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2 MILK ST - BUILDING INSPECTION (4C)� Commonwealth of Massachusetts . q Sheet Metal Permit Date: l 13 Permit# Estimated Job Cost: $ rJ J Permit Fee: $ t Plans Submitted: YES_ NO� Plans Reviewed: YES_ NO Business License#. Applicant License# l Business Information: 1 Property Owner/Job Location Information: Name: W,&cA vz�tK5 CR)1 \ t 4�S Name: p Street: 1 .6.)btAX � Street:. City/Town:W• L`1 N N City/Town: S Telephone: Telephone: W ~ ��ZS "�tO Photo I.D.required/Copy of Photo I.D. attached: YES NO sr2amisn J-1 Gunrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family' Multi-family Condo/Townhouses_ Other Commercial: Office Retail Industrial_ Educational Institutional Other Square Footage: under 10,000 sq. ft_� over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVACy, Metal Watershed Roofing— Kitchen Exhaust System_ Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: kv ^�s F�c NA - caNt�e� R INSURANCE COVERAGE: 1 have a current liabili insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy r Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: [am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement (? Check One Only . Owner ❑ Agent Signature of Owner or Owner's Agent By checking this box0,I hereby certify that all of the details and information 1 have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: - By Master Tile ❑Master-Restricted Iv`1 a city/Town ❑Joumeyperson Signature of Licensee Permit# - ❑Joumeyperson-Restricted License Number. Fee$ Check at www.mass.poyidpl Inspector Si re of Permit Approval 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 (Y� Ple a Print LeLvibly Name (Business/Organizaiion/Individual):U w-4 CS Address: �•�+�� City/State/Zip:W• L g)4 �AA , 01°t�� Phone Are you an employer?Check the appropriate box: Type of project(required): I-R I am a employer with 4. ❑ I am a general contractor and I » have hired the sub-contractors 6. El New construction employees(full and/or part-time). 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.t 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.[_1 Plumbing 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 13.0 Other employees. [No workers' comp. insurance required.] 'Any applicant that checks box HI 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. -^ Insurance Company Name: yr\ Policy#or Self-ins.Lic.#: � 'bq btl Expiration Date: a Job Site Address: 1`)1, SN City/State/Zip:S8� 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 c ti under the pains and penalties of perjury that the information provi ed ove is true and correct. sign; �p Date: Phone#' Offtcial use only. Do not write in this area,to be completed by city or town oJjiciaL 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#: UNIVE-1 OP ID: LS CERTIFICATE OF LIABILITY INSURANCE 0 911 912 01YY) 09/19/2013 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 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les)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 endomement(s). PRODUCER Phone: 781-598-4700 CONTACT _ NAME: James Lynch Insurance Agency 297 Broadway Fax: 781-599-0580 PaHCCONEO Ezt: INC,No: Lyynn,MA 01904 EMAIL Thomas R Ross ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Ins Company INSURED Universal Mechanical Cont. Inc INSURER B: Peter Lyon INSURER C: 9 Devlin Way Lynn,MA 01905 INSURERD: 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. INSRXP LTR TYPE OF INSURANCE ODL POLICY NUMBER MMIDD/Y YYYY MMIDD/YYYY LIMITS R GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 8500040425 06/30/2013 06/30/2014 PREMISES Eaoccunencre $ 500,00 CLAIMS-MADE OCCUR MED EXP(Any one Person) $ 5,000 PERSONAL S ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGO $ 210001000 POLICY PPCT RO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00 Ea accident $ A ANY AUTO 1020001502 06/30/2013 06/30/2014 BODILY INJURY(Per person) S ALL OWNED X SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S X HIRED AUTOS X AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TOR MITS ER L A ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N❑ N/A 9109150608 06/30/2013 06130/2014 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-FA EMPLOYEE $ 500,00 If yes,describe under DE SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 600,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lloyde Ternes ACCORDANCE WITH THE POLICY PROVISIONS. 2 Milk Street Salem, MA 01970 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD