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1-15 TRADERS WAY - HVAC PERMIT - LONDI'S Commonwealth of INlassachusetts Sheet N[etal Permit I>atc: -�� Pcnnic # -- — — �o n Fmimatcd Job (b,t: 5_ Permit Fee: S (J flan, Submitted: YES NO flans Reviewed: YESS� NO Business License # Applicant License # Business Intbrntation: Property Owner/Job Location Information: Name: Name: G�o,/ S get"fH Street: o Sheet: /S' / ilv.r.�f City/Town: /ddi� City/Towni le /q S � (/1J' rciephone: Telephone: �T�� 4 Photo I.D. required/Copy of Photo I.D. attached: YES— NO surct�du:�n J-1 / M-I-unrestricted license J-2 / M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. It. / 2-stories or less Residential: 1-2 family_ Nfulti-ramily_ C'ondu/ Townhouses_ Other_ Commercial: Office_ Retail Industrial _ Educational_ Institutional Other Square Footage: under 10,000 sq. tt. _ over 10,000 sq. @. _ Number of Stories: Sheet metal work to be completed: New Work: _ Renovation: I rVAC jZ Metal Watershed Rooling_ Kitchen Exhaust System Metal Chimney/ Vents_. Air Balancing 1'1-0vide detailed description of work to be done: /� / YjSfi� ,/Cell INSURANCE COVERAGE: 1 I have a current liability insurance 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: 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 chocking 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 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 l� Progress Inspections Date Comments Final Inspection Data Comments Type of License: By_ ❑ Master vile_ ❑ Master-Restricted Cop To`vn ❑Journeyperson Signature of Licensee Pernul x ❑Journeyperson-Restricted License Number. Fee 5 "— ❑ — ---- Clleck al:v,r.v.m.c;s. lovhlL Z+ Inspector Signaturo of Permit Approval CITY OF S.1LEM, K�SSACHL'SE'FrS f BUILDING DEPARTMENT 3 9 Ti e Ir 120 WASHIENGTON STREET, 3'FLOOR T EL (978) 745-9595 FAx(978) 740.9846 KI\[BERLF-Y DRISCOLL MAYOR DIRECTOR Sr.PlFexs DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\IMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (13usinusv(Jrganizatiom'Individual): 0� Address: 77 City/State/zip: Phone N: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ 1 ani a sole proprietor or partner- listed on the attached sheet. ; 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, workers'comp. insurance. y. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation mid its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.[:] .❑ 1 am a liomeowncr doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself, [No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required] t employees. [No workers' cunap. insurance required.) 13.0 Other 'Any applicant-dice checks box NI must also fill not section bcluwshowing their workets'compensation Policy inn,rm"tic n. 'I hnneowrwa who submit this allidavit indicating Ihey are doing all work and then hire outside contmctars mtut sArnit anew alydaviI indicating such :('ontrwton IheI chock This box must attached an additinrci sheet showing Ilw mmnie of the subtemracton and their workers'comp,put icy infurmation. i ant an employer that is providing workers'compensation iesurancefor my employees, below Is the policy and Jab sire information. Insurance Company Name: ._..-_ "/ �✓ e�`�� Policy 4 or Self-ins. Lie, d: _ s pirationDate_e9(J Job Site Address//S'�'!Yl' - C Cta7-tes/p: ,Attach a copy of the svorhers'compensation poll declarat n page(showing the policy number and expiration data). . Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition ofcriminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the fbrm of u STOP WORK ORDER and aline of up to$230.00 a day against The violator. Be advised that a copy of this statement may be furwarded to the 0111ce of I it vest igudons of doe DIA for insurance coverage verification. I rho hereby eery y unde thely. wt mu ojper] shut the infurnutlen provide)ab�ve�is true iannddd corrrrecc'L Phone rJ: Official use only. Do not write its this area,to be completed by city of town o fftciut CirynrTuwnc _.____ __ Permit/Llcenseq Issuing Aulhorily (circle one): I. Board of Health 2. Building Deparinicut 3.Citylrown Clerk 4. Electrical (nspectur 5. Pinnlbing lnspector 6.Other Contact l'crson:_ _. [ •,/� REIDMEC-01 KRISTI ,4coR0" CERTIFICATE OF LIABILITY INSURANCE DATE(MM9/201 Y) 1 2/1 2013 3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ` BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endoreemen s. PRODUCER NAME:CT Connie Parent Elliot Whittier Insurance Services,LLC PHONE EI I:(978)977-4884 lac No):(976 977-0850 75 Sylvan Street Suite 8202 *AIL c aren elliotWhittier.c_om _ �_ Danvers,MA 01923 ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAICp INSURER A:Excelsior Insurance Co 11045 INSURED INSURER B:Peerless Insurance Co 2419$ _ Reid Mechanical INSURER C: 27 Charles St 1113 INSURER D: North Andover,MA 01845.1664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. IN SR TYPE OF INSURANCE Nq OBR POLICY NUMBER M DD/YYYY POLICY LIMITS TR GENERAL LIABILITY EACH OCCURRENCE_ $ 1,000,00 A X COMMERCIAL GENERAL LIA81LITY CBP8457320 0512312013 05I23/20114 PREMISE SS Ea occcurrence $ 100,00 CLAIMS-MADE XOCCUR NED EXP(Any One Person) $ 5,00 PERSONAL S ADV INJURY $ 1,000,00 GENERAL AGGREGATE S 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,00 X POLICY PROIFC- LOC $ AUTOMOBILE LIABILITY Ea emde COED t SINGLE LIMIT $ 1,000,00 B ANY AUTO, - BAS443664 0512312013 0512312014 BODILY INJURY(Per Person) $ ALL OWNED X X SCHEDULED BODILY INJURY(Per awdeM) $ AUTOS AUTOS NON-OWNED PROPERTY HIRED AUTOS PEACCIDN $ $ X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,00 g EXCESS LMe CLAIMS-MADEI CU8466428 05/2312013 06123/2014 AGGREGATE $ 2,000,00 DED I X I RETENTIONS 10,0001 $ 2,000,00 WORKERS COMPENSATION X WC STATU- OTH- ANDEMPLOYERS'LIABILITY RVLIMITS B ANY PROPRIETOWPARTNERIEXECUTIVEY I N NIA WC8468524 05/23/2013 0612312014 E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE IS500,00 It es OF s,ce.leeuntler DES OPERATIONS below E.L.DISEASE-POLICY LIMII" $ 600,00 DESCRIPTION OF OPERATIONS/LOCATIONSI VEHICLES (AKAeh ACORD 101•Addltlunal Ranarks Schedule,Nmoespaee lsrequlred) 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. AUTHORU:ED REPRESENTATIVE City of Salem, 120 Washington Street A iSalem.MA 01970 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD rt COMMONWEALTH OF MASSACHUSETTS SHEET METAL WORKERS AS A BUSINESS I ISSUES THE ABOVE LICENSE TO: - I I 3 JOHN C REI:1 REID MECHANICAL CORP 27' CHARLES 5T y NORTH ANDOVEI? MA .01845-0000 511 01:/29/14 160766' Fold,Then Detach Along All Perforations ~ r -COMMONWEALTH OF MASSACHUSETT SHEET METAL WORKERS AS A MASTER-UNRESTRICTED. ISSUES THE ABOVE LICENSE TO: - 10HN ' C. REIDto �v 1500 SALEM ST i NORTH ANDOVER MA 01845-491 -5806 11/28/14 28008 F "Fold,Then Detach Along AR Peicrations