B-20-684 - 0061 BRIDGE STREET - Building Permit t
Co1),monweaIth of ttNfassae.husetts
Sheet tNletal Permit
Date: � 9-Zd
Permit # Zb — (vS
Intimated Job Cost: S- �
PCI'mlt Fee: S 2—L-75
1'I;111s Submitted: YF.S vO�' flans Reviewed: YES NO
131'siness License Applicant License t#
13usiness Information: Property Owner/.lob Location Information:
Name: /�r d -�) � � � Name: a 1� �a c,4 S��
Street: I2 �r --►� S Z Street:
City/Town: s City/Town:
> Telephone: 74 ! --7w —I 2 3 8
Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES NO
NI 1-unrestricted license `t"ff III I""I
J-2/NI-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-Tamil
� Condo/Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft•�over 10,000 sq. ft.
Number of Stories:
Sheet metal work to he completed: New Work: Renovation: JUg 10 L AM11=4
I IVAC 1-z:n7 jqetal Watershed Rooting Kitchen Exhaust System
Metal Chimney/ Vents Air Balancing
Provide detailed description of work to be done:
- G�LI S'�t✓ l�/ Ga ✓)�ic� u/
---7 1�.
�1
�t
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 Other type of indemnity ❑
Bond ❑
aware that the licensee doesYe the
this coverarequire9menquired by Chapter 112 of the
OWNER'S INSURANCE WAIVER: I am
t.
Massacousetts General Laws,and that my signature on this permit application —
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
n I have submittd(or entered)regarding this lication are true and
By checking this box0,1 herey certify
ri and that all the t he details and meta work Infaond Installations performrmatioeed under the permit issued for this application will be
accurate to the best knowledge
in compliance with all lt pertinent provision of the Massachusetts Building Coda and Chapter 112 of the General Laws.
Duct i
Duct inspection required prior to insulation installatlon: YES _ —
Nroaress Inspections
Comte S
Date
Find 111SDCCtioll
Comments
[Ttw
Type of License:
By 1�j<��!.c p Master
i
Fate 0 AAeg� ❑Master-Restricted I
i
__D M., ._ �uneyperson Signature of Licensee
!H' I
Permit z — �yv❑Journey person-Restricted License Number: j
Check at
{
inspector Signature of�ppr.val
The Commonwealth of Massachusetts
Department.of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
UW www mass gov/dia
Workers'Compensation in Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le 'bl
Name (Business/Organization/Individual):
Address:
City/State/Zip:_ V-�vim=--s Mia olf2? Phone#:_ `7 r —3 d d —12 3
Are you an employer?Check the appropriate box:
Type of project(required):
l.O I am a employer with employees(full and/or part-time).` 7. ❑New construction
40-10 a sole proprietor or partnenhip and have no employees working for me in
(�a�ny�capacity.[No workers'comp.insurance required.) 8• emodeling
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.)1 9. ❑Demolition
4.O I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.= 13.0 Roof repairs
6.E]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.D Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.)
Any applicant that checks box#I must also fill out the section below showing their wokers'com pensation 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.
=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 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: e, A i y 5-e Ctn.v 1)tt,/Ill f C✓2,, lines %.0e
Policy#or Self-ins.Lic.#: `Z LJ Expiration Date: //—Z 3 a Z/
Job Site Address:_ & 1 �-- City/State/Zip: StiJenM M 9-
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 vioMon-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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby tort" der the p s and penalties of perjury that the information provided above is true and correct
Si nature: !7
Date: -7cI
Phone#: 3 6-u—/2— 3 J?
Official use only. Do not write in this area,to be completed by city or town of iciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person'. Phone#:
fi0
� .;pas
ONIMOtWEALTH,OFMA$ / �iliS�
`k • Rol 0 •
i �$•`-fUE,S Ti#E FOLLOWING LtCENE
Jd13 tNEY, lkSOrN LI 1 SfiR1 �► sr� m
A WDON
BRANI�►1 ^TIM1 . 1
;f DANVE i 0192319 `s
t;14200 1
.m,
d; Insureon bOU sea-1984___. ------.-- 877-826-9067
41U►Il
Insureon(BIN Insurance'Holdings LLC.)
30 N.LaSalle,25th Floor,Chicago,IL 60602 INSURE B AFPORDMII COVERAGE NAIL 1►
INSURED INSURER A
INSURER a:
Brandon Vacketta DBA Brandon's Heating and Cooling INSURER C:
1.2 Braman Street,Danvers,MA,01923
RiSU1RER D:
INSURER E:
INSURER F: ---- ——
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MLYR SR TYPE OF INSURANCE POLICY EF POLICY
_. POLJCY NUMBER LIMITS
150
✓ COMMERCIAL OENPJ=IUL L1A81LrrY -
EACH OCCURRENCE S 1.000.000
CLAIMS-MADE a OCCUR S 300,000
MED EXP An an* rson S 15.000
A OKS60624534 11/42019 11/42020 PERSONAL d ADV INJURY S Low.=
GEN•L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S Z000A0
RPOLICY El JECT LOC PRODUCTS•COMPIOP AGG S 2000.000
OTHER:
S
AUTOMOBILE LIAB111TV COMBINED SINGLE LIMIT S
ANY AUTO BODILY INJURY(Pa parson) S
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per acckWfi) S
HIRED AUTOS NON OWNED AUT PROPERTY DAMAGE S
UMBRELLA LIAB OCCUR
EACH OCCURRENCE S
ExcEssI" CLAAMS-MADE AGGREGATE S
DED RETENTION S
WO10"$COMPENSATION PER OTH•
AND EMPLOYERS•LIASILfTY Y I NSTAMIF
ANY PROPRIETOR/PARTNERlEXECUTIVE
OFFICEAIMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT S
(Mandatory In NH)11 E� E.L.DISEASE E.
UnderEAEMPLOYE S
DCIPT O OF OPERATKxVS Itektw E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may bet attached It man apse@ Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DE8CRIBED POLICIES BE CANCELLED BEFORE
Insured Copy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVI810N8.
AUTNOMM REPRESENTATIVE
y
01988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
it