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B-19-860 - 0461 BOSTON STREET - Building Permit `. a�iln Commonwealth of Massachusetts :Sheet Metal Permit S' CA Datf�: 0 7 � Permit# 1 Estimated'Job Cost;$ ,a O. Permit Fee: .Plans Submitted: YES 'NO Plans Reviewed: YES NO o nse a Business License"# yg.J Applicant Lice ;Business Information: property Owner%Job Location Information: Narae Name: G/�G�GL Gel S sixP1:it• n� Q/ry/ Cltry� ONi rl: /� ///� City TOWtI: L ���// / W /fXO Telephone'.�i Telephone: . !?Zf' W62 JJr Photo:I.D.required!Copy of PhotQ LD. attached: YES NO ;J-1 / 1-unrestricted;license. J-21 M-2-restricted.to dwellings 3-stories or less and commercial up to lb,000 sq.ft.f 2-stories.or less Residential: I-2 family. ._ .. Multi-family. Condo/Townhouses Other Commercial:. Office, Retail Industrial Educational Institutional. Other square Footage: under,10_000 sq ft.. )e over 10,000 sq'_ft: Number of;Stories- Sbeet metal;work"to be:completed; New Work:. .. Renovation: IHVAC Metal Watershed Roofing Kitchen Exhaust System Metal,Chimney/Vents Air Balancing . . . Provide detailed description of vvork to be done:. a�,e I A� t � S r t ; iNSURANCi:::COVERAGE l i have a°currqW:I abili insurance:policy or its equivatent which meets itse requirements.of M.G.L.Ch.112 Yes Non' i If you have-checked Yes•indicate the type of ca:4erage by checking the appropriate box::below. A A liability insurance:policy, tither type of indemnity, [] Bond 17-1. OWNER'S INSURANCE WAIVERi1 am aware that the Acensee does nothave the insurance coverage•required by Chapter11,2 of.the Massachusetts General taws,and that,My signature on this permitapplication waives this:requirement Check One Only Owner ❑ Agent Q Siclhature of Owner or owner's Agent Sy°checking this box 1 hereby certify that al 11 of the details and Informs don.1 have-submtted(or-entered)regarding this application are true and accurate to the beSt . my knowledge,and that all cheat metalwork and installations performed under the.permit Issued for this application will be in compliancg with all pertinent provision of ft Massachusetts,Building Code and Chapte f'142<of the General:Laws. Ductinspection;required prior to i.nsulation'installatilon:YES NO.. Progrgss Insnectiions Date Cbm nents Final Inspection Date, Comments. Type of License; .� ByMaster Title Master-Restricted Cityrrown_. O.loumeyperson Signature of Licensee. Permit;#._ n 0Joumeyperson7Restricted License-Number: a2d Check at www.massgov1dj2l.. ff inspector SGgnatureof;P. Approval CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 07/31/2019 THIS CERTIFICRITE 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 pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATIQN IS WANED,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 NAME: Cheryl Rossetti Cleary Insurance Inc: HONE Ext, (617)305-0301 IAX fAIC,No. NIC e: (978)535-0309 226 Causeway Strel:t ADDRESS: emssetti@clearyinsurance.com INSURER(S)AFFORDING COVERAGE NAIC p Boston MA 02114-2155 INSURERA: Arbella Protection Insurance 41360 INSURED INSURER B: Preferred Air,Inc. INSURER C 461 Boston Street INSURER D: UnitA3 ' INSURER E Topsfield MA 01983 INSURER F COVERAGES CERTIFICATE NUMBER: CL1973140100 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. INSW LTR TYPEOFINSURANCE INSD WVD POLICYNUMBER MM/DD MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE g CLAIMS-MADE I--'%I OCCUR PREMISES Me occurrence) $ 300,000 MED EXP(Any one arson) $ 5,000 A 8500068845 08/0.1/2019 08/01/2020 1,000,000 . PERSOIJALBADVINJURY $ GEN'LAGGREGAT,ELIMITAPPLIESPER: - GENERAL AGGREGATE g 2,000,000 POLICY , JEa ❑LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 ANYAUTO , Ea aaident BODILY INJURY(Per person) $ A OWNED SCHEDULED 1020075365 08/01/2019 08/01/2020 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS X HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY X AUTOSONLY (Per accident) $ X UMBRELLA IJAB OCCUR 5,000,000 EACH OCCURRENCE $ A' EXCFSSUAe CLAIMS-MADE 4620085168 08/01/2019 08/01/2020 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 - WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY YIN X STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE A OFFICER/MEMBER EXCLUDED? N NIA 4220075506 08/01/2019 08/01/2020 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) 1,000,000 11 yes,desuibe undar E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OFIOPERATIONSbelow E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City Salem ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 120 Washington Street,3rd FL. AUTHORIZED REPRESENTATIVE Salem MA 01970 (;�flfA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(20161113) The ACORD name and logo are registered marks of ACORD 3'�E: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Lezibly Name (:Business/Organization/Individual): Preferred Air Inc Address: 461 Boston St#A3 City/State/Zip: Topsfield MA 01983 Phone#:978-750-8282 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 29 employees(full and/or part-time).' 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working for me in ❑ 8. ❑Remodeling any rapacity.[No workers'comp.insurance required.] 9. El Demolition 3.O I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[:]Roof repairs These sub-contractors have employees and have workers'comp.insurance. 14.E✓ Other HVAC 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'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 a 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 job site information. Insurance Company Name: Arbella Policy#or Self-ins.Lic.#:4220075506 Expiration Date:08/01/2020 Job Site Address: 18 Brittania Cir City/State/Zip:Salem MA 01970 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains and penalties ofperjury that the information provided above is true and correct. Signature.: Date: Phone#: 978-750-8282 V ` Official use only. Do not write in this area,to be completed by city or town official City olr 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#: Yt . 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