14 WINTER ST - BUILDING INSPECTION l� Con►monive:llth of Massachusetts
Sheet tNfetal Permit
CA R'
Date:
z
Permit f# --- o —'--�)
:,Ionated Job Cost: S 10 p 0 0 . 0 U
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�' ---t— Permit Ice: ,s m ='r—'
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flans Submitted: YES NO X Cnm
— flans Reviewed: YES_ NO rto
Business License# -71 y <
L Applicant License/# 016 ) D �,� c�
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Business Ittitrnmtion: "'
Property Owner/Job Location lntitnn: (ion:
Nance: 4-S ) fl er AIN, —w'e Name: 111M YOVNOI iNn�3�
Street: P6 )Q��ax ayo- �6 1„J�s }n) IUVI Street: Iy �l�N-rcR free F
City/1'own: +` -SJ/V City/Town: SALEM MQ 0/17U
Telephone: 7F1- '/Y-7q/yp Telephone: 14— 1-7 t)
Photo I.D. required/Copy orphoto I.D. attached: YES— NO—
J-1
O_J-1 : 1-1- nrestricted license st"111"11111
J-2/:N-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-flintily_ Condo/Townhouses
_ Other_
Commercial: Office_ Retail Industrial
--- Educational_
Institutional_ Other_
Square Footage: ltnder 10,000 sq. R, x over 10,000 sq, tt. _ Number of Storles: _
Sheet metal work to be completed: New Work:
— Renovation:
11VAC X, Metal Watershed Rooling_ Kitchen Exhaust System_
Metal ('hinutcy/ Vents_ Air Balancing
Provide detailed description of work tobedone: q
TVrml + JAIAAI� GpMA/I / NYI,I /NS✓Ikiz � SM L��L�
Sh.Sn �rr t l ov va�r1� 00
f rvn --lir
svf,.��t� G-��-i��Cs , N-al Ir�vrn. r,l�r�_--- —. .. -.
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INSURANCE COVERAGE:
I have a current liabili 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 X Other type of Indemnity ❑
Bond ❑
m aware that the licensee does not have the Insurance coverage required by Chapter 112 of the
OWNER'S INSURANCE WAIVER:I a
Massachusetts General Law and that my signature on this permit application waives this requirement.
Check One Only
Owner Agent ❑
Signature of Owner or Owner's Agent
By chocking this boxy.I hereby certity that all of the details and Information I haw#submitted(or entered)regarding this application are true and
in comaccurapliance the
with of my pertinent provision of at all
$hoot metal woralts Building Cok and ats rand Chapterions performed
of the General Lawso(the permit ued for this application will be
ll
Duct Inspection required prior to Insulation Installation: YES_NO
Ia rO CrCS3 I ltspl`L't in n9
Comments
Date
Find Inspection
Continents
Data
Type of License: I
By _ ❑Master
rine ❑hiaster-Restricted j
Cay,ro•.w__ --- ❑Journeyperson Signature of Licensee j
a �—--
Penna s _— ❑ aa
Journeyperson-Restricted License Number: �
Rau i .._-_—__.____-_ ❑- _ Check at:•.v.v n.rs•:.;Iuv'�IL
I
In speuor signature of Permit Approval
' 46MASSLICHF SETTS
- :.:BOAREf OF
SHEET METAL WORKERS
ISSUES THE FOLLOWING LICENSE ASA
MASTER-UNRESTRICTED "t IF
ANDREW T.CASOLI a i�
:p0'60)C 240
C AND S REFRIGERATION
U
- HANSON,.MA 02341-0240
2620 .! 1fl/28/2017 ', 2571
"0ML40NWEALTHl0F M[ASSAGHkISETCS-
• • • aMINE!• ,.'BOARti OFZl
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SWEET Mf7AL -WORKERV I ,
ISSUES TELE FOLLOWING LICENSE
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AS A BUSINESS �
*WtiffW T CASOLI
C AND .S .ItfAz `AERATION INC
PO BOX,_240
36 .I-NU.USTR I AL BLVD STE D
ao241
M 3
31 09/?911fi . 29:7b2
The Commonwealth ofMassaehuselts
Dep ext oflndustrialAccidents
I CongressStreeg Suite 100
Boston,M402I10 2017
www.massgov/dia
N urkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FnXD WITH TBE PERNDITING ADTHORWY.
Applicant hffigization Pica"
Name(Bosiaess/Orgamzation/fndiviib.D: 'j S 4 r�4�. r0 II 711
PO
. .
Address: 1' O Q a x a V0
City/state/Zip: YAnlSan/ .k. 023y1 Phone#:
Are
ono employer.'Clink the appropriate boa:
Type of project(required):
1.®1 am s employer wim emphryoes(foil a�iorl a tf me).• 7. ❑New construction
2.01am e.soh prop+ietororpartnerehip®dhave no empkyaeasvorhmg formeio g; ffRFmodeling
any capacity.(No whNken'comp.ioaamce m9tmed.7 9. 0 Demolitlun
9.01 em a homaw�aoing eU work myself.(No wodws'amp.inomnnce�cgnired.]T .
4.[]1 am a homeowner and will be hiring cunbractm to condod on work on my property. I will 10 0 Building addition.
este that all comms eitherhave workers'compensation mamaoeo orm sole 11.0 Electrical repairs of additions
O1B"'�°O 0?0CB' 12. Plumbing'repairs oradditions
S.Q ram a general cooftseoi and l have hired the sub-eouraetms listed oa the saadied sleet: 1Roof? .
These sub<arrmclmz have employes and have wodgs'comp.mnm^M t - 0 epaII6
6.O We are a corposatios And its officers here exorcised/herrn*of mempdon per MOL e. 14.[]Othc!
152,$1(4),and vre have no employees.lNo worlma'comp:b m mce required.] .
* apple ibatche boa Olmo ohotl0omtheswdMbdow skds'ving mer wmkm Sim policy inflimecm.
t Homcownas who sulmait me affidavit'" ..
' mdiatmg they are doing afi wort end tlxri live outside co�ectms must atrlsoit a new affidavit fidicatmg suck
tConractoaa that check this tins most arached an additional sheatsbowins the name of it sub-ce egmaand ante wtiethetanotthroeentitie+have
employom Ifthe aubempagma haveemployem they,most prwido*w workaa'oomp.policynnocr .. . ...-_
I am an employer than isproviding workers'eompgada0an iasurnincefor my eaiptiryees. Below is thepniky andjob site
Information.
Insurance Company Name: �?pJ Q f C'4J Av'1yLyA TN3vrAtJQ W f /aA&N —
Policy#or Self-ins.Lic.#: /y �D I Expiration Daft: S-
Job Site Address: y W iy f e r 5-t- GSty/Statemp: SAlPM, /*
Attach a copy of the workers'compensation policy declaration page(showing the policy number and'exptration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by fine up to$1,500.00
and/or one-year irnprisomnent,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 verification.
I do hereby certify thepains and penalties ofperjury that the information provided above is hue and correct
Signature: Date•
phone#: 7 S/- Yy7' 9/YU
Of wW use only. Do not write in this area,to be completed by airy or town o,BlciaL
City or Town: PerealMeense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Chy/fown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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 writtep."
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-contractors)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 Departoment 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 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 pemrit/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 permits 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 dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
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. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
AC RO O® DATE(MMNO YYYY)
ift.� CERTIFICATE OF LIABILITY INSURANCE 11/11,2015
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 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 CONCT
RAMP
CLIENT CONTACT CENTER
FEDERATED MUTUAL INSURANCE COMPANY
HOME OFFICE: P.O.BOX 328 (AIC,Nno EXs:888-333-4949 Fwc No:507-446-4664
OWATONNA, MN 55060 ADDRESS:CLIENTCONTACTCENTER FEDINS.COM
INSURERS AFFORDING COVERAGE NAIL/I
INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935
INSURED 301-932-0 INSURER B:
C&S REFRIGERATION INC INSURER C:
PO BOX 240
HANSON,MA 02341 INSURER D:
INSURER E:
NSURER F:
COVERAGES CERTIFICATE NUMBER:64 REVISION NUMBER:0
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 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.
INSR TYPE OF INSURANCE DL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
T INSR WVD MMID IYVV MIDDIY
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $100,000
CLAMS-MADE Fx]OCCUR MED EXP(My one perm)
A X BUSINESS OWNER'S LIABILITY N N 9411800 05/21/2015 05/21/2016 PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $2,000,000
X PODGY JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea
ANY AUTO BODILY INJURY(Per pars.)
AL OMED SCHEDULED
A AUTOS AUTON N 9411802 05/21/2015 05/21/2016 BODILY INJURY(Per&Wdenp
HIRED AUTOS '0..0." PROPERTY DAMAGE
AUTOS (Per acciftntl
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $1,000,000
A EXCESS LIAe CLANts-MADE N N 9411604 05/21/2015 05/21/2016 AGGREGATE $1,000,000
DED I I RETENTION
WORKERS COMPENSATION X WC STATU- OTH-
AND EMPLOYERS'LIABILITY ,.y N TORY DMR$ ER
ANY PROPRIETORIPARTNERIEXECUTI%T ❑ E.L EACH ACCIDENT $500,000
A OFRCERIMEMBER EXC LUOEDT NIA N 9411801 05/21/2015 05/21/2016 E.L DISEASE-EA EMPLOYEE
(Mamalory In NH) $500,000
Uyea,&zce eIndex
DESCRIPTION OF OPERATIONS aglow E.L DISEASE-POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ARNO ACORD 101,Addimmi RemMu Stmaula,11 mora spa.la"Ulmd)
JOBSITE: 14 WINTER ST, SALEM MA 01970
CERTIFICATE HOLDER CANCELLATION
301-932-0 540
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
93 WASHINGTON ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
SALEM, MA 01970-3527 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
O 1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/0.5) The ACORD name and logo are registered marks of ACORD