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15 SABLE ROAD WEST - BUILDING INSPECTION Commonwealth of Massachusetts q Sheet Metal Permit ►�',V Date: /J Permit# Estimated Job Cost: Permit Fee: $ Plans Submitted: YES NO Plans Reviewed: YES NO Business License # 12 Applicant License # Business Information: Property Owner/Job Location Information: Name: 1(1ayyt e,6s-� ��Paf,'ahy Name: �/crvr'� /C4g44,ve/ / Street: W l� �je et Street: 9dye ,�/ City/Town: /G�yty�i.'�/ /� Q 'City/Town: Y9/�P'1 //( . Telephone: qT� ��/'� as Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO_ staff initial J-1 /M-1-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories or less Residential: 1-2 family_>�' Multi-family Condo/Townbouses 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 X - Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: /l PF,10tn Qn� P�atL �r ilaaG+/N 4r• C7ine%nSp/ INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes❑ No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box[],1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑ Master Title ❑ Master-Restricted City/Tom ❑Joumeyperson Signature of Licensee Permit# ❑Joumeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.gov/dpl Inspector Si ature onPem, )prove] CERTIFICATE OF LIABILITY INSURANCE 7/2 3/2 012 0M YY> 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 tie endorsed. If SUBROGATION IS WAIVED, 'subject to the terms and conciitions of the policy, certain policies may require an endorsement. Astatement on this certificate does not confer rights to the certificate holder in lieu of such endoreement(s). PRODUCER UUNIALT NAME' M P ROBERTS INS AGCY INC PHONe FAx Osgood Street AC.No.E# 978 683-8073 Ac,H.) (978) 683-3147 1060 Os B ADORES . sand3.@mproberts:Lnsurance.com North Andover, MA 01845 INSURER(S) AFFORDING COVERAGE NAICO INSURER A: MERCHANTS INSURANCE INSURED NORTHEAST HEATING 6 COOLING, INC. INSURER a: QUINCY MUTUAL COOLING, INC. INSURER C. 90- HALE STREET INSURER D' HAVERHILL, MA 01830 INSURER F 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. liix ttPE OFINSURANCE INsp svvu POUCV NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000 ,000 "on- ZDAERIED'­ X COMMERCIAL GENERAL UABIUtt SE PREMIS(Ea occurrence) s 500,000 'CLAIMS-MADE CI OCCUR MEDEXP(Any oneparson) $ 15,000 A PERSONAL SADV INJURY $ 1,000 ,000 BOP9093769 04/26/12 04/26/13 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE UMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000 ,000 POLICY PRO PRO-JECT F1 LOC $ AUTOMOBILE UABIUTV .. 1,000,000 Ea accident $ IANVAUTO BODILY INJURY(Per Person) It ALLOWNED SCHEDULED AFV205908 04/26/12 04/26/13 B I AUTOS X I AUTOS BODILY INJURY (Par accident) S NON-OWNED PROPERTY DAMAGE S X HIRED AUTOS X AUTOS (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CIAIMS-k1ADE AGGREGATE S DED I I RETENTION $ S WORKERS COMPENSATION VrC STATU- OTH- AND EMPLOYERS'UARIUTY YIN TORV UNITS ER ANY PROPRIUORtPARTNEWEmCUMVE E.L EACH ACCIDENT $ 1 Q0O 000 A (Mandaaun,iin NN) CLUOEO? ❑ NIA WCA9094494 09/26/12 04/26/131,000,000 r r Ifye;desrihe undo E L DISEASE-FA EMPLOYEE $ 1,Q Q Q,Q Q 0 DESCRIPTION OF OPERATIONS bel. E.L.DISEASE-POLICY LIMIT S 1,000,000 I IT I DESCRIPTIONOFOPERATIONS(LOCATIONSIVEHICLES(A11atlIACORD101,Addimanal RemarksStlledule,0mares mism,Wre ) CERTIFICATE HOLDER CANCELLATION 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 11 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD