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31 UPHAM ST - BUILDING INSPECTION O (3wb ?1 � Commonwealth of Massachusetts 3� CV Sheet Metal Permit INSPECTIONAL SERVICES Date: U 1 Permit ivj m zQ P?_on q \ Estimated Job Cost: $ S20O Permit Fee: $ !� Plans Submitted: YES _ NO Plans Reviewed: YES NO X Business License # 141 Applicant License # 2912 00 Business Information: Property Owner/Job Location Information: Name: Swampscott Refrigeration Inc Name: Maria Toomey Street: 163 Essex St Street: 31 Upham St City/Town: Lynn, Ma 01902 City/Town: Salem, Ma Telephone: 781-592-1519 Telephone: 978-744-6483 Photo I.D. required/ Copy of Photo I.D. attached: YES X 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 X Multi-family _ Condo /Townhouses_ Other_ Commercial: Office_ Retail_ Industrial Educational Institutional_ Other_ X Number of Stories: Square Footage: under 10 000 s . ft. over 10,000 s . ft. 9 g q q — Sheet metal work to be completed: New Work: Renovation: f HVAC X Metal Watershed Roofing Kitchen Exhaust System . Metal Chimney / Vents Air Balancing Provide detailed description of work to be done: Installation of one new gas forced hot air furnace and modification of ductwork. G(al�t_. i.�NGn ' fJONL 11 121{ GA L-Ltz o LA � . U i ,RAA Gr COVERAGE: ��— ,y have a current)!ability Insurance policy or its equivalent which meets the requiremgIhis of M.G.L. Ch. 112 so a No ❑ If you have checked Y�ra , indicate the type of coverage by checking the appropriate box below: A liability insurance policy ® Other type of indemnity ❑ I good ❑ OWNER'S,INSURANCE WAIVER: I am aware that the licensee yes not have the insu ance.coverage, require by Chapter 112 of the Massachusetts General Laws,and that my signature on this pennit application waiv this requirement. Check One Only Ov ner ❑ Age ❑ Signature of Owner or Owner's Agent ey checking this boxy,I hereby cortify that all of the details and information 1 have submitted or entered)regarding this pplieahon am true and accurate to the beat of my knowledge and that all sheet metalwork and installations performed under the pormlt Isnued fo this application will he in compliance with sll pertinent provlslon of the Massachusetts Building code and Chapter 112 of the General Lawa. Duct inspection required prior to Insulation installation: YES ..� NO Progress Inspections Date Comments I Final Ins ection j Date Comments Type of License: By ❑Master 1'il!e ❑ Master-Restricted City/Town --.�rdr=- 7 ❑Journeyperson pormlt a' I Signature of Licen ee ❑JournaypersornRestricted " rocs ❑ License Nurr>ber �1 / I Check at .mass. ovld I Inspector Signature of Permit Approval I INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes a 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 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 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 PCOECess Inspections Date Comments Final Inspection Date Comments Type of License: By ❑ Master Title ❑ Master-Restricted city/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.gov/dpl I Inspector Signature of Permit Approval 09/26,'2014 09:31 FAX 978 512 2217 CROSSIINSURANCE CJ001 I i CERTIFICATE OF LABILITY INSURANCE 1 $/26/2 Q 01426/2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION C NLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE)HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AME MD, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONST TUTE A CONTRACT BETWEEN THE ISSUING INSURER(S 1, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDE L IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, Ihe policy(ies) must be Endorsed- If SUBROGATION IS WAIVED.subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not Confer rights to the certifleate holder in lieu of such endorsemen s . PRODUCER AME T Lauren Goldman Cross Insurance-Peabody PHONE (976)S9Z-S445 P' . l 701532-2417 139 Lynnfield Street E-MAIL ,lgoldman@crossagency.com INSURERS AFFORDING COVERAGE NAICI Peabody MA 01960 WSUReRAAmerican States Ins Co 19704 INSURED INSURER Citatign Ins Co MA on;.y 40274 SWAMPSCOTT REFRIGERATION INC INSURER C'Oh i 0 S 0 CUri ty Ina Co 24082 103 FSS X ST INSURERO INSURER E LYNN MA 01902 WSURERF: COVERAGES CERTIFICATE NUMBER'CL1A72 15166 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELO HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONOI ION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC r TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AF ROED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY AVE BEEN REDUCED BY PAID CLAIMS. wool UBft POLICY EFF POLICY E%P LTR TYPE OF INSURANCE POLICY NUMBER MM/DOn OMITS GENERAL LIABILITY EACH OCCURRENCE 1,000,000 PR " Nu rcBnee 200,000 R COMMERCIAL GENERAL JA81ITY �e�pce A CLAIMS-MADE a]OCCUROICG82734300 /Ys/2014 /15/2015 MED E%PAPy one oerean) 10,000 PERSONAL$ADV INJURY 1,000,000 GENERAL AGGREGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO 6 2,000,000 X POLICY PRO- LOC COMBINED SINGLE LIMI AUTOMOBILE LIABILITY I. Ea acridem IS BODILY INJURY(Per peredn) t 500,000 ANYAUTO B ALL OWNED X SCHULED 4NMCRSZW III 4/12/7014 4/12/2015 BODILY INJURY(Per acdden) $ 1 000 000 A ED NON-OWNED PROPERTY AM/1GE g 100 OOO X HIRED AUTOS X AUTOS � Medical cols S $ 000 UMBREL JAB OCCUR EACH OCCURRENCE I EXCESS LIAe CLAIMS-MADE AGGREGATE S DEO IRETENTION$ WC STATU- OTH-15 C WORKER$COMPENSATON AND EMPLOYERS'LIAe1UTY Y I N AM PROPRIETMPARTNERIEXECUTIVE❑ NIA E,L.EACH ACCIDENT $ SOO OOO OFRCERIMEMBER EXCLUDED? SS5654132 ( /28/2914 /29/2015 E,L 015EASE-EA EMPLOYE S 500,000 IMendeldry m NMI IFYY0 dpTo1.9 under E.L DISEASE-POLICY LIMIT S 500 000 DESCRIPTION OP OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATONSI VEHICLES (AHaCh ACORD lei,Adwlio-R mane SChedUla,if more spaco Is rPRWre4) Refer to policy for exclusionary endorsements an special provisions. i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES FIE C NCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL E DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Salem 120 Washington St AUTHORIZED REPRESENTATIVE Salem, MA 01970 Timothy Tramonte/NDI 1HY > d• ACORD 26(2010106) 01980-2010 ACORD CORPORATION. All rights reserved. INS025(xoi0os).m The ACORD name and loo are registered marks of ACORD AS Ms sA LusE `~ DIVER' N + idn' ��g20i2s9�NONE EN ra eumreea 77 C � ; ?✓(P F.G�y ai _ SGU9925[5-. it t 195z I V q7 � e WAMPSCOR t MA 01907-1044 5 W fld51pl2 Hev 0].fSp09 I Foi,Tnen Delach Alono A'.?=Aorzrbns COMMONWEALTH OF MASSACHUSrTTS BOARD SHEET METAL WORKERS SM AS A BUSINESS ISSUES THE ABOVE ;CENSE TYPE JAMES V CARONE SWAMPSCOTT REFRIGERATION INC -B 163 ESSEX ST LYNN MA 01902-0000 289245 141 12/06/14 289245 Fold,Then Detach,Along All Perforations 0 MMO.N VtALTH�OF MA SAC® ® ® . � s fi•+,�, i' '�i�`iv rP�'' BQARD"C!Fyx ,., a a � SHET�MEzpL� WORKE42S 9 � �k �iS nUES T 0 L04ylt�G L h�ENQ AS�A��ST�EF�,,�UN=�R�T,R>I"rTED f SWAMPS CO N . , RT'f��R'E'FR�f�iE�Rgr�1'i3ON "rz��: . u763tESSElAtk, � LYNNj r 4> SMAOt19,Q2° 96 - .'