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15 SCOTIA ST - BUILDING INSPECTION e57 Commonwealth of tNlassach I � usctts Sheet Metal Permit Permit tt Intimated Job Cost: S_ SOD _ Permit Pee: S Plans Submitted: YES _ NO_ Plans Reviewe(l: YES NO Business License !f _ 2-1 Fj Applicant License It ,5' 114 ( 3 J 46 13usineSS fntbri nation: Property Owner/Job Location Information: Name: l/ G-4 7 Co Name: f-I IL) I Street: 0 , Sox, Street: /.T— 9(2.0- iry - City/Town: Dx'g Y/T /79/J City/Town: Telephone: S 2'9 32 Telephone: `2 C/ 6 G 26i Photo I.D. required/ Copy of Photo I.D. attached: YES NO J-1 Ounrestricted license Slafr Ildual J-2/ M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. 11. / 2-stories or less Residential: 1-2 family 7 - Nlulti-Family_ Condo/ Townhouses Other Commercial: Office_ Retail_ industrial _ Educational Institutional Other— Square Footage: under 10,000 sq. tt. 6/ over 10,000 sq. tt. _ Number (if Stories: Sheet metal work to be completed: New Work: _6'1-�Renovation: I IVAC ;MeWl Watershed Routing_ Kitchen Exhaust System `fetal Chimney / Vents_ Air Balancing Provide detailed description of work to be done: INSURANCE COVERAGE: 1 have a current liabilityInsurance 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: / Other t El liability Insurance policy L�' 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 emby certify that all of the details and Information I have submitted(or entered)regarding this application are true and In compliancee ewbest ith alitpertinent provision of all shoot Metal work and Installations perfored under the perit Building Code and Chapter 112 of he Generaln ad for this application will be my knowlede and that Lawsu Duct Inspection required prior to insulation installation: YES_NO Progress Inspections Date Comments Final Inspection 111te Comments Type of License: By ., aster tale — ❑ Naste -Restricted i cmp io:•.n __._— Jour leyperson Signature of Licensee � I J urneyperson-Restricted I License Number.'I�m 1 Pau i -- -- ---- -- - - -- Check at .v:v_:r ut,c;s.•iw!�IL I i Inspector Signaturo of Permit Approval i CITY OF S U.E ,1, NL-1SSACHUSETTS BL'B.DING DEP.-tRTmEDiT p. 120 WASHINGTON STREET, 3}D FLOOR TFL. (978) 745-9595 F.ax(978) 740-9846 KI\tBERLEY DRISCOLL MAYOR TTi0A1As ST.PtFxR6 DIRECTOR OF PUBLIC PROPERTY/BUII.DIDIG C0'S6IfISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name (BusiixssOrganization/Individual): �t C�"T�� z L Address: City/State/Zip: !�/�46611- AN 01$-Ztf Phone It: SO 1S !J! -- 1 e 32 Are�you an employer?Check the appropriate box:. Type of project(required): 1.Bd't am a employer with 2 4. ❑ 1 am a general contractor and 1 6. Q-Ke—w construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These subcontractors have it. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition (No workeri comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL I i.❑ Plumbing repairs or additions myself. (No workers'camp. c. 152, ¢1(4),and we have no 12.❑ Roof repairs insurance required.)t employees.[No workers' comp. insurance required.) l3.❑ Other -Any applicant thud chucks box At must alw fill out the section below showing their workers'compensation policy inrurmatioe. t I b.euwwners who submit this aHldavid indicating they ate doing call work and then hire outside contractors mmu submit a new affidavit indicating such. =Contractor,that chuck this box must attached an additional sheet showing the name of the sub+contractom and their workers'comp.policy infomsition. l um ire employer that is providing workers'compensation insurance for my employees. Below Is the pollcy and fob site information. ,;?�Insurance Company Name: `GSC[Gdr 1.911.5' Policy 4 or Sclf-ins. Lie. d: U C- `7 Z G(,-. 3 6 e Expiration Date:— 2 �/10 /'3 �z � Job Site Address: f S J CnT-/!9 ST City/State/zip: _ 54%r�i✓1 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Fuilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. f do hereby certify wider the pains and penalties ofperfury that the hitforrrtatlon provided above is a and correct Sienaturc' Daro: / 2 tit / �r t P o e�: �o$ S a �J® 3 Z OJflriul use only. Do not trite in this urea,to be coatpleted by city or town afficiub City or 7bwn: Permit[License Issuing Authority(circle one): _ I. Board of licafth 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.01her._.. _.__ __ Contact Person: Phone#: A CERTIFICATE OF LIABILITY INSURANCE 11/19/2012MM DDIYVYY) 141 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 endorsement(s). PRODUCER CONTACT Andrea Gallagher NAME: Fred C. Inc. PHONE 9783227172 FAX 9784541865 41 Wellmanan Street AIC,No Ext (AIC,No): Lowell,.MA 01851 E-MAIL (800)225-1865 ADDRESS: agallagherQfredcchurch.[om INSURERIS)AFFORDING COVERAGE NAIC# INSURER A: Selective Insurance Company of the Southeast 39926 INSURED INSURER B: HEATCO.LLC INSURER C: PO Box 6T5 Dracut,MA 01826 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 21142 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 AGOL SUER POLICY EFF POLICY F.%P LIMITS LTR s POLICY NUMBER MMIDDI' MMIDDn'TTY GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X DAMAGE TO RENTED 100.000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurtence $ CLAIMS-MADE OCCUR MEDEXP(Anyoneperson) $ 10,000 A S1841598 2/2412012 2/2412013 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000.000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG $ 3,000.000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - Ea accitlent $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PerOaccitlenl AMAGE $ HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION % WC STATU- OTH- AND EMPLOYERS'LIABILITY R YIN ANY PROPRIETORIPARTNER/EXECUTIVE EL EACH ACCIDENT $ 10D,000 A OFFICERIMEMBER EXCLUDED? ❑ NIA WC7264366 2/24/2012 y242013 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE -� P Client* az5u9 Mat* 21142 Cert Holder# ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD