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18 SAVOY RD - BUILDING INSPECTION (3)
Commonwealth of Massachusetts RECEIVED Sheet Metal Permit >yPECTIOHAL SERVICES Date: `� Ib Permit 401h APR 20 A II', 29 N 9 Estimated Job Cost: $ 17F 7b7. Permit Pee: $ t Plans Submitted: YES NO_ Plans Reviewed: YES NO _ Business License# C7n Applicant License# /RZ 1 Business Information: Property Owner/Job Location Information: Name: �r11k� IEW�IY�Ak,�,"� C(5v1�'Oul In( Name: t � qt Street: �3`i (,l)�Jl�A�YIu - StrecC 9 JA14)Y ) City/Town: Uke rf 4, �yb City/Town: �[IOLM Ila, (3076 Telephone: ��I ZZ�-Z�a1 Telephone: �7�' 744- 4760 Photo I.D. required/Copy of Pho o'f D. attached: YES /NO Staff IIIIf1aI �!/ J-1 / M-1-unrestricted livens J-2 / NI-2-restricted to dwellings tories or less and commercial up to 10,000 sq. ft. / 2-stories or less Residential: 1-2 tamily Multi-family Condo/Townhouses_ Other Commercial: Office Retail_ Industrial Educational Institutional her_ Square Footage: under 10,000 sq. ft. _ over 10,000 sq. ft. Number of Stories: Sheet metal work t�e completed: New Work: Renovation: HVAC C Metal Watershed Routing Kitchen Exhaust System_ Metal Chimney/ Vents_ Air Balancing Provide detailed description of work to be done: lee(/4fian/ a e 4k fy1)IL-� Al ( 4ek✓ fZdbL INSURANCE COVERAGE: I have a current liability insurance policy or it equivalent which meets the requirements of M.G.L. Ch. 112 Yes❑ No❑ lJ� if you have checked Yes, indicate t ype 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 boxE1,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 Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ]&aster Title ❑ Master-Restricted City/Town ❑Journeyperson U Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Aj_92 Fee S ❑ Check at w,.yw.mass.govhiul Inspector Signature of Permit Approval The Commonwealth ofMassaehusetts UVDepartment of IndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apnlicaut Information �; Please Print Le 'blv Name (Business/Orgartization/Individual): Jyjq/I �FPr�u1 Li/r) ( /// c Address: e�7 MIT Q/4ffpfl� City/State/Zips Phone#: Are you employer?Check the appropriate box: Type of project(required): 1 I am a employer with employees(full and/or part-time).• 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.❑ m I a a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 4.❑I an a homeowner and will be fining contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.El Plumbing repairs or additions 5.❑I not a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Ro p'airs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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. lContractors that check this box most 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi u der t pai and enaId ofperjury that the information provided above is true and correct. Si Date: � Phone#: ��22 2 fit/ 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.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. - Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, ` express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements pf this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia TOTATEM-01 LCARUSO A CaNt O- DATE(MMMD/YYYY) CERTIFICATE OF LIABILITY. INSURANCE 9/22/2015 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(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 endorsement(s). PRODUCER CONTACT NAME: Salem Five Insurance Services,LLC PHONE (781)933-3100 W.WE (781)933-9048 445 Main Street A/c Na E> : E-MAIL Woburn,MA 01801 . _ - Aooaess:insurance.services@salemflVe.com'. _ INSURER 5 AFFORDING COVERAGE -NAIC 11; INSURERA:Ohio Security Insurance Co 1rysuRED, - INSURER B:American Fire&Casualty Co .J TdtaLTemperature.Control Inc INSURERC: 39,West Water Street �nsuRERD: Wakefield,MA 01880 " INsuRERE: . - .. .INSURER F: — .r'COVERAGES .;r 'CERTIFICATE NUMBER: " ':•REVISION NUMBER: THIS IS TO CERTIFY TH.AT,THE'POLICIES'OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE'.INSURED NAMED ABOVEFOR THE POLICY PERIOD 'a .+:INDICATED. NOTWITHSTAND114G ANY REQUIREMENT, TERM.OR CONDITION!OFh 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 ALLTHE TERMS, EXCLUSIONS.AND CONDITIONS'OF:SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN:REDUCED BY PAID CLAIMS. INSR . TYPE OF J SURANCE •`ADDLPOLICYEFFPOLICY EXP LIMITS - : "LTR M S POLICYNUMBER MM/DD. MM/DD YYYY A X COMMERCIACGENERAL LIABILITY ,. EACH OCCURRENCE '$ _'..1 i000,000. CLAIMS MAIJC%'OCCUR BKS56291199- ' - 09I10/2015 09/18/2016 PREMISES fEa occurrence "-$ :_.100,000 MOD EXP(Any one person) $ - 10,000:, PERSONAL&ADV INJURY $ 1,000.000'. GENL AGGREGATE LIMITAPPLIES PER, GENERAL AGGREGATE" $ 2,000,000 ;X POLICYL. JJEEC-•' LOC PRODUCTS--COMP/OP AGG E 2;000,000 OTHER: AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $' 1,000,000 Ea aia'denl B ANY AUTO' ` 13AA56291199 09/18/2015 09/18/2016 BODILY INJURY(Par person) $ : ALL:UWNED AUTOS ACHEDULCD AUTOS - BODILY INJURY(Par accident) $ X NUN OWNED - PROPERTY $ - HIRED AUTOS ` AUTOS Pat ac<In nl 8 X. UMBRELLA LIAR X '.00CUR EACH OCCURRENCE %'- E .1,000,000 'A EXCESSDAB ",`cv".I: A., US056291199'>� 109/1812015 09L1 B/2016 AGGREGATE' "- 'E ty000,000 ' F ry DED I'X. RETENTION$ 10,000 _. 1- ._.. ... E �• WORKERS COMPENSATION AND,EMPLOYERS'LIABILITY" _ STA UTE ER- A-. my PROPRIETOR/PARTHEPoEXECUTIVE r/N ' ' XWS56291199 091'18/2015' 09/1812016 EL EACH'ACCIDENT -;" E " 11000,000 OFFICER/MEMBER EXCLUDED? N H/A (Mandatory in NH) ) E.L.DISEASE EA EMPLOYE $- 1,000,000 H yes,describe under - DESCRIPTIONOFOPERATIONSbelow E.L.DISEASE'-POLICY LIMIT 1$1 1,000,000' . DESCRIPTION OF-0PERATIONsi LOCATIONS VEHICLES (ACORD-101,Additional Remarks Schedule,maybe attached If more apace is repaired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Boston City Hall THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN One City Hall Square ACCORDANCE WITH THE POLICY PROVISIONS. Boston,MA 02201 - AUTHORIZED REPRESENTATIVE A/ ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD . o • Fold,Then Detach Along All Perforations - f OMMON1NEdLTH:OF M9HUSEFTS w< r • • • • • - �h q. wry �Ry�' SF y s SHEET,Mf AL WbRl a .#ISSUES kE� .'OLLOWING LIOEEASA ,,• `- - . . . �« ' �5IER UNR,F ��I�TED (QIN J AMBROSINO � r",tYOTAL EMP�tRA�T`URE 6NTRL - INAKF�FIELb,,MA 01> S�LJ•F4 �" � � ° . ! . . - - y " 7592Y 28�121 �.� Fo id,Then Detach AIoh9 All Perforations- '" - ' .;:. -:• - �f�OMfIIONWEIfLTH'OFMiIYSE�TS , , • • • 1012 o r SHEE'�' ETAL WORRSxksr - ` . SU jrx - y„' HAL TEM L2'lkTURE m sQ 21Z>