60 WASHINGTON ST - BUILDING INSPECTION (10) ` Gam. Z31 b�
mmonwealth of Massachusetts
CJ Sheet Metal Permitpow,�)
Date: Permit# 201b DEC - I P 4' 11
I 60
Estimated Job Cost: $ 1.2 4'0 d f d/ Permit Fee:$ I JZ
Plans Submitted: YES_ooNO Z Plans Reviewed: YES_ NO_
Business License# d Applicant License# 3 9Q
Business Information: Property Owner/Job Location Information:
Name: T+,0A Xr 556-fern,�% ZJVC. Name:�1�hQ.�q
Street: YYlap1#- Strtet Street: to L3
Cityrrown: Nqui yy M o_i<9a3 Cityirown: ekn
Telephone: 47 a 777 — -1619 Telephone:
Photo I.D.required/Copy of Photo I.D.attached: YES A— NO
sr rtlotwt
J 1 /4 trestricted license
J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. 8./2-stories or less
Residential: I-2 family_ /Multi-family_ Condo/Townhouses. Other—
Commercial: Office V Retail Industrial Educational
Institutional_ Other_
Square Footage: under I0,000 sq. ft U� 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:
�Q-fJ\�_vr�X _-A- �C
i
I
INSURANCE COVERAGE:
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 in.aurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the nsee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that sign n this permit application waives this requirement.
Check One Only
Owner ❑ AgentX
Signature of Owner or Owners Agent
By checking this bo i hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and
accurate to the be of 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
Proeress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By Master
Title
❑Master-Restricted
Cityrrown ❑Joumeyperson
Signature of Licensee
Permit#
❑Joumeyperson-Restricted
License Number.
Fee$ ❑
Check at www.mass.gov/dol
Inspector Signature of Permit Approval
i CITY OF S. .E 9 �iL�SS.�CHI SETTS
B1:ILD4NG DEPARTMENT
• 120 WASmINGTON STREET,r FLOOR
dj TFL (978) 745-9595
7 7 FAx(9 S) 40-
9846
KIJiBERLEY DRISCOLL
a14AYOR THoMAs ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information \ 'I/�1 C Please Print Le ibly
Name(Business,OrganizatioNindtiiddual): 11e C Yl Y i� r JL•
Address: V�Ca ` ' , C`C-%��P_ • q
City/State/Zip c_N�rer S (11� O\°i�� Phone#: C[ c VA11`) _rl G 1
Are ygu an employer?Check the appropriate box: Type of project(required):
1. I am a employer with �— 4. ❑ I am a genLml contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ I am 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. 9, []Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.ElI am a homeowner 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.❑Roof repairs
insurance required.]t employees. [No workers' !3.[�Ether \V A C
comp. insurance required.]
•Any applicant that checks box At most alw till out the section below slowing their worketa'compensation policy information.
t I inmeownen who submit this affidavit indicating they am doing all work and then him outside corttmemns most submit a new affidavit indicating such.
:Contmeton that check this box most attached an additional sheet showing the name of the sub-camnectws and their workeo'comp.policy infotmaion.
I um an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
information. \' 1 \ t
Insurance Company Name: f�'t=. e'.d\'�. �. �1 1p r¢I S t- 0,,� 0ft
Policy 0 or Self-ins.Lic.#: 2 1 1 b )A U G 3 Expiration Date: "'L` ac A-1
Job Site Address: City/State/Zip:
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 of the DIA for insurance coverage veritica' n.
I do hereby certify under tI nd per f perjury that the information provided aboveeiis��tru /nd correeL
. i gnat ne• t-�9� ei Date: /� JV /4
Phone X: ���- 1. \ -�GL `
Ojjleial use only. Do trot write in this area,to be completed by city or town nJreiaL
City or"rown: PermitlLicense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: ____ Phone#:
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to 1 r 1 : ' 1certificate no. : : ebilbence1 practice
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In -sestim6upI 1affixab 1the ftecutibe Ovedor1 (P 1 : a
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October 21, 2010
<27 COMMONWMTH OF BRA- At31i08ETTS
qy -
SHEEfAlETAL WORKERS--,"Ix �r
` {ISSUES THE FOLLONING LICENSE AS Al V f�-` _ — •
_ \
MASTER UNRE3TRCeTED
F v f c \ 1 • \l
PETER M ZAGOR$' \
359, SBURYST. ,`
SHAMIL,TON MA 019821307s
3199 16736 v ,`\\ _ ,. . .•4.
Fold,Then Detach Along All Perforations
a GOMMONWEALTt1 OF M"CIiISETf
« � s s - •
s m SHEET METALWORKERS
r;
ISSUES THE:FOLLOWING00twSE
s ` BUSINESS. ?� V
PETER M ZAGORSKI a
z
� e
ECy-AIR SYSTEMS INC w
156 MAPLE STREET " 'N
DANVERS,MA 01923 -
J
82 Ap
10t1412018 166626
uA
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' CASELLA WASTE SYSTEMS,INC INVOICE
F� ti PO BOX 1372
WILLISTON,VT 05495-1372 SERVICE ADDRESS
156 MAPLE ST
CUSTOMER NUMBER 79-07766 1 PAGE 1 of 1
INVOICE# 2859358 TECH AIR SYSTEMS
BILLING INQUIRIES(800)445-1318 DANVERS MA 01923
INVOICE DATE 11/01/16
DATE DESCRIPTION QTY. RATE TOTAL
10/31/16 8YD FL 1 X.MTH TRASH. # P/U: 01 - 1.00 - - - - 104.00 -
- --- TOTAL TAXES AND FEES --- -
- Total Fuel/Oil Fee: .00
Total Sustainability/Recycling Adj . Fee: 5.21
For info on Sustainability/Recycling. Adj - -
Fee: Visit casella.com/sra
Air X
m
S
652306A
FOR SERVICE DURING NOVEMBER
PAY THIS AMOUNT
$109.21
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ram lzl'1 i F"PMM&MM
DUMSUMME
Q'A� t/IatasaaGadoawane�
CO/lSITUL'M%O/T Debris Disposa/Affiid17W
(required forall demolition andrenovation work)
in amide a wo d►e skm edition of the State haft-Code,. MOM% Sudw 111.SDebllj
and the womms of AWL coo,S 54;Ih"w Pem* is Uxod with the
con"On that the debris r+e"ft from this workshe#be dkpand of in a properly fte med
Waste deposit f 19Y as deft ed by A46L c 111,S 15K
'The debris will be transported bi
(name of hauler)
The debris will be disposed of In:
(name of fadl
(address offadlity)
Signature of applicant
Date
DEC-01-2016 04 :42 PM Tech Air Systems INC. 978 777 7689 P. 02
6 Vr LSmamj I e n�we�rter.vr
THIS CERTIFICATE IS ISSUED AS A R OF INFORMATION ONLY AND CODERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY ji NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS
CERTIFICATE OF INSURANCE DOER NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR
PRODUCNR,AND THE CERTIFlCAT[NOLDE
IMPORTANT: N#10 MURCdR holdRr Is an JIDDITIONAL INSURED,"PONCypaE)must be addnrseA.IT SUBROGATION IS WAIVED,:uRloct t0 the terms
and 0wwftBIM of(tw policy,owtdD pdldOMW MON IM RNtlsTsaRnR.A Mahe n On this arB1MRb doss not DRIMar HON1 to On CartHH ds holder
in lieu of Pic"
PRODUCIR a ACT
FEDERATED MUTUAL INSURANCE COMPANY oxR� FAR
HOME OFFICE:P.O.BOX 323 a MAN.
OWATONNA.MN SSM
MMURM AFFORqM 2MAOS NMCP
NmmitAt FEDERATED MUTUAL INSURANCE COMPANY 13M
INSURED 36 INSURER BI
TECH-AIR SYSTEMS INC INSURER a
1E8 MAPLE OT Insonen m
DANVERS,MA OIM
INSURER C
INSURER R
COVERAGES Ce RTIPIIJ ATE NUMBER:ED REVISION NUMBER:0
THIS 18 TO CERTIFY THAT THE POUCIBB 01 INSURANCE URTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIRE POUCY PERIOD
INDICATED, NOTWITHSTANDING ANY A 11 RMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATe MAY BE ISSUED OR MAY RTAI 1.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,MCCIAZIONS
AND CONDITIONS OF SUCH POLICIES.LIMITS 1 4OWN MAY HAVE SEEN RODUC90 BY PAID CLAIMS.
ME Of INSURANCE Me POLICY NUMBER LIMITa
X C MMSRCIALOMMALUABIUTT EACH OCCURRENCE $1411001000
TO aNTID $100,000
etaxa•MAOI Q OCWR MID EEP IAre ON onsold EXCLUDED
A Y N >804802 Os/28R016 01n8r7017 Pano"L S AOV MauRT $1,000.000
AO UNITAPLISS PIRI OENLRAL AOORWATE A0001000
X POLICY ICJ IIm ❑Lac nMDUM-COW roP AM $1,ODDA00
OTKM
AUTOMOBILE LIABILITY MBINeD MNORI LRArt $1,000,0D0
X ANY AUTO GODLY MAMY IParFN"N1
A AALTO$NRD AAUUITOtl$OlaO N, N 9BOSW4 04/2912018 OWSMOIT ROWLY ammo IPorATdew11
HUMDRUM ATS ED TY i
AUTOS
UMSM�LIAI OWUR RAGI OOCLOUISM
EICaaS LIAR C4UMR+MM[ AeORWATS
M I I RETENTION
WOMMM COMPENSATION X RR erATvrE
ARID EMPLOVOW LIABILITY LL SUCH ACCIDENT $300.D00
ANY PRWRMTORMARTNERNfEICUTIVE NI N 98048IX3 04/2812010 04l29/201T
A ORRORMMEMSRaRXCWDIIdI LLDMwa-RAEMPLOVaa $60D,D00
MarAh t,IFM RHI
__ n LR OVA[—..._ ..._ .._. .. .. ... - .... .. .. 'LLL pMROREwPOIJtry LMNT .._....._.. •S5l1U,D� .
oXdll oR m aareRAlldeR LetelP
DESCRIPTION OF OPERATIONS I LOCATIONS I ZZLIR( Sob ACORO 101,ASdSRNI RalmotR SdNddA It IIRn VAN IR MW NI
TNII CERTIFICATE HDLDot IS AN AD= MAL INSURED SUBJECT TO THE CONDITIONS OF THE ADDITL'ONAL INESURED BY CONTRACT
ENDDRSENENT FOR MMU ESSDNNERS LIN ILITY.
CERTIFICATE HOLDER CANCELLATION
0
SHOULD ANY OF THE ABOVE pESCRIBI3)POLICIES BE CANCELUA BEFORE
THE gXpIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AVTNCRMED RIPReaaNTATIV!
0 I1111104D14 ACORD CORPORATION.AN it"reserved.
AOORD 25(2014101) nm ACORD NO and lop an rOBISIEN mRIRS of ACORD