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14 WINTER ST - BUILDING INSPECTION (3) Commonwealth of € kVicEs 22 Sheet Metal 119" 31 A cf 5`I Date: J'7�-I(i Permit# p � O Estimated Job Cost: $ � v Permit Fee: $ 1� (J) Plans Submitted: YES_ NO Plans Reviewed: YES NO X I _ .9 Business License# Jo2 Applicant License# �j 6 Cl Business Information: Property Owner/Job Location Information: �-- Name:spn{t 0Lj Cool i na+U P }ems; Tnc Name:_ /y� (�yNG4�Ot✓j�/ Street:-2 m r+- i!P 4tre cL Street: Z City/Town:-W6h ..rn, M11 a/yo/ City/Town: ��9Z -i All 0/970 Telephone: -7k t-y33_ gFy Telephone: Photo I.D.required/Copy of Photo I.D. attached: yES_)!( NO_ d-1`/ K-1)unrestricted license Staff Initi., 2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories or less Residential: 1-2 family-L Mu1t-family_ Condo/Townhouses_ Other_ Commercial: Office— Retail_ Industrial Educational Institutional— Other_ 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:_ HVAC 4 Metal Watershed Roofing— Kitchen Exhaust System— Metal Chimney/Vents_ Air Balancing— Provide detailed description of work to be done: //vim-L- AJ� GW--f � [J l77--1 /`� B /it/fv[�rno�✓ mtAIL,4r-r, Lj /-7 INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 YesX No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: !!!ll��� 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 boxldl,l hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best//off 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 Prouess Inspections Date Comments Final Inspection Date Comments Type of License: By W Master Title ❑Master-Restricted City/rown ❑Journeyperson Signature of Licensee Permit# 4 Q ❑Journeyperson-Restricted License Number: l� / Fee$ ❑ A Check at wwwinms.Spyldel y�o Inspector Signature of Permit Approval 4\ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 y` Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le¢ibly Name(Business/Organization/Individual): Central Cooling and Heating, Inc. Address:9 North Maple St. City/State/Zip:Woburn, MA 01801 Phone#: (781)933-8288 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 70 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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 workingfor me in an capacity. employees and have workers' Y P Y� 9. ❑ Building addition [No workers' comp. insurance comp. insurance? required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.[1 I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself ' right of exemption per MGL Y [No workers comp. 12.❑ Roo epairs insurance required.] t c. 152,§1(4),and we have no t employees. [No workers' 13. ther 1 V X ! comp. insurance required.] *Any applicant that checks box#I 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 a new affidavit indicating such. rContractors 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 job site information. Insurance Company Name:Arbella Indemnity Insurance Company Policy#or Self-ins. Lie. #:0048681113 Expiration Date: 11/30/2016 /7 Job Site Address: t/ I� �i E� City/State/Zip: - Mom} tJl9 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 certify un e pains and penalties o prerjnnury that the information provided above is trueand correct. Si nature !.?J`C_- Date: Phone#: 7819338288 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#: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future pernuts or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 7-2013 www.mass.gov/dia �r��A�S��ACI°IEU ETTaDRIeERi --- II(li LICENS _ e, ( r�' ea ENR�JM NUMBOt I rir i L e 70 LIBERTY ST r .N ANDOVER,MA-01845.J357 oounmurtwoi.jsaos COMMONWEALTH OF MASSACHUSETTTSS �• 1 BOARD O SHEETWETAL WORKERS . ISSUES THE FOLLOWING LICt:-:NSE AS A 1 MASTER-UNRESTRICTED `"' ¢ DOUGLAS A HAMILTON j CENTRAL qOOL,[NOa&HEAT � A 9 NORTH MAPLE STREET:','' � YV, EIVRN,MA 01801 17f3 ^ 469 11,212812017 8377 "a•COMMONWEALTH OF MASSACHUSETTS • • • • = SHEET METAL Wd3RKRS' ISSUESTHE FOLLOWING LICEN AS A BUSINESS tbuU LAS A HAMILTON CENTRAL. COOLI-NG AND HEATING INC 9 N MAPLE ST I < WOBURN., MA 01801 l .� `� CERTIFICATE OF LIABILITY INSURANCE DAT3/26/zons ACORO 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 have ADDITIONAL INSURED provisions or 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 CONTACT Risk Strategies Company NAME: Risk Strategies Com an 15 Pacella Park Drive, Suite 240 PHONE FAX Randolph, MA 02368 E--NIAae Ea ac Ne: ADDRESS: INSURERS AFFORDING COVERAGE NAIL# www.risk-strategies.com INSURERA: Navigators Ins.Co. INSURED INSURERS: Arbella Protection Ins Co Central Cooling & Heating, Inc 9 North Maple St INSURERC: Woburn MA 01801 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 29172765 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 ADDLTYPE OF INSURANCE JNM SUER POLICY NUMBER MMDDPOLICYEFF MMMD POLICY UP LIMITS A ,/ COMMERCIAL GENERAL LIABILITY NY15CGL1767151C 11/30/2015 11/30/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE To RENTED CLAIMS-MADE IV] OCCURPREMISES Ea occu ante $ 50,000 ✓ $25 000 DEDUCTIBLE MED UP Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ✓ POLICY PRO-JECT LOG PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY 1020009316 11/30/2015 11/30/2016 OMBI EDtSINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY ✓ AUTOS HIRED Nq AUTOS ONLY ✓ AUUTNOSONLDV Perr acden DAMAGE $ 8 A UMBRELLALWB �/ OCCUR NY15EXC8588021C 11/30/2015 11/30/2016 EACH OCCURRENCE $ 5000000 ✓ EXCESS UNB CLAIMS-MADE AGGREGATE $ 5:000:000 DELI I I RETENTION$10,000 $ B WORKERS COMPENSATION 0048681113 11/30/2015 11/30/2016 ✓ 1 PER STATUTE ERH AND EMPLOYERS'UABILITY ANYPROPRIETOR/PARTNEWEXECUTIVE YIN NIA E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached N more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityy 01 Salem - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washington Street ACCORDANCE WITH THE POLICY PROVISIONS. 3rd Floor Salem MA 01970 AUTHORRED REPRESENTATIVE Michael Christian ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 291]2765 1 2015-2016 Maater I Allison Petkiewich-Sousa 13/28/2016 9:19:08 AM (EDT) I Page 1 of 1