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13 ORIENT WAY - BUILDING INSPECTION Commonwealth of Massachusetts Sheet Metal Permit G � 023 )a Permit# Date: C� 47T Permit Fee: $ r ES n Estimated Job Cost: $ -` =rn Lo f < Plans Submitted: YES_ NO Plans Reviewed: YES_ NO—� rn� Business License#. ( 1 Applicant License 9- Business Information: Property Owner/Job Location Information: Nane:UssiVfs � ,Q .C��`r - Name:"Co))'Cl ,`Street: D�� �� V' � Street City/Town: I, City/Town: Telephone: ��� � Telephone: Photo I-D.required/Copy of Photo I.D. attached: YES_ NO �'� saar� J-1XM mrestdcted license J-2/MM--2--restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft /2-stories or less Residential: 1-2 family_ Multi-family_ Condo/Townhouses Other Commercial: Office Retail_ . Industrial__ Educational Institutional— Other Square Footage: under 10,000 sq.ft. over 10,000 sq. ft_ Number of Stories: Sheet metal work to be completed: New Work:_ Renovation: HVAC `� Metal Watershed Roofing— Kitchen Exhaust System Metal Chimney/Vents Air Balancing— Provide detailed description of work to be done: MC) TO Cb tJN- ps-co L INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of NLG.L Ch.112 Yes I, No❑ If you have checked Yes'indicate the type of coverage by checking the appropriate box below: A liability insurance policy+� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I air aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General taws,and that my signature on this permit application waives this requirement Check One Only \Q Owner ❑ Agentf Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progresslnspections Date Comments Final Inspection Date Comments Type of License: ' By 'Master Titl ❑ ^� e Master-Restricted (/�0 City/Town ❑Joumeyperson Signature of Licensee Permit# {y ❑Joumeyperson-Restricted License Number Fee$ ❑ Check at www.mass.g avid pl Inspector Signature of Permit Approval 1'tte commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compewation Imurance Affidavit: General Businesses Applicant Information P e 1 ase Print Legibly . Business/Orrganizatiion Na'me: Owl e$ S S1 �QL �1� C4, C � 0 C 1 C Address: City/state/Zip: L oN P, d> l Phone#: Are you an employer?Check the appropriate box: Business Type(required): 1 I am a employer with employees(frill and/ 5. ❑Retail or p�_�)= 6. ❑Restaurant/BmEating Establishment 2.❑ I am a sole proprietor or partnership and have no 7_ ❑Office and/or Sales(mcl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp.insurance required] $• ❑Non profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 101-1 Manufacumng no employees. [No workers' comp.insurance required]e 1L❑health Care u 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.❑Other °Any applicard that checks box#1 most also fill out fie sectionbelow showing ibeirwori='compensation policy information p Mthe corporate offs have exemptedthemselves,but the coepomtionhas other employees,a wmkecs'compensation policy is requited and such an orga�should check box K. I am an employer that is providing orkers compensation insu a ace for my loyees Below is the policy information. Insurance Company Name: -sk� s L �► , InstnefaAddress: V Ci /Statdzi : tY F �p Policy#or self-ius. Lio.# l -l�� 0baO ExpirationDate: 15N16i 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 MOL 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 ofup 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( err the pains andpenaldes of peduiy that the information provided Bove is true and correct Signature: ��yDJ` ®�,�•\p °� Date �11� 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person• Phone#: www�ass.gov/dia for af,01-1 and instructiOns Gzueral Laws chapter 152 regnh'es all employes to provide workers' compensatdon fior flies employee_ . Pursuant to this s a sYe,an amployee is defined as -.every prason n service of anon coder any cenfra A oft e, express or implied, oral or wriitr " association corpordhan or ot�legal enfity,or any two of more An aMPloyer is def>ed as an ndividual partnership. the le resrmt ves of a decersed emplayrz,or the of the foregoing engaged in a jo nt enterptise,and iuclnding gal red e to mP H eT,or f the receiver or tmgtm of an individual.partneship, association or o`ffi=legal entity,emplaying mP Y owner of a dwelling house having not more than three aP�nts and who resides therein or the occupant of the int—n construction or repair wDric an such dwellimg house dweIlm an g horse of other whio employs persons to do e con be deemed to be an emplaym" of on the grounds or building apPurtevanf thereto shad notb"-a=of such emp ymerrt MGL chapter 152, 525C(6)also states that"every state or 10ml Scensimg agency shall withhold the issuance or renewal of a Iir�nse or permit to operate a business or to construct buildings in the,min ealth for applicant who has oat prodnr�d acceptable evidence of compliance with.the msurau coveragerequired." A djtLoraily,MGL chapter 152, §25C(7)staTss Nether the commo rwealfh nor any of its poIikical subd v sinus shaIl enter ruin my cuotract for the perfom ante of publ c wor3t until acceptable evidence of mi.aplianm with tcreq nsmznce ,n-rmzR,te of this chaptea bave been presented to the contracting authonty." AppIimats apply to your srtrrahon and Plea fill orb the workers' compensation affidavit completely,by checking the boxes that £ se neoassary,supply�o�tor(s).n-el's),addrass(es) and phase mmmber(s)along with their certificates) of or Limibsd Liability Paninersbll's (1,U)wrL no employees other than the cn,-anrr.. Limited Liability Companies(t.LG� - If an LLC or LLP does have members or partners, are notreq�'ed to carry workers' compensa.�.-on insurance- cniPloyDCS a Policy is rid Be advised that this affidavit may be submitind to the Department of Industrial Accidents for confirmation of ms^a^co coverage: Also be sure to sign and date flit affidavit The affidavit should be returned to the city or town that the application for the pElmh or license is bejjjgxbqnc&t-A not td to hDepartment ep�t of l dust-ial Accidents. Should you have aIIy questions regarding the law or if you are Iequ-s compensat on policy,Please cell the Department at the number listed below. Self-insured companies should entry their self-mR,rnnce license mnnber on the appropriate line. City or Town Officials Please be gist that the affidavit is complete and prindte legibly. The Department has provided a space at the bottom of the affidavit for you to f ll o�in the event the Office of Inve_sdgations has to contact you regarding th.t appli=t Please be sore to fill inthe permitflicm-s number which will be used as a reference nmmber. In addition,an applicant that must submit m,dtnle permittliceose applications in any given year,need only submit one affidavit indicating current and under"Sob Site.Address"the applicant should write"all locations in (arty or policy information ffnecessary) town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses A new affidavit mast be filled out cash year.Where a homecitizen is owner or citi is obtaining a license or pure not related to any business or commercial.ventist. (Le. a do g license-or permit to bum leaves etc.)said person is NOT r upir d to complete this affidavit. The Office of luvestigations would lace to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a calL The Deperfinent's address,telephone and fax number- The Commonwealth Qf Massachusetts Department of Industrial Accidents Office of Investigations 6D0 Washington Street Boston, MA 02111 i Tel. 4 617-727-49DO ext 406 or 1-977-MASSAFE Fax# 617-727-7749 Revised 4-24-07 an Ru-mass-govJdia UNIVE-1 OP ID: LS ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE 06/24/2015 �i 24/2015 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(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 endorsements). PRODUCER CONTACT NAME: A James Lynch Insurance Agency PHONE 781-598-4700 ac No:781-599-0580 297 Broadway AIC No Ext: Lynn,MA 01904 E-MAIL Thomas R Ross ADDRESS: INSURER(S)AFFORDING COVERAGE NAICa INSURER A:Arbella Protection Ins Company INSURED Universal Mechanical Cont.Inc INSURER B: Peter Lyon INSURER C 9 Devlin Way Lynn, MA 01905 INSURER D: 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 DDL Un POLICY NUMBER MPOLICY /OI CIYYEVYV MMIDDIIYYYY LIMITS TR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE rx�OCCUR 8500040425 0613012015 06/30/2016 pREMISEs Ea ocwrrence $ 600,000 MED EXP(Any one person) S 5,000 PERSONALBAWINJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- ❑ LOG PRODUCTS-COMP/OP AGG $ 2,000,00 ECT OTHER'. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,00 Ea sodden) A ANY AUTO 1020001502 0613012015 0613012016 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Peraccident) $ AUTOS NON-OWNED AUTOS -PROPERTY DAMAGE $ X HIRED AUTOS X. AUTOS Per accident $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS S WORKERS COMPENSATIONPER AND EMPLOYERS'LIABILITY STATUTE EORH YIN A ANY PROPRIETORIPARTNER/EXECUTIVE ❑NIA 9109150608 06/3012015 06130/2016 EL EACHACCIDENT S 500 OFFICERNEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500 f yes,desmbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 50O DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks SCheduie,may be attached if more apace Is required) hvac CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem City Hall Bldg ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washingto Street Salem, MA 01970 AUTHORIZED REPRESENTATIVE I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD OMM NWE61L7H OF M_OWA USEM , oAt�D QI SHEET SL 410RKLJS ' ISSGES THE FOLLOW WO Li•CEN'SE s "` AwyA1ASTER PEGL LYON ° a 9 OEVLa�11 `wky""" o , L1YM Z , � A 01905 Universal Mechanical Contractors, Inc. 9 Devlin Way Lynn, Ma. 01905 Phone 781 -595-9222 Bringing Quality and Comfort to families for over 25 years. July 20, 2015 Page 1 of 2 Proposal Submitted to: Mr. Richard Penkul Phone: 978-744-5347 13 Orient Way Email: easygoing] @verizon.net Salem, Ma. 01970 W X )1$ Proposal Submitted for: the replacement of the existing, 65,000 btu, 65% efficient, gas furnace and 1 .5 ton a/c system. We shall install a Trane, 80%, 60,000 btu furnace with a new, 1 .5 ton, 13 SEER a/c system. Equipment: M# TUD1 B060A936 XR furnace M# 4TTB301 8 outdoor unit M# 4TXCBO04CC3 cooling coil The furnace shall be reconnected to the existing supply and return ducts. A condensate pump shall be installed to pump the a/c condensate outdoors. New refrigerant lines shall be installed. A new outdoor unit pad shall be installed. Phone 781 -595-9222 Email peterC)getair.org Fax 781 -595-9643 Page 2 of 2 The existing room thermostat is newer and shall remain. The furnace vent shall be reconnected to the existing B-vent chimney. Installed price: $ 6,475.00 Price includes: Equipment, labor, sales tax, electrical, gas piping, permits and removal of old equipment and debris from the job site. Warranty: Two years all parts and labor Ten years on Trane functional parts Twenty years on heat exchanger If in agreement with proposal: sign one copy of agreement and return to Universal. Keep one copy for your records. Payment: 50% on start of work and delivery of equipment, balance due on completion of installation and options. Submitted by: -Peter Lyon �-q Date: 7-/-20-/1 5— Z (Accepted by: Date: 3 Universal Mechanical Contr, may withdraw this proposal if not accepted within 30 days.