A L in) SUP. FkW CE N El-Woo( K� TNC. Policy # or Self -ins. Lic. #: Job Site Address: 35-606 2 9 634 Expiration Date: 11 /36 /2.6 i 0 / kola hla iv/1,e 1 3,2j City/State/Zip: 4exih2917.0.1 , 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investiga ' ons of the DIA for insurance coverage verification. I do hereby . fy the pains and penalties of perjury that the information provided above is true and correct. t Si e:. .. :'�L$�: .. Date: Phone it: '781- 933 - a-�8 Official use only. Do not write in this area, to be completed by city or town ofj'iciaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Permit/License # 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 that apply to your situation and, if necessary, supply sub - contractors) 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 600 Washington Street Boston, MA 02111 Revised 11 -22 -06 Tel. # 617 - 727 -4900 ext 406 or 1-877-MASSAFE Fax # 617-727 -7749 www.mass.gov /dia jiixA ;��.L ,/_teg a /A- Map #: ! -7' Lot #: Unit #: Street #: 'treet !V ne: =rreet Unit #• Department: Bui n Document Type Winn. --7302_5 f TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof 30.7 lard 554 Property Address: ,-4ki,eee # o Owner of Record :_' d" M fJ . Co Assessors Map #7` Lot #.... f CL Type of Occupancy: f£tj ?k ce. New: Renovation: ...._ Replacement: jt Plans Submitted: Yes No _•__y Installing Company Name: (e vt-1 -r«,1 Cc 4)-1.5 + ¥-rrAiihg ,t,nc - Company Street Address: g N, maps' .sf- City: rvd,hc tt✓A Zip: diiti/ Company Phone Number: 71/ -932_ er.2 -Pg Estimated Cost: $ ? K indicate total number of units in the applicable box below Basic Building Code Commercial 1 &2 Family Basement °o II 2 "d Floor 3'd Floor o c ce lb 2 Air Handling Units Draft Inducers Oilfired Equip Hydro Air Unit Kitchen Vent & Exhaust Equipment Evaporative Coolers Pool Heater Heat Pumps Process Piping Range Hoods Vented to Exterior Roof Top Units Refrigeration Units Radiant Heat Central Air Conditioners Hydro Air Systems Ventilation Fans Energy Recovery Ventilators Central Air Conditioners Other: Furnaces- Oil Generators Other. tack a erg 9as Faneke X Basic Building Code Commercial Basement 1st Floor 2 "d Floor o u. M Roof' c p 6 Generators Draft Inducers Oilfired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may berequired. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment Is subject to Lexington's Noise By -Law: I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above applicat'' • is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations p orm -d under the permit issued for this application will be in compliance with all pertinent provisions of the M: -chu - to Su' ding Code, the intemationat Mechanical Code, and all laws/bylaws/regulations of the Town of xi gton Signs re: Print Name: E- er_nmsrvli Type of License: S-137 License #: This Section for Office' U e Only Perm fee: 30 co Receipt #: _ ; - q Date Received: f Issued :y : 0 Received by: Revised 12/31/09 Approved Date: t(t7 /t� Permit Number: f ®' 13g5- 6-c ((7 die-4 ,ttt-- Map #: Z Lot #: Unit #: Street#: 3 ( 7) street Name: /'.&+CP OP /dam .Ereet Unit r: Department: i=3«i]timg ()o!` r ent Tyre: (P1.: ) (Pict ) (Perm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL PE T 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781 - 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof )7 wax/ 51- Property Address: I i<41-011011',1 A r;vt #' j 6 J Owner of Record: wzezis Assessors Map # 7 '-( Lot # f c-- Type of Occupancy: New: Renovation: Replacement: Plans Submitted: Yes No )c Installing Company Name: Cev -rt-i C ;j,� r N-(613,�,,) Company Street Address: ? AL 5i-rec+ City: L,ebaffi Company Phone Number: --7, ; _ 4'34_ roc -g or Officai Zip: 6/ Ft/ Estimated Cost: $ 2 k Indicate total number of units in the applicable box below 1 & 2 Family Basement 1St Floor °o N °o co Roof .,punoie Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil Generators Other: g_cF 1 aw_ lju� rurrtc,c X Basic Building Code Commercial Basement o u_ r 2nd Floor °o LI Roof* c o 0 Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems Central Air Conditioners Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may besequired. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: 1niZ Cr't 0l i <Kx- tr 6-J Furn&cc c,/ f1C r�A7 ii •, I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above appli . '• true and accurate to the best of my knowledge, information and belief, and that all mechanical work an • installations .erformed nder the permit issued for this application will be in compliance with all pertinent provisions of the M. .sachu.et s ate Buildi+ g Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of L ngton: Pill Ck 0.-e f ( eon s c,s,; Nn o', {T4 15737 Sign ture: Print Name: Type of License: License #: This S ection f Perm fee: 30 , ©c7 Issued Receipt Us Only Date Received: i2- >8'/0 Received by: ( proved Date: Z1%�/ `� Permit Number: Revised 12/31/09 JixA idar_ Map #: 6 Lot #: Unit #: Street # �3 o street Name: COeric,p =rreet Unit#: 'rrnit #: Department: u ldin t) cuur,ent Type: (plot) (Perm) TOWN OF LEXINGTON APPLICATION FOR MECHANICAL` PERMIT 1625 Massachusetts Avenue, Lexington, MA 02420 Ph: 781- 862 -0500 x -211 Fax: 781- 861 -2780 This Application shall only be used if the work authorized is NOT done in conjunction with a Building Permit FEE: $12 per one thousand valuation or any portion thereof Property Address: 31.0 .14 Rd- Assessors Map # % = Lot # ) Type of Occupancy: v -- New: y Renovation: Replacement: Plans Submitted: Yes No Installing Company Name: 1S br yto �1 Company Street Address: Qro 6F,V. L{5/4 City:��� I r� Company Phone Number: 9 (d (17 Indicate total number of units in the applicable box below Air Air Handling Units Hydro Air Unit Evaporative Coolers Heat Pumps Range Hoods Vented to Exterior Refrigeration Units Central Air Conditioners Ventilation Fans Energy Recovery Ventilators Furnaces- Oil c 0 E m ca m 0 0 0 u_ N 0 0 c!) 0 0 cc Generators Other: Basic Building Code Commercial Basement o _u_ N 0 IL C N_ u_ M Roof Ground* Generators Draft Inducers Oil fired Equip Kitchen Vent & Exhaust Equipment Pool Heater Process Piping Roof Top Units Radiant Heat Hydro Air Systems j Central Air Conditioners of Other: Describe Project: *Note: If any equipment is being placed outside of the footprint of the building, indicate setbacks to property line. A land survey may be required. Roof top units may require a Structural Engineer's review. Equipment that is visible from a public way and within a Historic District will require prior approval of the Historic Districts Commission. All equipment is subject to Lexington's Noise By -Law: citA 1 Th9D SiS c cap FCC I certify that I have the authority to make the foregoing application and that all of the information I have submitted (or entered) in the above application is true and accurate to the best of my knowledge, information and belief, and that all mechanical work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the achusetts State Building Code, the International Mechanical Code, and all laws /bylaws /regulations of the Town of gton: tom_ V ern (Iwlvii � Off ' 335 Print Name: Typa e of License License . Permit fee: i Issued By- 'd This Section for Offical Us On Receipt #• Date Received: k Received b Approved Date: �O A` 5ermit Num G7 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 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 #: 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 x 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.] 1. Er 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.] t 7 Coo l Type of project (required): 6. 7 , � New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 1 1. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.0 Other H(%4 C *My 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 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. 1 Insurance Company Name:'ec 1 e'S-C Policy # or Self -ins. Lic. #:C / F7' Expiration Date: Job Site Address: 3t cc A City /State /Zip: )Ly �'i 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 hereb e ' i "`under the pains___Lcunip4nalties of perjury that the information provided above is true and correct. ...�.•� Date: vvVp a ZO7t7 Si' ature: Phone #: C17 \ \ Official use only. 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 Contact Person: Phone #: