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96 SWAMPSCOTT RD - BUILDING INSPECTION (23)P� Commonwealth of Massachusetts Gr- 391 Fsg $31c� Sheet Metal Permit INSPECTIOfNAL SERVICES RECEIVED Date: S Permit#Estimated Job Cost: $ 1 0 .°D Permit Fee: �015 APR 3 LI A b: I b r Plans Submitted: YES_ NO Plans Reviewed: YES NO � I Business License# Applicant License# Business Information: Property Owner/Job Location Information: Name: _D0n0\ja0 SKttf M 1 TA Name: fGCp ULI I'�2`S l�J Y } �oojCle} I Street: ni 34 Street: q 5 m Ro city/Town:M add fi b \ i M A, City/Town: SW -1 Telephone: Telephone: 91F- 791- �uD Photo I.D. required/ Copy of Photo I.D. attached: YES V 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/Townhouses_ Other_ Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. _ over 10,000 sq. ft. Number of Stories: oZ Sheet metal work to be completed: New Work: Renovation: 14VAC Metal Watershed Roofing_ Kitchen Exhaust System Metal Chimney/ Vents_ Air Balancing_ Provide detailed description of work to be done: 3- f-ajl y (od-No Vv)its oy r ( A VckwSe a/ S�v.�-r Tb INSURANCE COVERAGE: —/ I have a current liabilityinsurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes f� No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy Q/ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 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 underthe 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/Town ❑Joumeyperson .Signature of.LicenSee Permit# ❑Joumeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.gov/dpl Inspector Signature of Permit Approval CITY OF S.U.EN1, ,tLkSSACHUSETTS • BUILDING DEPARTMENT 120 WASHINGTON STREET, 3w FLOOR TEL (978) 745-9595 FAX(978) 740-9846 (Q,%ffiFRi EY DRISCOLL MAYOR T HoMAs ST.Pmm DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CONMUSSIONF1t Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busim-&OrganizatioNindividual): �py10J9f1 S�1QQ f o �F Tnc Address: ✓rn UtoIS 3 �} City/State/zip: M i v-\ IAA Phone #: Arepu to employer?Cheek the appropriate box: Type of project(required): I.iJ 1 am a employer with Q- 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7• ❑ Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9• ❑ Building addition [No workers'comp, insurance 5. ❑ We are a corporation and its lo.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself.[Na workers comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.}t cmployees. [No workers' comp.insurance required./ 13.�Other V� Any applicant that checks box B I must also GII uui the section below slowing tboir workers'compemation policy information. 'I lomeown end who submit this affidavir indicating they one doing all work and them him outside commuors must submit a new affidavit indicating suck :Comm,non that check this box must attached an mlduiwal shexl showing the name of dhe sub-contractors and their workers'comp.policy information. I um an employer that is providing workers'c ompensadon insurance for my employees. Below Is the policy and fob site information. �n] / Insurance Company Name:—/if►tGuarf� �Cx& f rrseca iou Policy#or Self-ins.Lic.#:C ( � 17\A I CC ('\S q%Z Expiration Date: Job Site Address: - I(o JW0LNy-)S(1A4 FAO&d City/State/zip: (,�1004?-m Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations urthe DIA for insurance coverage verification. /do leereby certify sad he pulps and pertal!!es of perjury that the information provided above is true and correct m•t tr Date Phone#: OfAcial use only. Do not write in this area;to be completed by city or town offtcia[ City or Town: _ Permit/l.lecuse# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: .v 4'OMMONWEALTH OF MB SSA 'H[(S 9oA-w E SHEET-METAL WORKERS ISSUES THE FOLLOWING LICENSE AS A SUS1-NESS UAWRENCE R DONOVAN DONOVAµ; METAL INC 5 FORMS WAY wr U.NITS23:AND 4 'MIODLETgN a o194g,, `Q•COMMONWEALTH OF MASSAdHUSET IS - SHEEtW7ALWORKERS ISSUES .THE FOLLOW ING'J:ICENSE: AS:A MASTER UNRESTR)CTED i LAWRENCE R DONOVAN Mi` , 101 GRANVILLE LN NQRTH 'ANDOYER MA 0184 4�5 9 �01 7 1 0028/15 ^734; INS �St1cH 3TE P COMMERCIAL _ DRIVERS LICENSE Y� '1120 12 NONE $16a14872 '. IA ERN 9101 GRANVILLE LANE I/ N ANDOVER,MA 01845.4901 - A/// 5 PU 1b14RR Pev O1dSA09 r DATE '; CERTIFICATE OF LIABILITY INSURANCE 4/14/20015 1 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. N 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 endorsemen s). PRODUCER NCAME:CT Bill Cordaro Risk Strategies Company PHO� (781)986-4400 AX o 1791)963-4420 15 Pacella Park Drive EAIAI Spite 240 INSURE a AFFORDING COVERAGE NAICN Randolph MA 02368 INSURER AAmerican Fire and Casualty 4066 INSURED INSURERB:EXCeleior Ins Co 11045 Donovan Sheet Metal, Inc INSURERCAmGuard 42390 5 Forma Nay, Unit 3 & 4 INSURERD: INSURER E: Middleton MA 01949 INSURERF: COVERAGES CERTIFICATE NUMBER:Master 04032015 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 POLICY NUMBER POLICY FY M POLICY XP L M LIMITS GENERAL LIABILITY EACH OCCURRENCE - $ 1.1000,000 DAMAGE TO RENjhu X COMMERCIAL GENERALUABIUTY PREMISS a occurrencel $ 100,000 A CLAIMS-MADE FxJOCCUR BKO52998556 /3/2014 /3/2015 MED EXP(Any one person) $ 10,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POUCV PRO-JECT 7 LOC $ AUTOMOBILE LIABILITY a tlED SINGLELIMIT(Ea 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED M SCHEDULED 8413562 /3/2015 /3/2016 BODILY INJURY(Per accident) $ X AUTOS ALMOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOSAUTOS (Per accident) Uninsured motorist BI split limit $ UMBRELLA L L48 OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS=MADE AGGREGATE -3 DELI I I Rgrunoms Is C WORKERS COMPENSATION X WC STATU. OTF4 AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOWPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1 000 000 OFFlCERIMEMBER EXCLUDED? NIA $7C555998 9/10/2014 /10/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY UMIT $ 1,000 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more space is required) Evidence of insurance only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN IMBC, Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 11 Willow Road Ayer, MA 01432 AUTHORED REPRESENTATIVE Michael Christian/WMC �� '�-� ' ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(2o1Do5).o1 The ACORD name and logo are registered marks of ACORD