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3 SALT WALL LN - BUILDING INSPECTION (2) 1 Commonwealth of Massachusetts Sheet Metal Permit Date: 9 2 B H Permit # Estimated Job Cost: $ /j Permit Fee: $ 6 Plans Submitted: YES NO ✓ Plans Reviewed: YES NO Business License#_ /02'7 9 Applicant License # Business Information: Property Owner/Job Location Information: Name: 0. Al.S. Name: �s�®ev /06ywe- Street: 3� �or .,pb� (7i Street: City/Town: City/Town: Telephone: 978-6/9-/0e9 Telephone: Photo I.D. required/ Copy of Photo I.D. attached: YES NO_ s I if III IIIaI J-1 / NI-1-unrestricted license J-2 / NI-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: 2 Sheet metal work to be completed: New Work: Renovation: HVAC vl" Metal Watershed Rooting_ Kitchen Exhaust System Metal Chimney/ Vents Air Balancing_ Provide detailed description of work to be done: boo r y INSURANCE COVERAGE: / I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes 2 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❑,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 hroEt'ess Inspections Date Comments Final Inspection Date Continents Type of License: By ❑ Master Tine - ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ;0journe erson-RestrictedLicense Number: Fee S yl Check at w,,vw.mass.novldpl i Inspector Signature of PeLiCAppraval ,h CITY OF SALEM � ,1' PUBLIC PROPRERTY i° DEPARTMENT .nil'., ill I y 10IN \I%11'a 11: \VA1IONI;HL\)I:ItL•1' a SAu•w,M.1».u.ln u I lv�l77] Iht. 77L.'rSuftS � p1x 'Na•'rC•'IxM Workers' Cumpensatton Insurunce %irlduvit: U wilder � s/Cuntraatur 1 ill•• s/EI aunt In urmrUo ectrlddns/Pfumbers PI • .� Int Le 'hl V;IIne IIhlvllry l)raanl ratio#onus v,duul l: r 'Iddres.x: CityrSrarc.%ip• '— �� I'huneiY 727 8 - I .\rr I nu an aaployer.1 Cheek the apprnprluts boa: I.❑ I:un a empluyur with 4. ❑ I ;,In a gcnural couuae(or and I h)M ufpro)uut(reyulnd): 3•Er,/vntpluyeea(lull anfl/ur pirl•linte),a huva hired Ihu,+uh•cunvactun ('' New uunruuctiun I.till a iolu prnpricnw or partner• liswel on the anuched.rhvilt 7. G?RelnodelinE .rhip and Nave no umpluycua Thee iub•contractors have working her main any cipiclly, tvorkero'comp, insurance g' ❑ Demolition I No Workurs'cutup, insurance J. ❑ We art a cnfpontinn and its 9. ❑ 01111411ind addiliws nyuircd.) 'Olean have exenixd their 10•❑Elecrrieal repsin or additions ' ❑ nyyclf.(No{veartivn'tiall c,I l II work right of exemption put M1IQL 1 I.p I'lumbinS repairs or additilln t p• C. 152,11(4),and wt h I re inaurunce rcyuired.) r cmpluyeua. (h'o%workep• 1 2•0 Ruul'mpain cnm(s, insurancareyuind.) 13'[]Other Anr,,;gdw'+1%IhW chccb a,fa rl mui.Ilw till Inn IM@rflWI(wluw.Iwwuf r t l�myl,%ryrs l•Iw.,afoul lhlaamdavll irWll'Ulln 1 e Mir%wIWrwflreoualun stoke#mai1rwYaiyl� e M itr Join#all wurt Jew Ilia,him"Side eemnerm am m"a itut"il a Mw uRdavil i nil grin#%v► C,Mrnwnln JI M.Mvh this Eat m,Nt afuehe#,,n addrfunel.h,Nf.liewifis IM IIaaN ortrla IYe�eanfrsefara aad IhfN%voters•roily,pulfr ,n /eta un rurpleyrr that d prvvlrHnr urkry•rurrrprnrrl//en Inrarnfrctjw my rtn u. y � m injurrnufhrt4 P/J tee 9dub la fAepo/lay unJ/u1.1/N Invurunw C'umpany .Vaate �_ . Policy a ur.sdr•ina. Lic.fr. /49714L-- _ • ----------------- //// EApirullon D;ns:-44Z- — Iula Ire�\{hlresx: �••` .lftach a citify of Iht svarkare'cumpenratlae posse# duclaratlun to v pugs(thawlnq the tPolicy nun and vpl durs), ti^w Pu,luru ucule cuverugs as required under Seeders 2JA ul'�IGL v.. 132 la eau lead to the im up nt SI SoO.rM un,Yur uue•year nnprivnnmcnt. av well ua civil permlhu in Ihit farm of a STOP WORK ORDER and a fine of up leii?10.!)n,f JayI ainat the vLNamr. Ile advLu,'d that a al position rar'uiminal penalties ofa g py of lhta.malvani may be I'ureurded la the Otlicu ul' Int rnh�uu,IIU uYalu I1L� Ibr Ilt+ur.u'ce :,,v;N3d %c,jI44llun. /du/terrAy f crtljy trill hr p,tinr,rnJprnrl/tier a �prr/nry/huI der injurtnal/ow prvailled ubuv#it true tard eorrurC rr„ : • 1 � � _Lam 9�R/.. r1//Iriu/m1 oil/y. /)u nnI,rrirr in dilr urru. ru Aa[unty/rlyd A Y[iry ur I#,rn,a//I[iuL ( sty, r♦ I'nwn: `' p\nniul.lnma II f"Itin lulhurit g y (cih'le noe): L IL,.u'd 'If llv•tlfh I. IIw1dnly Ucp.fr rulcnl L (:i f1.141%a Clerk J. l•'Icclritll ln+tccfur i, G. lyl It, I Phuabiny Inlyccfar I t "'It.Act Vkr,uff: �� Ihll lltl �• information and Instructions eve I+an in the service of anulher un,let I'ny:onlrlct of hire. �I,I,;,I:hu:eos V:octal Lawf:hayar I i2 ,:ywrcs all eugtlo)en to provide workers' cun,pensauon for heir cmp uyees. I•unu.uu to lies a141uld,an rrepfuved is Jet fled aI" every pe :.press or unphej. oral of written." era lon of usher legal entity.of any two or snare uyer.or he to .vnpfu)ar +decided sd"an Individual, partnership.Association.:ory \ the I�ueyomg engaged m a lams enteryr sa, and onciuding the legal represenute"Playing f or"'^t`n Vlo)ees.calitj lHowevcr he ,ecmver or uusleo of•at indicaing p umerYhlp, asdoelauoa or other legal amaly, D Y a ant of the ing to + Woos to do'naintanunca,cunavuctiun or repua work to such in tinpl haute owner of a dwelling house having not snare shoo three aparoT'enu and who refldes therein,or fill act .Iw:ll,ny huu;a of anchor who cmp Y• Pe or ,nt rho ground!or building appurtenant hereto shall not.beeause of such empleymcnt be JeemeJ lit be an employer. *aclt Of �iGL chapter 152. dISC(6) slso states that"Ivory slate er local Ileenslmg ageaay shag withhold the lff ulrany renewal of a license or pernslt to updrate a huflasfs or is co■etifflistruce with Ih slnfu lid raneCO'a forage Irequr say • pP produced Acceptable cceptabJ1eovidancli he ommonwcaldt our any of its political subdivisions.+hall 1 lleset ly\has not p nce %jailionully, �IGL chapter l S-, i-S :Weer into'any:ontraet I'w the parfomtan evantedbo the contact g 3ccepitablC rityviJancl of conlpliulce with he msura ra4uiremcnls of this chupter haw been p' Applicants checking the bolted that apply to your situation altd if horn numbers)along with hair certificut*(s)of pica** rill out the workers' compensation a1lWavit completely. Y LLP)with no employuas other than the necessary,supply sub•eontraclor(s)nar"(LLC1 o e�mitadL+ability Paruunhips( have insurance, Limited Liability Comp workar$, compensation insurance. If as LLC or LLP does Inelmbars or partners-ors not required to carry bd submitted to the Department of Industrial empb odes,a policy is requited Be advised that this alto be unsy artment of or town that the application for it pcnnit or licarof f you i requusk t ando obtain it workers' %ccidants for conflrmaticm of insurancaP oversge Also be fun to slgr and Juts the ul'flduvlf. the Tlu ollidavit should ha rcwmed to Ills city ou have any queftietu regarding the law ur if you ass rey industrial,%eeidants. Should y attment at the number listed below. Salf•indured companies should snot their compensation policy, please call the Dep .elf-insurance license number on the a ro riots line. ('Iry or-rows Officials ft Pl:nsc tum he sure that the affidavit is complete and printed legibly. "Cho Department has provided u space h the leant „f dta affidavit for you to till nut in the event the OlTtce of Investigations has to contact you rcn addition, the a applicant ear, need only submit and Uuutiun indicating current ior f fit a ba davitre l till in the puLlut in thea number which will ba used a+a refere co nuntb*e to addition•am aPD and under"Job Site Addrasi'the applicant should write"I'll luwtiuns in l' Y hat must submit multipl* pannit'and utn er"Job SiM A any given y provided to the policy iuformuliun.t if necessary) ed or marked by the city or town 11 ba p town)•"•%copy of Ills utlidavit that has been offlciulty sump' business orcommareial dug cac applicant as proof chat a valid af6duvit is on file t'or tLturs permits or lot felas. t now a urines must be filled nut sac )ear. Where a helms owner or citizen is obtaining a lies"**or Penn" not related to any t i.e. .1 Jug G%:dA d or permit to burn leaves etc,)said person is NOT requited to camplala this old y uthavo•oly 4uesumis, 1 Ise ,)Ili:u,d Invevligations would IIAI to dunk you in jdvance for Your :aoparalion and vhuuld y I,lea.e Jo not hesilaro to give of a call. fhc U:panmenl•s addrai+. eelcphuna and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Of)1te of Iavesd4adons 600 Wa5mriston Street Boston, MA 02111 (el. 4 617-127-00 7 "t 06 o77J9"-MASSAFE jov/dia 1 , 1 CITY OF sm-E.`[, Ulss.-1CHUSETTS BLILDLNG DmurnIEUNT 120 WASHNGTON STAEfir, Y°FLOOR TI L (978) 745-9595 F.ut(978) 740-9946 KIJOlERLEY DRLSCOLL MAYOR Noma ST.Pmmz DIRECTOR OF PL OUC PROPERTY/8UM.0LYG CONNISStONER Construction Debris Disposal Aftldavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section I l 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit Al is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposedof in (name of factlity) (address of faMhty) atureofpermi phcant date A ^� DATE(MM/OO/YYYV) $f CERTIFICATE OF LIABILITY INSURANCE 9/28/2011 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 coHTACTNAME: P Pam She and Bernard M. Sullivan Insurance Agency PHONE (978)356-5511 FAX (9T8)356-0214 12 Market St. E-MAILRess.pshepard@sullivaninsurance.com P.O. BOX 568 INSURERS AFFORDING COVERAGE NAIC It Ipswich MA 01938 INSURERA:National Grange Mutual Ins Co. 14788 INSURED INSURERB:SafetY Insurance Company 39454 Douglas Saunders INSURER C: PO Box 512 INSURER D: INSURER E Ipswich MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1192801551 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. INS. TYPE OF INSURANCE AODL BDBR POLICY NUMBER MM/DDPOLICY/YYYY MM/DD EFF Y EXP LT. /YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 DAMAGE TO RENTED 500,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE MOCCUR 064412 5/26/2011 5/26/2012 MED EXP(Any one person $ 10,000 PERSONAL S ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 TPOLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED 5051758 10/12/2010 10/12/2011 AUTOS X AUTOS BODILY INJURY(Per accident) $ NON-OWNED PeraccdT n DAMAGE $ HIREDAUTOS AUTOS Underinsured motorist Blsplit $ 100,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- DTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE� N/A E.L.EACH ACCIDENT $ EXC LUDED?CLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 City Of Salem ACCORDANCE WITH THE POLICY PROVISIONS. Building. Inspector Salem, MA 01970 AUTHORIZED REPRESENTATIVE J Lewis, Acct. Exec./ ACORD 25(2010105) ©'1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD