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3 WINTER ST - BUILDING INSPECTION (4) 1bZ,4 $ q!� � Commonwealth of Massachusetts Sheet Metal Permit t Date: Permit# Estimated Job Cost: $ ©, W/, a Permit Fee: $ Plans Submitted: VE�— NO_ Plans Reviewed: YES_ NO Business License# Applicant License# Business Information: {� Property Owner/Job Location Information: Name:!'�{�.e T P(C(/��/.>' l7/l� �!'1 G Name: X"1.( Street:4&/ A5-4on 5t i4 3 Street:c_ &)14 &M City/Town: /506S "eH City/Town Telephone: Telephone: /a Photo I.D.required/Copy of Photo I.D. attached: YES_ NO_ Stott 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¢_ v m a C1 Commercial: Office_ Retail_ Industrial_. Educational— om N Zrn Institutional Other rr--< Square Footage: under 10,000 sq. ft.�L over 10,000 sq. ft.— Number of Stories: _ Sheet metal work to be completed: New Work: _ Renovation: _ = rn HVAC Metal Watershed Roofing— Kitchen Exhaust System Metal Chimney/Vents_ Air Balancing Provide detailed description of work to be done: m a ► t,t,r� g J d� 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❑ If you have checked Yes.Indicate the type of coverage by Checking the appropriate box below: A Ilabiitty Insurance pollcyV 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 andChapter 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 ❑Master Tw; ❑Master-Restricted r chylrown ❑Joumeyperson Signature of Licensee Permit s ❑.1oumeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.gov/dat Inspector Signature ofPermit Approval The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston; MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorYlgdividual): YY�76I,—, 1� d l i— /�/� i Address: 4(� / s 75� zo�q 3 City/State/Zip:! az ne Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with /J~ 4. ❑ 1 am a general contractor and IVV fi. 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 for me in any capacity. 9. ❑Building addition [No workers' comp.insurance comp. insurance? required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs of additions 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 MOL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no j employees. [No workers' 13.N Other 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 hire outside contractors must submit new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they moat provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /! Insurance Company Name:��/CLIP/ c� ( �'a p-ekk— — olicy#9r Self-iins.Lic.. #: q�y �, V )q '7,1119 3 Expiration Date: / y Job Site Address>-/ &)IX LJ_Lde �t '/ City/State/Zip: "Il el7o 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 cerd under the pains and penakies of perjury that the information provided above is true and correct Si a re Date: (/—Ir&l t lY r — Phone : Ojpdal 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#: ' ALA PREFE-2 OP ID: KS1 CERTIFICATE OF LIABILITY INSURANCE DATEo9/011114IM Y) vla THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDS 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 policypes) 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 endorsement s. PRODUCER 781-914.1000 NAAM: T Kelly Sturtevant 401 CrossterPia Insurance,Inc. PHONE 401 Edgewater Place,Suite 220 .781-914-1000 Wakefield,MA01880 -WUL AX No:781-246.2601 Chris Hawthorne ADOREss:ksturtevant@tgacross.com_ —. INSUREWS)AFFORDING COVERAGE NAIC0 INSURER A:Mbella Protection Ins.Co. 60 INSURED Preferred Air,Inc. �-�--------------- ---- 461 Boston Street,Unit A3 INSURERS:_ TopSflBld,MA 01983 INSURERC: INSURER D: NSURERE: 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. INSR TYPE OF INSURANCE POLICY EFF POLICYEXP ----- INSRWADPOLICY MMIDD MMID LIMITS GENERAL LUUIILIIY EACH OCCURRENCE ____ E 1,000,000 A X COMMERCIAL GENERAL LIABILITY 8500026668 08101114 08,01116 AG=RENTE� PREMISES(Ee aca,rrer¢el_ E 300,00 CLAIMS-MADE LK OCCUR MED UP(Any we person) S 15100 PERSONALS ADV INJURY E 1,000,00 GENERALAGGREGATE E 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO f 2,000,0oO POLICY EXI PRa LOC § AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A ANY AUTO 1020003133 08/01/14 08/01116 BODILY INJURY(Per Person) E AALL ED X SCHEDULED ----------- — AUTOS BODILY INJURY(Per accident) E NON-OWNED X HIREDAUTOS X NON-O ( PER MAGE _ -- PAUTOS -NgWdept E X UMBRELLA UAB X OCCUR EACH OCCURRENCE _ E 2,000,00 A EXCESS Like CLAIMS-MADE 4600037647 08/01114 08101116 AGGREGATE E 2,000,00 DED X RETENTIONS 10.000 '— -------- E- W)SHERS COMPENSATION WC STATU- OTH- ANDEMPLOYERS'IJAKUTY YIN __jTQRY LIMBS ER_ ANY PROP RIETOR/PARTNER/EXECUTIVE ISSUED DIRECTLY FROM - OFFICERIMEMBEREXCLUDEDi NIA _E.LEACHA_C_CIDENT __ § (Mandatory in NH) THE CARRIER E.I.DISEASE-EA EMPLOYE E _It yes,describe un i r DESCRIPTION OF OPERATIONS below E,L.DISEASE-POLICY LIMIT § I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Renurks Schedule,if M.spans Is required) CERTIFICATE HOLDER CANCELLATION CITYSAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. Fax: 978-740-9846 120 Washington Street,3rd FI. AUTHORIZED REPRESENTATIVE Salem,MA 01970 U©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ` .CER`fIFIATEdF1JBLf t [ � RCrE� 8/15/2014 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 CONSTITITE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORRED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiflcete holtler is an ADDITIONAL INSURED,the policy(lea)must be endoreetl. If SUBROGATION IS WAIVED,subject to the terms and conditions of fhe Polley,certain policies may require an endoreemen4 A statement on this c rtHlcata does not confer rights to the certificate holder In lieu of such endoreemente(e) PRODUCER CONTACT TGA Cross Insurance,IDC. PHONE (A/C,ND,E#): (781)914-1000 (A/C NOT (781)224 FAX -5577 401 Edgewater Drive,Suite 220 E-MAIL Wakefield,MA 01880 ADDRESS: PRODUCER Cl1RTOMFR ID B' INSURERS AFFORDING COVERAGE NAIC M INSURE:Air, INSURER A'. Allaritic Charter Insurance Company VDAC 44326 Prefe . INSURER BINSURER C461 et,Unit A3 INSURERDTops 01983 INSURER E: NSURER 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 MAYBE 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. Ism TYPE OF INSURANCE ADUL 9UBR POLICYNUMBER POLICY EFFECTIVE POLICY E%PIRATON LIMITS INBR MNO DAM(MMIDDrlY) DATE(MMIDDIM (In TRRUund I GENERAL LIABILITY EACH OCCURRENCE $ COMMERCMLGENERALUAMUTY ErtmwENTED PREMISES S CLMMS MADE ❑ OCCUR ❑❑ ED EV(My Pna paean) S ERSOI BADV INJURY S GENERALAGGREGATE $ GENLAGGREOATE LIMITAPPLIES PER: PRODUCTS-COMPIOPMO $ POUCY ❑PROJECT ❑ me AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (Ea AWEene $ ALL OANEO AUTOS ❑❑ BODILY INJURY SCHEWLEDASJTOS (PR P.) t BODILY INJURY S 111REDAVT03 (EeA dtl ) PROPERTY OHMAGE S NON-04lHDEDMITOS (Ee Aatidmd) fMPLO�R& ELIA ❑ OCCUR UTY EACH OCCURRENCE $ SS UM CLAIMS MADE AGGREGATE S CTIBLE 4 S _ON' S LIABILITI'ORI �NAND WCV00971103 08/01/2014 08/01/2015 xSTAMORYOTHER TOILPAmNEWEECInIVEIN LIMITSBER EXCLUOEDi N NIA ❑ y PDIIC Coverage State:MA EACH gOLIOENT S 1,000,000 Mende vIn NH IFM&Mnee pmv WECML PROVISIONS W. DISEASE-PoUCY LIMIT S 1,000,QQQ DISEASE EACH EMPLOYEE a 1,000,000 OTHER ❑❑ DESCIRMON OF OPEMTION&LOCATIONSNFHICLES(AMch ACORD 101,Addebnel R A,s SCM1edule,ff rom spaceH Muiled) iC��#vAT _._. 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 OR REPRESENTATIVES. UIHORQED REPRESENTATIVE /T ACORD 26(2008109) Page 7401104 CERTIFICATE HOLDER COPY 01988-2009 ACORD CORPORATION. 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