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15 HARRISON AVENUE - SHEET METAL APP. 3s00CK 2 L{ Commonwealth of Massachusetts Sheet Metal Permit Date: $ " �" G�, Permit# po Estimated Job Cost: $ 5, 000 Permit Fee: $ J — � Plans Submitted: YES NO Plans Reviewed: YES NO_ (7° Business License# Applicant License # 9� 1 9 Business Information: Property Owner/Joh Location Information: l Name: -Win I,l� Name: PO r4,. BeIr�E 1 Street: Q S� c�u� S7• Street: is- City/Town: s Qrrl� 7. j— A I �/ City/Town: s41ca AA City/Town: NI fwlch A• Telephone: q 7 8 7 -7 1 1 9 o y Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO - SIJrI II11IlAI J-1 / VI-1 unrestricted license J-2 / M-2-restrieted to dwellin>s 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less Residential: 1-2 family v� Multi-family_ Condo/Townhouses Other Commercial: Office_ Retail_ Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. V over 10,000 sq. ft. _ Number of Stories: 3 Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Rooting Kitchen Exhaust System Metal Chimney/ Vents_ Air Balancing Provide detailed description of work to be done: +-- - /� •T- hJ rad/ -TT-I.- At,- J l—ur..e� c twTo >• ucr- Vn�T y I/IVtT PVH inTa 1w7 1) J _ GAt.L- y P , U M\C\C-\PtLL— 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 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 Pro2ressInspections Date Comments Final Inspection Date Comments Type of cense: BY Master Title/ /(1� ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted `,L 9 License Number: Fee$ ❑ Check at www.mass.gov(duI Inspector Signature of Permit Approval The Commonwealth ofMassackusem Department oflndustrialAccrdents I Congress Street,Suite 100 Boston,AM 02114-2017 www massgov/ria Workers'Compensation Insurance Affidavit:Buflders/Contractors/Etectridans/Plumbem TO BE FH.ED WITH THE PERMI IMG AUTHORITY. Applicant"formationPlease Print I.enbly NaMe(Btuiness/o'gamzetion/lgmvidadl: ,A-�,-A,-r . Address: d s 0 s 0 City/State/Zip- s c /� 019 70 Phone#: 9 ? 1 7 ?/ / f a y Xthg 4ao empbyerP Check 11m proPiiate boa. am a employer with amployeaa(fill and/or . ape of project(required): °me)' 7. ❑New construction am a sots prop dao se p hip and have oo employees wodting formevkY capaciry.[No worker .vkatoance regemM.] 8. ❑Remodelingm a homeowner doing ak myself(No wmkeks•comp.imurence required.]t 9. ❑Demolitionma homeowner and willing contractors to coact an work on my property. I win 10❑Building addition mc that an ccnuwm tiave workers'compemauon insurance or are sole11. Electricalprietors with no employ ❑ repairs or additions m a 12.❑Phunbing repairs or additions ese sub-wnhac�mrs�klurvane hued the sub-conpactms listed on the atmched sheetyees and have worker'comp,inrmaaeet 13.❑Roofrepairs are a corporation and itss have exercised theirti ght of exemption per MGL c 14.❑Gthef_ �-1 r+Tr.31(4),and weheve ao eees.(No wmkerr'comp-inskoaoce requited]applicant that rLeclo laz al must also 1nl out thesati®below showing Weirworker'compmsaym policy info+nkatim. i Homeowner,who subrmt this affidavit iodicatiug they are doing an work and than hire OUM&conbaetms must sulsm a new affidavit indicating such 1Cfmb8rmr,that check this box must attached m additronal sheet showing the kmme of the sabcentiactor,and state whether or not Wcee entities have enVloyaes. Ifthe mbconl actors have employees,they mutt provide Web watkvs'comp.polxynumber. lam an employer,that it providing workers'compensation insuramee for any emplo)ees. Below is ihepoluy and jab site laformafiom n / Insurance Company Name: A - Policy#or Self-ins.Lic.M OCC S,1;0 .SOI S3 7 4 `.1015, 4 Expiration Date; p :l� / 6 Job Site Address: 15' pa rrk l o�1 J-1. / /q- ty policy Attach a copy of the workers'compensatlon Policy declaration page(showing thea policy number and expiration date} Failure to secure coverage as regtdred under MGL C. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-yew 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ven.fication. I do hereby certify under thepaha andpenalaes ofpepury that the mformahon provided above Is true and correct Suture: ^144A - Da_ Phone M q 71' '771 1 4 o y Oficial use only. Do not write in this area,to be completed by,city ortown o,�ciai City or Town: Permil/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Alrnspector 6.Other Contact Person: Phsue#• 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'Weither 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 theate lime. 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 permittlicense 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) coPY ."A 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 permits or licenses. Anew 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 t to bum leaves etc. said on is NOT required to complete this affidavit. license or permit ) I� i.e.a do p ( g The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia OOMMO WEALTH OF MA: ACI IUSETTZZ ' � SHEET METAL WORKERS 4 r ISSUES THE FOLLOWING LICENSE ASA MASTER UNRESTRICT t,r MICHAEL SHEPPARD ~ a 26,;OSGOOD ST « SALEM MA 01970-0116 a c C 298 06/28/2017 1258 e From:Johm Walsh Insurance 978 745 9557 08/10/2016 09:32 #601 P.002/002 9AFFI01 OP ID: DP nCo/rO` CERTIFICATE OF LIABILITY INSURANCE DATE RR/101201 vvl os/1a2o1s 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(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 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Mark W. Bettencourt John J Walsh Ins Agency,Inc NAME:PHONE P OBox 4407 Jac n,E.r745-3300. ____1ac nPp_ 557 Salem, MA 01970.6407 EMAIL 978-745-9 Mark W.Bettencourt ADDRESS: ' ____, INSURER(S)AFFORDING COVERAGE_____- _ __- � _NAICd___ _INSURER A:Essex Insurance COmeany INSURED Affinity Construction, Inc wsuRERe:Commerce Insurance Company 34754 _ 25 Osgood St — --- --- _ __�_Y _.__ _._. Salem, MA 01970 ---------- INSURER A_LM, Mutual Ins. Companies INSURER D: INSURERE._____ 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. (NSR TAOOL SUB ' LTR TYPE OF INSURANCE ^POLICY EFF POLIEY EXP j - -" --"-- D POLICY NUMBER MMIDDIYYVY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY I 1 EACH OCCURRENCE $ 10K000 A X co. r_ DtACErORFNTEo-- I - ----- ---- CLAIMS-MADE 1.X I OCCUP I,i 3EC8446 12101!2015 12/01/2016�pREMISESL occurrence/ $ 100,000 MEo EXP(Any one person) I s 5 000 PERSONAL 8 ADV INJURY 1 $ 1,000,00C j GEN'L AGGREGATE LIMIT APPLIES PER: F-1 _ _LOC I GENERAL AGGREGATh_ $ _ 2 000 00 PRO ( PRODUCTS COMPIOPAGG S 2000000 ..I POLICY L .PRO I.OTHER: IIS '_.--- AUTOMOBILE LIABILITY f COMMUNED SINGLELIMIT $ t 000,000 i "-- �a BcciGanlj __ __ _ ANY AUTO _ - RX0160 11126120151 11/26/2016 BODILY INJURY(Per parson) $ _ AUTOS ALL NEO X AUTOSULED I 1 BODILY INJURY(Pe au Eenl) $ X�HIRED AUTOS AUTOSWNEO PROPERTYDAMAGE $ Per accitlenil -.._ __ UMBRELLA LlAs TII OCCUR EACH OCCURRENCE .$ - - I --� EXCEBS UABCLAIMS_MAOE I —�- —_ F — _ !AGGREGATE DED RETENTION S WORKERS COMPENSATION - ANDEMPLOYERS'LIABILITY YIN F STATUTE- yER� C ANY PROPRIETORIPARTNER/EXECUTIVE (WCC-500-5015376-2015A 112/20/2015 1212012016,E.L.-EACHALCIDENT s 500 DDU .OFFICERIMEMSER EXCLUOEOi NIA ..., ._._ -'(Mandatory in NH) I E L.DISEASE EA EMPLOYEE$ 500 00 ((yes,describo under E DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space is required) I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Salem 93 Washington Street ACCORDANCE WITH THE POLICY PROVISIONS. Salem, MA 01970 AUTHOPoZED REPRESENTATIVE Mark W. Bettencourt ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD