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58 MEMORIAL DR - BUILDING INSPECTION (2) Commonwealth of Massachusetts Sheet Metal Permit t Date: D /5 / Permit# av Estimated Job Cost: $ le�oe�, Permit Fee: $ Plans Submitted: YES NO— Plans Reviewed: YES— NO— I — Business License# 44 013 Applicant License# /(e 3 3 Business Innformation: {� Property Owner/Job Location Information: Name: NY2 y64, 2(/`�/� ,RIK- 14 Name: �IIP.V $ �i�O�IGe� cp7dU�LP� Street:'54lo/� /��0n � �A,3 Street: �r �//ne�ylbR/!Lz City/Town: /Df�Sr/� ��J City/Town:&—a,44 /WA 70 Telephone: Telephone: C/��7y�' ✓�f 9 Photo I.D. required/Copy of Photo I.D. attached: YES— NO— Staff loiHal J-1 M-1-unrestricted license J-2/M-2-restricted td dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family Multi-family.— Condo /Townhouses— Other— Commercial: Office Retail Industrial Educational — z Institutional Other rn a Square Footage: under 10,000 sq. ft. Y— over 10,000 sq. ft.— Number of Stories:'_z m J Dm Sheet metal work to be completed: New Work:— Renovation:_ '-m mo HVAC Metal Watershed Roofing— Kitchen Exhaust System— ty < Metal Chimney/Vents— Air Balancing— _ rn Provide detailed description of work to be done: i INSURANCE COVERAGE: i 1 have a current liability Insurance policy or Its equivalent which meetsthe requirements of M.G.L.Ch.112 Yes No❑ If you have checked Yes.indicate the type of coverage by checking the appropriate box below: A liability Insurance policy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the Insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only �� /f /�➢ Owner ❑ Agent ❑ Sign re of Owner or Owner's Agent By checking this box[],I hereby cerdty that.all of the details andardormatlon'I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit Issued for this application will be In compliance with all pertinent prevision of the Massachusetts Building Code and Chapter tt2 of the General Laws. Duct Inspection required prior to Insulation installation: YES_NO Progress Inspections Date Comments 1 Final Inspection Date Continents Type of Lloense: BY ❑ Master Tm ❑Master-Restricted r Chy/Town ❑Joutneyperson Signature of Licensee Pernik S ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.gov/dpf Inspector Signature ofPermit Approval The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name(Business/Organizationdgdividual): Address: City/State/Zip: C . . $ - Are you an employer? Check the appropriate box: Type of project(required): . am a genera contractor and I I.� I am a employer with /� 4 ❑ 1 l 6. New construction employees(full and/or part-time).' have hired the sub-contractors. 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Phimbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13. Other rI VAL comp. 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 affidavitindicating they are doing all work and then hire outside contractors must submit 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:� n� �,(i /� olicy#or Self-ins.Lipc. #:�/JW( , y do!2� 71(�,& Expiration DatepDd �J � r/ Job Site Address:-d /rl�O40 iat � )it City/State/Zlr,, /�.Q,00� �`7!0 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 rd under the pains and penalties of perjury that the information provided above is true and correct., Signature. Date: Phone • — lJ-"S 8 OJ)Wal 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#: PREFE-2 OP ID: KS1 �,..� CERTIFICATE OF LIABILITY INSURANCE F °"'08r01/14lnaYY' oa THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NORIGHTS UPON THE CERTIFICATE HOLDS[,. 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 policypes) must be endorsed. If SUBROGATION IS WAIVED, subjm 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 endorsements. PRODUCER 781.914.1000 NDUN,IE"oT Kell Sturtevant TGA Cross Insurance,Inc. ---�-- 401 Edgewater Place,Suite 220 PHON o 781-914-1000 ac Sp;781-246-2601 Wakefield,MA 01880 -MAIL Chris HawthorneHawthorne ADDRESS: kstu_rtevan gacross.com_ INSURERIS)AFFOROINO COVERAGE NAICtl INSURER A;Arbella Protedlon Ins.Co. 4136B INSURED Preferred INSURER B: 461 Bostonn S Streeree t,Unit A3 ---------- --- ------__-._— ___ Topsfleld,MA 01983 INSURER C INSURER D NSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: - REVISION NUMBER: 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. INSR ADM SM TYPE OF INSURANCE POLICY EFF POLICY EXPP POLICY NUMBER MM/DD/YYYY MMMDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE _ $ FOO-01 00 A X COMMERCIAL GENERAL LIABILITY 8500026668 08/01114 08/01115 -PREMISESC`a cGue� E— 3D6,DD CLAIMS-MADE OCCUR MEDEXP(Any one person) $ 15,00 PERSONAL S ADV INJURY $ 1,000,00 GENERALAGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 LlPOLICY X PRO- LOC $ AUTOMOBILE LIABILITY COMBIN D INGLELIMIT Ee ecGeeML____ 1,000,00 A — ALL OWNEDANY AUTO 1020003133 08I01/14 09/01116 BODILY INJURY(Par person) $ AUTOS X SCHEDULED ------------- - — AUTOS BODILY INJURY(Per ecci0ant) E N X HIREDAUTOS ON-0WNED X A�pg PROPERTY DAMAG€ f -- Peracgdent E X 5tNTION X OCCUR EACH OCCURRENCE E 2,000,000 A CLAIMS-MADE 4600037647 08/01114 08/01115 AGGREGATE E2,000,000 S 10,000 -- '----"--'- S- WORKERSCOMPENSATION WC STATU- OTM- ANDEMPLOYERS'LUIBILTTY _jT�RY LIMITS _ ER- ANY PROPRIETOR/PARTNERIEXECUTIVE YIN ISSUED DIRECTLY FROM f E.L,E_A_CH ACCIDENT OFFICER)MEMBER EXCWDEDT 1:1NIA _ (Mandaroryln NH) THE CARRIER E.L.DISEASE-EA EMPLOYE E If yyeea,deevlbe uMer — _ _ DESCRIPTION OFOPERATIONS below E.L.DISEASE-POLICY LIMIT $ I i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Affech ACORD 101,Additional Remarks Schedule,If more apace Is required) CERTIFICATE HOLDER CANCELLATION CITYSAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Fax: 978-740.9846 AUTHORQED REPRESENTATIVE 120 Washington Street,3rd Fl. Salem,MA 01970 � ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ��^Ro* CERTIFICA OFrLla ilr�°TY t�IHSf� tA�1C 8/15/2014 —_, -5 .saes„m-F�s.`.m, ..;}��ecr: ��•",,,,��' 'z_*�-tea seuu�kw ._ Ln^ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY 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 REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the cartlflcate holtler Is an ADDITIONAL INSURED,fhe policy(ies)moat be endoreetl. If SUBROGATION IS WAIVED,subject to the tense and conditions ofthe policy,certain policies may require an endorsement A statement on this c rtificete tloes not confer rights to the certificate holder In lieu of such endoreements(s) PRODUCER CONTACT TGA Cross Insurance,I1 C. PHONEFM IA/C,No,Ed): (7g 1 9I4-I000 WC Na.:) (780 224-5577 401 Edgewater Drive,Suite 220 E-MAIL Wakefield,MA 01880 ADDRESS: PRODUCER CUSTOMER I DO INSURERS AFFORDING COVERAGE NAIC 9 INSURED INSURER A. Atlantic Charter Insurance Company VDAC 44326 Preferred Air,Inc. INSURERS, INSURER C: 461 Boston Street,Unit A3 wsURER D. Topsfield,MA 01983 INSURER E. INSURER F: COVERAGES: CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR TYPE OF INSURANCE ADOL SUW POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR INSR MND UMIT9 DAM(MMIDDMY) DATE IMMIDDIYY) (In TIIDueand) GENERAL LMBIDtt EACH OCCURRENCE § COMMERCIALGENERALUNNU DAMAGE TO RENTED PREMISES tt E,mcm nee f CLAW MADE ❑ OCCUR MED EXP(my me pr,M) § PERSONAL L AW INJURY f ENERALAGGREGATE f GENI-AGGREGATEUMITAPPUESPER: PROWCTS�COMPIOP AGO § POLICY ❑PROJECT ❑ LOC AUTOMOBILE LMBIUTY ANYAWO - E.MMB ft.qSINGLE OMIT § ALLOYMED AUTOS BODILY INJURY SCHEDULED AUT09 BODILY INJURY f HIRED AUTOS Ee A.4ml) PR OPMAGE § NON-0YMDED AUTOS Eaa AxAlm Pcddenry MMBREL ❑ OCCUR EACH OCCURRENCE LIABILITY i EXCESS LAB❑ CVJMSMADE AGGREGATE f DEDUCTIBLE ❑❑ s § RETENTION f A NORKERSCOMPENSATION EMPLOYERS'LIABILITYAND WCV00971103 08/01/2014 08/01/2015 X STATUTORY OTHER ANY PROPRIETORPMTNEPJEXECUTIVE (N LIMITS DFFICERMEM y BEREXCLUDEDT N MA ❑ Polic Covers a State:MA EACH ACCIDENT If1,000,000 lAmdele,M NH g N yes,deseelpe unfr SPECIAL PROMSIONS helm 019EASE-POUCYUMIT § 11000,000 DISEASE-EACH EMPLOYEE f 1,000,000 OTHER ❑❑ DESCRIPTION OF OPERAIIONSLOCATION9IVEHICLES(AtuN ACORD 101,Addi ienal Rmuns Schedule,a men space H mRuIpNh aF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Salem EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 120 Washington Streeet,3rd Floor 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. Salem,MA 01970 BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. UTHORIZEO REPRESENTATIVE /t ACORD 26(I009109) Page 74 or 104 CERTIFICATE HOLDER COPY 0198&2009 ACORD CORPORATION.All rights reserved. ,-00+' 3> 4 :MASSA;EHUSETTS' W r DRIVERS — LICENSE , € 2. NW 2013 NE 9 O �S19539973 zRO ERTV' �t �.,1 t i n 15 LESLIE RD x {3 ROWLEY,MA 01969-7118' : ;Q% so�aeumiswvor.+smoe - <1`GOMMONWEALTH OF M At,HUSET-- TS a,.4' BOARD`QE , SHEET METRL.V70RKERS : ISSUES THE FOLLOWIIG IRE,ENSE AS STER UNRESTRICTED l¢=4 mx ,y J S F y r $ ROBfRT V SMITH,L 15 LESLrIERDV' e # W „ x e t633 _ .`og/z8/15 to5771