16 SCOTIA ST - BUILDING INSPECTION (2) s
�\ Commonwealth of Massachusetts
Sheet Metal Permit
Date: _Vnq
'
j Permit ttI:,tim;ite lJob Cost: .S--- tL 0e _ Permit Pee: S
Pl;ms Submitted: YES _ NO_ Plans Reviewed: YES NO
Business License tt 2 j $ Applicant License t# 316 --
Business luliormation: Property Owner/Job Location Information:
Name: k1 CWTCo Z L G Name: ,Y1o"i Sv ��i ✓`P�
Street: / -O- Ix ( 7: Street: / ,5
City/'Town: L)jACUT, p�f oja6 City/Town:
Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES— NO
J-1 / rnrestricted license — Staff od�r:�r
Dbl
J-2/ NI-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. 11. / 2-stories or less
Residential: 1-2 family �Nlulti-family_ Condo/Townl7ouseS Other
Commercial: Office_ Retail_ industrial_ Educational
Institutional Other_
Square Footage: under 10,000 sq. R. er 10,000 sq. tt. _ Number of Stories: _
Sheet metal work to be completed: New Work: Renovation:
I IVAC / Metal Watershed Roofing _ Kitchen Exhaust System
Metal Chinuwy/ Vents_ Air Balancing
Provide detailed description of wor
k to be done:
ivl ln/ /�i� C�@cJT 92 / t'r -71- 2,v�_ C
,
INSURANCE COVERAGE: D
I have a current liabilityInsurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes Ly�No ❑
If you have checked Yes, indicate the type of coverage by checking the appropriate box below:
Other ❑ Bond El
A liability Insurance policy � type of indemnity
ensee does not have the Insurance coverage required by Chapter 112 of the
OWNER'S INSURANCE WAIVER: I am aware that the lic
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 hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and
ons performed under the prmit
In compliance with alltpmy knowlede and that ertinent prow sion of all sheet metal work and
Building Cods aind Chapter 112 of he Gener issued for this application will be
al Laws.
Duct inspection required prior to Insulation Installation: YES_NO
Progresslnspections
Date Comments
Final Insucctiou
Date Comments
Type of License:
By aster
tale _ ❑ %t aster.Restricted
i
en,:ro:•:n __ ❑Journeyperson Signature of Licensee
3❑Jaurneyparson-Restricted _ I
License Number:
Foe
_. L ------ Check at •�•v.ut.tss..luv'�IL
Inspvctor151q nature of Pcr royal ..-.
CITY OF Siu-&1,I, 1ANSSACHUSETTS
BUILDING DEPARTM&NT
120 WASHINGTON STREET, 31D FLOOR
TEL (978)745-9595
FA.x(973) 740-9844
KI.NfBFRT EEY DRISCOLL
MAYOR MONW ST-PMRM
DIRECTOR OF PUBLIC PROPERTY/BUIIDLNG CONMISSIONER
Workers' CotnpensatIon insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legibly
Name(BusilxS&Orpnizatiorvindividual): d c-47C O Z�<f
Address: A 6 /i h G 7 S
City/State/Zip: 924CO T, r1461726 Phone M: -5-0 8 ")ST /63 2
Are you an employer?Check the appropriate boat Type of project(required):
1.L�J'I am a employer with 3 4• Q 1 am a general contractor and 1 6. ❑Now construction
employees(full and/or Part-time).* have hired the sub-comnictors
2.❑ I am a sole proprietor or partner• listed on the attached sheet t 7• [3 Remodeling
ship and have no employees These sub•contmetors have U. (]Demolition
working for me In any capacity. workers'comp.Insurance. 9. 0 Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their
10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'camp. C. 152,y 1(4).and we have no 12.C1 Roof repairs
insurance required.)t employees.[No workers' IJ.❑Other
comp.insurance required.)
•Any a m ppllca that chuks beset mutt atru fill out the scclioe bclowshowing their worker'compeer eoloo polity inlormadom
r 1 hvnuuwrtrs who submit this affidavit indicating they am doing all work and Ihen litre"lsidecontmctrxs marl aabmll a new amdavil indicting ruck
=Conuxlun that cheek this box mart anachrd oat addillurd rhml showing na name of tho subaomrscton and their workors'comp.policy infonranon.
l are are employer that/s providing iverkers'compensadon lass rance jar my employees: Below Is the policy and fob ilia
information.
Insurance Company Name.
Pulicy A or Self-its. Lic. H: QC -7.26LA 3 i<G Expiration Date: -2
/
Job Site Address: �o sco Z/ City/State/Zip: )l9�G sLJ
Attach a copy of the workers'compensation policy declaration page(showing the polley number and expiration date).
Failure to secure coverage as required under Scclion 2$A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonmento as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a Jay against the violator. Ise advised that a copy of this statement may be forwarded to the Office of
Investigudu s of the DIA for insurance coverage verification.
l du hereby certify under the puins mrof It/ ajperJury that the inifannallon provided ubaver is sue and correct
iicn:lure. � � —) Moo: 12,31 / -
Phone i, S O — Cl5--6
x� 2
U/Jiriul use ratty. Do not write in rids area,to be completed by city up rawer a/prlud
Cityorruwm
- Permit/License d
Issuing Aulhorily(cirdo one): --` _---_-
1. Berard of health Z. Building Deparrncnl 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person: . Phone tie
f
f- - Fold,Then Detach Along All Petloratlone
COMMpryyyEA Ho MASSACMUSETTS
AD • . ..,
-� -
AS A,MASTER UNRESTRICTED
F �v s80kE 110ENSE 70
ETEPHEN P�, WEENEY V�
HEATCO . LLC
` DRACUT
b MA81826 h,
3
6
1316. �`"_:,c t .»s . 0 75
03%28%14
t � 129143
Fold,Then Dete - -
ch Along All PetloraYone
'* r G
_
AM FRED C CHURCH X .
978-454-18 65 PAGE 3
OF 3
ACiR,&
CERTIFICATE OF LIABILITY INSURANCE YYY) .
THIS CERTIFICATE IS ISSUED AS A MA DATE
CERTIFICATE DOES NOT AFFIRMATIVELY p OF INFORMATION ONLY AND CO
TE(Mneoon
_ IE1 NFERS NO Dwo3rzD'2
4 REPRESENTATIVE OR PRATE OF INSURANCE DOEESANOT CONlvCLT STITUTE
EXTEND OR ALTER THE COVERAGE
THE CERTIFICATE
r A ODUCER,AND THE C N TD, E A CON VERAGE AFFORD HOLDER. THIS
IMPORTANT: If the certifcate holder Is ER7IFICATE HOLDER. RACT BETWEEN THE ISSUING AFFORDED BY THE POLICIES
the terms and conditions of tha an ADDITIONAL INSU INSURER(S), AUTHORIZED
Carl holder in lieu of such enUo Semrtain policies m RED, the policy(ies) must be
ay require an entlorsemem, q sta$eme orsetl. If SUBROGATION IS Pretl c.Ch�,r:h,mc. m on this certificate does not,conl eEDnghts)to the
m '4 41 Wellman Seen,
- ' : �° Lpweil,M401661 O
'v
NAME: ArIdree Gallagher.f (800)2251865
PHONE 9783227172
„ i 9 E-MNL FAX 97845416fi5
m
ADDRESS: agallaghar�TetlhI C No
4` • `7¢ ` q INSURED
°; `s HEATCO,LLC INSURER(SJ AFFORDING COVERAGE
A,a INSURERA: Selective Insurance Company plme Soulheest
>r • NAIL f
A _ 3 PO Ber 675 INSUNa:RB: 39926
i a
+ Drawt,MA 01626
INSURER C.
P INSURER D:
COVERAGES INSURER E:
THIS IS TO CERTIFY CERTIFICATE NUMBER- 1 INSURER F:
TH k, AT TH ER.
r IND E PO
CATED. NOTyyITHS LICIES OF INSURAN
TANDING ANY REOUIREM CE LISTED BELOW HAVE BEEN ISSUED T REVISION NUMBER'
CERTIFICATE MAY BE ISSUED OR MAY P
EXCLUSIONS ENT, TERM OR CONDR O THE. .g AND CO ERTgIN T IOM OF INSURED
.. .. NDR HE I ANY NA
'st= ILTR IONS OF SUC NSURANCE AFFORDED CONTRACT OR OTHER D NAMED ABOVE FOR THE POLICY PERIOD
es , .e Lrn N POLICIES.LIMITS SHOWry Mqy HAVE B BY THE POLICIES DESCRIBED H�EUMENT WIT}t RESPECT TO WHICH THIS
w a TYPE OF INSURAN
v ' r a GENERAL LIABILITY EEN REDUCED BY Pglp CLAIMS. REIN IS SUBJECT TO ALL THE TERMS
POLICYNUMBER POLICY EFF X POL
ICY
M E ID %P
COMMERCIAL GENERAL L M
IABILI7V LIMITS
q CLAIMS�riADE � CCUR OCCURRENCE O EACH O
'D) $ 1,000,000
w w.
PREMISES Ea oaurrenca
51841696 MED EXP(Any one
2242012 2/2412013 person) $ DODO
GEN'L AGGREGATE LIMB APPLIES PER:
PERSONAL&qpV INJURY $ 1.000,000
A + ...F POLICY 7Coi GENERALAGGREGAiE $ 3,000000
I
� -� § -' AUTOMOBILE LIABILITY LOC
PRODUCTS-COMP,Op qGG $ 3000,OOD
N 3 LANYAUTO
.a :s ALI OV.NED $4 SCHEDULED acatlen
AUTOS
4> a IIREDAUTOS NONO0VrNED BODILY IN..URY(Parp.,I $
tKy_ BODILY IN,.URY(Par acadenl) $
UMBRELLA LIAR PROPERTY DAMAGE
OCCUR - Per accident $
IXDE$S LIAR
'. EY CI-AIMS-MADE $
"Y ¢ DED RETENTION$ EACH OCCURRENCE
p 'A*
- WORIMRS COMPENSATION $
e?&' "d. `+' _ AND EMPLOYERS LIABILITY
q ANY PROPRIETOR/PARTN Y/N
DER D9 AGGREGATE
OFFICE �/?aTIVE $
T 'T/`ey s •T." Needatory In NH)
. LUCE Li N/A % WLSTATU-
q $t . If Yes, anbe under WC7264366 V I OTH-
N' DESCRIPT ION OF OPERATIONS belmv 2R42012 EL.EACH ACCIDENT $ 1pD,00D
x 2/242013
Y
EL DISEASE-EA EMPLOYE $ 100.000
,
E.L.DISEASE- LIMIT 500 000 g
OESCRIPnON OFOPERATIONS/LOCATONS/
4r� 4 3 V@eCLES (Apaeh ACORp 101,A0dILIAnal Ramar%a ScheGule,I/more apace is MI >w:,�