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3 WINTER ST - BUILDING INSPECTION (3) Commonwealth of Massachusetts ct� 1 6Z3 '5 1 ( 5 Sheet Metal Permit t Date: 94(F115-1141 Permit# 06 Estimated Job Cost: $�� A()n' Permit Fee: $ i Plans Submitted: YES_ NO_ Plans Reviewed: YES_ NO Business License# 44013 Applicant License# Business Information: l7{� Property Owner//Job Location I/nformation: Name:PVC y pfVl'� /V- 14Cr Name: �j�./(/!�/may Street:'/o/ �O/2 t 4iq 5 Street:`- /,f/_l/al e'e- � City/Town:JD�>/r? �� City/Toww, G eM 76 Telephone: 9`/Q- �5�-��g� Telephone: Photo I.D.required/Copy of Photo I.D. attached: YES_ NO_ Staff Initial J-1 M-1-unrestricted licensse 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 rn r•m a . c-) Institutional Other c) or^ N Zrn Square Footage: under 10,000 sq. ft. Y.over 10,000 sq. ft._ Number of Stories:-j �m N mC3 Sheet metal work to be completed: New Work: _ Renovation: _ by c� HVAC Metal Watershed Roofing_ Kitchen Exhaust System_ — N - Metal Chimney/Vents_ Air Balancing Provide detailed description of work to be done: nn Px i lit=n �� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street i Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/tildividual): /�J/ Address: 4(a City/State/Zip: �2 hone #: Jr - 2 Are you an employer? Check the appropriate box: Type of project(required): I. I am a employer with 15- 4. ❑ I am a general contractor and I 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 g. Demolition employees and have workers' working forme in any capacity. 9. ❑ Building addition [No workers' comp.insurance comp• insurances required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs of additions q ] 3. I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions ❑ myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13. Other /t_e✓ 7 v comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hive outside contractors must submit new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors-have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name:/Z �1 R olicy#9r Self-ins.Lic. #: /,{/ V��+� �J� Expiration Date: i%d C)/t A Job Site Address& IV IA17- CX U� • City/State/Zip: gaileI;��; F'[C j� U 97V 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$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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerk;fy under the pa' and penalties of perjury that the information provided above is trueand correct Signature,: Date: t-9 0 Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: INSURANCE COVERAGE: t I have a current liability insurance policy or Its equivalent which meets the requirements of M.G.L.Ch.112 Yes No❑ B you have checked Yes.indicate the type of coverageby checking the appropriate box below: A liabiltty insurance pol(cyv Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not the Insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Sign a of Owner or Owner's Agent By checking this box[],I hereby certify that all of the details and Information have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit issued for this appikation will be In compliance with all pertinent provision of the Massachusetts Building Code andChapter 112 of the General Laws. Duct Inspection required prior to Insulation Installation: YES_NO Proeress Inspections Date Comments t , Final Inspection Date Comments Type of License: BY ❑ Master rme ❑Master-Restricted r Ctyrrown ❑Joumeyperson Signature of Licensee Permit e I ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.00v/dpt Inspector Signature of•Permit Approval PREFE-2 OP ID: KS1 'MMI°°""`"' CERTIFICATE OF LIABILITY INSURANCE 08101/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS-NO RIGHTS UPON THE CERTIFICATE HOLDEF. 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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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 endorsement(s). PRO GA Cross Insurance,Inc.ER TGA 781.914-1000 CONTACT Kelly Sturtevant PHONE --'-- 401 Edgewater Place,Suite 220 a .781-914-1000 Wakefield,MA01880 E-EWL - - �No:781-246-2601 Chris Hawthorne ADDRESS: kstu_rtevant@tgacross.com_ -_.-. INSURER(S)AFFORDING COVERAGE _ —_ NAIC0 INSURER A:Arttlla Protecllon Ina.Co. 41360 INSUREDre Preferred Air,Inc. _----------------- 461 Boston Street Unit A3 INSURER B: Topsfleld,MA 01983 INSURER C: INSURER D: NSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE-INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, REMENT; TERM OR CONDITION CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDEDD .ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISBY 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 EFF POLICY EXP _ _ ----- POLICYNUMBER MMM MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE ___ E 1,000,00 A X COMMERCIAL GENERAL LIABILITY B600025668 08/01114 061011i6 _DAQ RENTED PREMISES omma�_ E_ 300,00 CLAIMS-MADE EK OCCUR MED EXP(Any one person) E 15,000 PERSONAL S ADV INJURY $ 11000,00 GENERAL AGGREGATE S 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,060,000 POLICY EXI PRO- LOC S AUTOMOBILE IIABIDTY COMBINED SINGLE LIMIT Ea accJdent____—_ E 1,000,00 A ANY AUTO 1020003133 08101114 08101116 BODILY INJURY(Per person) E AA ED X SCHEDULED -------- -- — AUTOS BODILY INJURY(Per actltlenl) E NON-0WNED X MIRED AU OS X AUTOS PROPER YDAMAGE _ E J( UMBRELLA UAB X OCCUR EACHO_CCURRE_NCE E 2,000,00 A EKCEss LIAs CLAIMS-MADE #ISSU00 647 08101114 08101115 AGGREGATE __ E 2,000,00 DED X RETENTIONS 10.000 _ WORKERS COMPENSATION VJC STATU- OTH- AND EMPLOYERS'LIABILITY _—tTORY,LIMITSAu- _.__ ER ANY PROPRIETOR/PARTNERIEXECUTIVEY� ECTLY FROM El A_C_CI_DENT___I_E_ _ OFFICERAEMBER EXCLUDED? NIA F _ _ t (Mandatory In NH) THE CARRIER E.L.DISEASE- II yyaaa,tleeWOe uMar _ EA EMPLOYE S DESCRIPTION OFOPERATIONS.Iow E.L.DISEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Pasch ACORD 101,Additional RemaMs Schedule,N more space is required) CERTIFICATE HOLDER CANCELLATION CITYSAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE LFax: em THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 40-9846ngton Street,3rd FI. AUTHnnORzeDREPRESENraTWE 01970 4ZAAA� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD u, THIS CERTI M 8115120141 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BV 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 cerURcate holtler le en ADDITIONAL INSURED,the policy(lea)moat be entloreetl. If SUBROGATION IS WAIVED,subject to the tome and conditions of the policy,certain policies may require an entloreement A statement on thle c rtlFlcate does not confer rtghta to the certiFlcate holder In lieu of such endoreements(a) PRODUCER CONTACT TGA Cross Insurance,It C. PHONE (AlC,No,Ezp -1 OOO (Z N0:) (781)224-5577 401 Edgewater Drive,Suite 220 E-MAIL Wakefield,MA 01880 ADDRESS: PRODUCER INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Atlantic Charter Insurance Company VDAC 44326 Preferred Air,Inc. INSURER B. INSURER C: 461 Boston Street,Unit A3 INSURER D: Topsffeld,MA 01983 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 60CUMENT 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 POOL SUER POLICYNUMSER POLICY EFFECTIVE POLICY EMPIRATION LIMITS LTR INSR VNO DATE(MMIODIYY) GATE(MMIDDJYIT (In ThOYYnd) GENERAL LABILITY CHOCWRRENCE $ WMMEROALGENERALUABIUW DAME RO WPD PREMISES $ CWMSMNDE ❑ OCCUR ❑❑ MEa E%P(Anyone penm) $ RSO AAWINJUW S GENERALAGGREGATE 3 OFM AGGREGATE OMIT"KIES PER: ROWCTS.COMPIOPgGG f PoLILY ❑PROJECT ❑WL AUTOMOBILE LABILITY COMBINED SNGLE LIMIT ANY AUTO (Ee AWd ) f ALLOVMEDAMTOS ❑❑ BODILY INJURY rya prawn) $ SCHEDULED ALTOS BODILY INJURY $ HiREDPllf09 (Ea MdEwn PROPERTY DAMAGE f NONL ED AUTOS (Ee AWUem) AEMMOYMS' MBRELIA ❑ OCCUR eRMIN EACH OCCURRENCE S LESS LAB❑ CLAMSMADE AGGREGATE f DUCTIBLE ❑❑ S f ENTION' $ WER MAP LITY AND WCV00971103 08/01/2014 08/01/2015 7( STATUTORY OTHER fLYINLIMITSMcI MEMMBBEREXLLUDEDi N NIA ❑ Policy Coverage State:MA EACH ACCIDENT $ 1,000,000 Ifm.dnwlG YMe SPEUY PROVISIONS below pIBEA$E-POLICY LIMIT 3 I,000,000 DISEASE-EACH EMPLOYEE S I,000,000 OTHER ❑❑ DESCRIPTION OF OPBIATIONS&OC4TON9NEHICLE1(A.M ACORD 101.Addltlon.1 RMmMks Schedule,B more spew is ROujn ) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Salem EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 120 Washington Streeet,3rd Floor 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. Salem,MA 01970 BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS �AGENTS O.�R�REPRESENTATIVES. UTHORIZEO REPRESENTATIVE /FV'w/YUe+w AGE✓✓en. ACORD SS(20DN09) Page 74 of 104 CERTIFICATE HOLDER COPY 01988-2009 ACORD CORPORATION. All rights reserved. M ASS H IT)SETTS p DRIVERS �— � ; LICENSES ;ass T.e M 4e nur M 92 2013" r-RE S19539973 x� a a�zoaa 09101959 b B* �s srx M� mxsr 6104 ,SMITH ^ 2R08ERTV s 18 LESLIE ROW[EY,MA 819W2718 kGOMMONWEALTH OF M SSACIiUSETTS • • • • • • • ' tea x-s BOIAR6QF n � ,SHE METAL tVORORS , ISSUES pTHE FOLLOWIG LI@ENSEJ ° MAS TER ASTER UNRESTRICTED v . .. _ ROBERT V SMITH a .' 15 LESLI E RD RaW�Ev MA o1969 2318� a 1633AA {='og/28/15 3^ l 05771 1 1 MwAS`SAEHUtSET I S DRIVERS K-_ k LICENSE.. e ` a'a rss -2013'.e NONE ae xuxecR -•t^ . zzo�a S19539973l t " ;- FM20a8� :09-101959 41n[[s£d`- .+?'izrnrr his sex M. �e xc1510 M+ +� t.s * zROSERTV �..,. s 15 LESLIE RD ROWLEY,M0.07969-2318 (� soo ao-umu xr or ismm r 1, �o OMMONWERLTH OF MA 5kQWUSETTS�". ®onRn o� � SHEE3`,,METAL.'WORKERSx ISSUES THE FOLLOWIRW'1 6ENSE : > A'S, AMASTER UNRESTR I CT6D u is ROBERT V SMITH � .FR J NIaG •a x �� ffie8 ,if i' �S lu 15 LESLI E RB as Rar19iO MA o1969 z3i8 09/28/15:#, 105771