96 SWAMPSCOTT RD - BUILDING INSPECTION (32) Commonwealth of Massachusetts 55 Grp Si
Sheet Metal Permit c`-r 435Z-1 I
Date: r�Z41)-�- RE r %I , nCFS
1NSPECTIUt���- -A
Estimated Job Cost: $ `- R YJ 1 Permit Fee: $
Plans Submitted: YES_ NO All R viewed: YEES NO
M Business License# t t Applicant License# '1`I 5'1
Business Information: Property Owner/Job Location Information:
GU V 9-
Name: ee-VfnzAtil S:gskem T
�} � DC'J� n Sn� Name: Co0lC�vel,n,�A-Yirt.,.
6� Street: 11 �{D?ctinl ,i 12c� Street: 131 SwFnnscctF (LC, U l
City/Town: er«s City/Town: `AQ
Telephone:g h3—Uo5-719 Telephone:
Photo I.D. required/Copy of Photo I.D.attached: YES-)�_ 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:
Sheet metal work to be completed: New Work: Renovation:_
HVAC_ Metal Watershed Roofing_ Kitchen Exhaust System_
Metal Chimney/Vents_ Air Balancing
Provide detailed description of work to be done:
N1P.
7 d i6
Sheep tmetal Systems & Design,Inc.
- HVAC/Sheet Metal Contracting
Richard Harlow
President
77 Alexander Rd Unit 3
Billerica MA 01821
Office:(978)663-7781
Cell: (978)808-7175 -
Fax: (978)663-5521
Rich@sheetmetalsystemsinc.com
OMMONWEALTH OF &L S ;
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ISSUES THE FOLLOW IAG1IUNSE
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RIFD W HARLOW a'
;'•SHEE METAlalE1►S AND O,gSIGN yl
77 ALE; ' RD p i
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INSURANCE COVERAGE:
.I'have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 YesXNo❑
tl 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 Owners Agent
By checking this box[],1 hereby cenHy that all of the details and Information I have submitted(or entered)regarding this application are true and
accurate to the beat 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 PfMaster
Title ❑Master-Restricted t.,)
Cityffmn ❑Joumeyperson
Signature of Licensee
Permit 0
❑Journey -Restricted License Number:
Fee$
6 Check at www.mass.00v/dPI
Inspector Signature of Permit Approval
07/22/2015 10:22 FAX 781 942 2226 GILBERT Z 001
I I
A CERTIFICATE OF LIABILITY INSURANCE ' �,izz/zolsn
TOIS 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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(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 an this certificate does not confor rights to the
cert36cate holder In Ilau of such endarsament(s).
PRODUCER N TDawn Cram, CIC, CISR
SlAME•
Gilbert Insurance Agency, Inc. PHONE NA '(791)942-2226
137 main Street EMAIL AbDRFSS:dcraJe@gilba a rtinsurnce.com
INSYR 8 APP0110010 COVERAGE NA169
Reading MA 01867-3922 INSURERA:R® ubliC Franklin Ins Cc 12475
INSURED INSURERB:Grnh1.0 Arts Mutual Ins CO 25984
shoat Metal Systems 6 Design I INSURERC:Utiea National ASSCIranCa Co 10687
77 Aloxandar Rdr Unit 93 INSYRER O: —
INSURER
Sillerica HA 01821 INSURER F:
COVERAGES CERTIFICATE NUMBER:15-16 MASTER 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 AWL BUSH TYPE OF INSURANCE POLICY NUMBER POLICYEFF L�IY41E1{f—
TR LIMn6
R GOMMERCIALGENERALLIABIDTY EACH OCCURRENCE s 1,000,000
A CLAIMS-MADE OCCUR PR M REMISES(EA o rc"AM 6 300,000
CPP4457099 7/15/2015 7/15/2026 MED EXP(Any one person) S 5,000
PERSONAL&ADVINJURY S 1,000,000
GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 2,000,000
X POLICY❑7E'C'T F LOC PRODUCTS-COMPIOP AGG S -_2,0000000
OTHER. 5
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5 1,000,000
R ANY AUTO BODILY INJURY(Per pereon) $
AUTOS ALL E0 X AUTOSY�D AAC4457901 7/15/2015 7/13/2016 BODILY INJURY(Per ecommu $
X HIRED AUTOS X NOWOWNGO PROPERTY DAMAGE $
AUTOS Per.Adenl
UNrnumd mclerizl 91s it limit S
UMBRELLA UAS OCCUR EACH OCCURRENCE $
EXCESS LIAP CLAIMSIIA➢E AGGREGATE S
mo-71 RETENTION 5 S
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN $TAME .
ANY PROPRIUOWPARTNEREXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ 500,000
C (Manaawry mDEIn NH)EXCLUDE07 4447960 7/3S/2015 7/1$/2016 E.L.DISEASE-CA EMPLOYE E 300,000
If ye4 deecibe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY MIT S 500 000
DESCRIPTION OF OPE nON51 LOCATIONS I VEHICLES (ACORD 101,AddlNonal Remarks SeMdule.maybe enacted If more"ae9 Is Rg411,94)
CERTIFICATE HOLDER CANCELLATION
(978)740-9846
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City Hall ACCORDANCE WITH THE POLICY PROVISIONS.
Salem, NSA 01970
AUTHORIZED REPRESENTATIVE
M Gilbert, CIC/DAWN �G
C)1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025(2olaol)