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29 GRANT RD - BPA 15-454 HVAAC Gt= z23y � l I O� Commonwealth of Massachusetts RECEIVED Sheet Metal Permit INSPECTIONAL SERVICES Date: 18 e 5_, W Estimated Job Cost: $ Permit Fee: $ Plans Submitted: YES_ NO_ Plans Reviewed: YES_ NO_ Business License# y��j Applicant License# / 6,3 Business Information: Property Owner/Job Location Information: Name: ���?/4/,d �l /xc-, Name: C;&z/ �, Street:0(y &Lll�pol &��J Street:62�? ��i aZ22I CityiTown: /��lzllw pau&, 3 City/Town4 !!�?/ Telephone: Telephone: Photo I.D.required/Copy of Photo I.D.attached: YES_ NO_ smrtmin,� J4CM-1-,u_nrestricted license J-2/M-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-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 Metal Watershed Roofing_ Kitchen Exhaust System— Metal Chimney/Vents_ Air Balancing Provide detailed description of work to be done: /O_/d GO/Gf� �4af5 �'l , l' r'Id ��� &j 41 INSURANCE COVERAGE: I have a currentfiability insurance policy or Its equivalent which meets the requirements of M.G.L.Ch.112 Yesf 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:t 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 hls:bo i hereby.certNy.thatail of the details and Information I have submitted(or entered)regarding title appocalion ambrue and accurate to the best tmy knowledge and that all sheet metal work and Installations performed under the perk Issued for this application will be In compliance with all paNnent-provision of the:Massachusetts Building Code and Chapter112-of the General Laws. Duct inspection required prior to insulation installation:YES NO Prouess Insnedions Date Comments Finallnsogetion Date Comments Type of License: RY 36Master Title ❑Master-Restricted Cilylrown — ❑Joumeyperson Signature of Licensee Pan+IN,# ❑Joumeyperson-Restricted L ense Number: 1403 Fee$ ❑ Check at www.mass.acivIdol Inspector Signature of Permit Approval The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians✓Plumbers. A licant Information _ Please Print Le 'b Name(Business/Organization/individual). Address: �<v/ 565-1no lop '.93 // J Phone#: -f tE City/State/Zip. IJ / == Q �` Are you an employer?Check the appropriate boat 'Type of project(required): �-, 4. 1 am a general contractor and I 1.5Z I ama employer with 6. ❑New construction employees(full and/or part-rime):* have hired the sub-contractors 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 working for me in any capacity. employees and have workers' 9 Building addition [No workers'comp,insurance comp•insmance.t required.] 5. We are a corporation and its 10.F1 Electrical repairs or additions 3,❑ I am.a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13. Other r JL1J e2 — comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infomration. 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 cheek thin oz must attached an additional sheet showing.the name of the sub-contactors and state whether or not those entities have employees,. If the subcontractors-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: ��P�{�/Q/Q P //2 //1 c C Policy#or self-ins.Lic.#: "140 Expiration Date: �/ l Job Site Address f '� City/State/Zip:(( 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$i,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 U50.00 a day against the violator. Be advised that copy of this statement may be forwarded to the Office of Investigations of the DIA.forinsurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si afar Date: Phone Official use only. Do not write In this area, to be completed by city or town official City or Town: Permit/License# Issaing Authority(circle one): 1.Board of Health 2.Building Department 3.CityrFown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6;Other Contact Person: Phone#: --RE, T 141ERTI . '� L1BIi" �tI�dN _C , x,f N 1 5 . /20 14a . __. 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(lea)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 c rtlficate does not confer rights to the certificate holder In lieu of such endomements(s) PRODUCER CONTACT NAME AX TGA Cross Insurance,Inc. (AJCC,No,,EXt): (781)914-1000 (A)CC No.,( (781)224-5577 401 Edgewater Drive,Suite 220 A MAIL DDRESS: Wakefield,MA 01880 PRODUCER INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Atlantic Charter Insurance Company VDAC 44326 Preferred Air,Inc. INSURER B: INSURER C: 461 Boston Street,.Unit A3 INSURER D: Topsfield,MA 01983 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 CONTRACTOR 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 ADOL sUBR POLICYNUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INM WVD DATE IMMIDDIYY) DATE(MMIDDIM (In no...d) GENERAL LIABILITY EACH OCCURRENCE S CIXAMERCIAL GENERAL LIABILITY IDAMAGE^O en RENTED PREMISES $ CLAMS MODE El OCCURD❑ MED E%P(My w,e peon) S PERSONGLaADVIWURY $ GENEMLAGGREGATE f GENLAGGREWTEUMITAPPUESPER: PRODUCTS-COMPIOPAGG S PoIJCY ❑PROJECT ❑ LOG AUTOMOBILEUMBILITY COMBINED SINGLE LIMIT S ANYAUTO E.APdd t) BODILY INJURY O110YMFD AUTOS (Per Peron) S SCHEWLEDAIROS ❑❑ BODILY INJURY S HIRED AUTOS (E.Actltleni) PROPERTY DAMAGE s NONOKNDED AUTOS IS.ftd&MI NMBRI ❑ OCCUR U1MUTY EACH OCCURRENCE f EXCESSUAB 1-1 CLAMSMADE AGGREGATE S DEDUCTIBLE 6 E RETENTION $ ORKFA9COMPBILITY NAND WCV00971103 08/01/2014 08/01/2015 X STATUTORY OTHER A MP ICERS C'LIABILITY LIMITS ONYPROPRIETORPMTNEREXECUIIVE YIN OFFICERIMEMBER EXCLUDED? Nr WA Policy Coverage State:MA FACH ACCIDEM : 1,000,000 Mmtlatwy In NH Ifyr,tin W undx SPECIAL PROVISIONS belay DISEASE POLICY LIMIT S 1,000,000 DISEASEFACH EMPLOYEE 5 1,000,000 OTHER ❑❑ DESCRIPTION OF OPERWONS&OCATIONSNEMCLES(Aftc ACORD 101,MtlROW R r1.SG,etlul.,M...W.I.mlul.) * SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Salem EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 120 Washington Streeet,3rd Floor 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. Salem,MA 01970 BUT FAILURE TO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. UTHORIZED REPRESENTATIVE / A.U+✓�ACORD 26(2009/09) Page 74 of 104 CERTIFICATE HOLDER COPY 01988.2009 ACORD CORPORATION.All rights reserved. PREFE-2 OP ID: KS1 CERTIFICATE OF LIABILITY INSURANCE °" 0810 081011°"YY"' 114 '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 an this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 781-914-1000 CONTACT TGA Cross Insurance,Inc. NAME: Kell Sturtevant__ 401 Edgewater Place,Suite 220 ac°No 781-914-1000 FAX No:781-246.2601 Wakefield,MA 01880 E-MAIL Chris Hawthorne ADDRESS:ksturtevant@tgacross.com INSURER(S)AFFORDING COVERAGE -_ NAICN INSURER A:Aro"a Prolectlon Ina.Co. 41360 INSURED Preferred Air,Inc. INSURER B: 461 Boston Street,Unit A3 -------- -- -- Topsfield,MA01983 INSURER C: INSURER 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. INSR POLICY EFF POLICY E%P L TYPE OFINSURANCE POLICY NUMBER MMIDDIYYYY MMIODIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 8600025668 08101114 08/01115 PREMISES(Ea occurrence) E 300,00 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 15,000 PERSONAL B ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 JFCT El 17 POLICY X PRO- LOC E AUTOMOBILE LIABILITY EOaBIOEDt SINGLE LIMIT $ 1,000,000 A ANY AUTO 1020003133 08101/14 08101/15 BODILY INJURY(Per person) $ ALLOWNED SCHEDULED ALTOS X AUTOS BODILY INJURY(Per accident) $ Ix HIRED AUTOS X NON MED PROPERTYDAMAGE AUTOS Per amdent $ ' E X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,00 A EXCESS LIAB ri CLAIMS-MADE 4600037647 08/01114 08/01/15 AGGREGATE $ 2,000,000 DEC) I X I RETENTIONS 10,000 $ WORKERS COMPENSATION WC STATU- OTH- ANDEMPLOYERS'LIABILITY YIN ISSUED DIRECTLY FROM TORV LIMIT ER ANY PROPRIETORIPARTNERIEXECUTIVE E OFFICERIMEMBER EXCLUDED) O NIA E.L.EACH ACCIDENT (Mandatary In NH) THE CARRIER E.L.DISEASE-EA EMPLOYE E "yes,desmbe under DESCRIPTION OF OPERATIONS hal. EL.DISEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,It more space is required) CERTIFICATE HOLDER CANCELLATION CITYSAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department Fax: 978-740-9846 AUTHORIZED REPRESENTATIVE 120 Washington Street,3rd Fl. Salem,MA 01970d U©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/OS) The ACORD name and logo are registered marks of ACORD A�tSt1GHUSETTS` DRIVER S i LICENSE a s 4d Nubee+ -s =w� 2.2013 NDNE $19539973 ' ]g 1 g 2018 09-101959 Y Y-72 ]A CU55,44NRiST 155IXM iSNGT 510 SMITHROSERT P} 1 SMIT Y e 15 LESLIE RD RDWLEY,MA 01969-7318 SOY O&14Al1Rev ObbID09 aF COMMONWE4iTH OF MA SACiiUSETTS: .,BOARD OF S H E E ,{1EfA kRKERS& � fff ISSUES, THE FOLLOWIND LftENSE� 'AMASTER UNRFSTR I CTE"Q ja" tI ROBERT xV SMITH ma 15 LES1 1 E46 ti 'I6xW1EY J, PtA 01969 23 P8 I' 1633 og/28/1r ; 105711 f Fold Then Detach AlongAWportoretlons �� otviF�+ q`-Aus � 4 •,� N ��`l i I y'i f ,�tta;S�NSE' - c y nl