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23 GREEN ST - BUILDING INSPECTION (2) Commonwealth of Nlassae u h l SERVICES ,C,�t49,1 it Sheet Metal Permit,% FEB 21 A 11-. Sd Date: �a 0�6 Permit # 1 Estimated Job Cost: S 'ennit Fee: $ 3 1 ��' k l Plans Submitted: YES NO Plans Reviews : YES NO Business License # I� 9a 3 Applicant License # Business Information: Property Owner/Job Location information: Name: l�✓�tJllr� 7U�/ �i`✓�ZVC,Name: ��,4�IJ �l I/�f/�fj/ 4/r Street: < I X4f l6 .&' Street: ,21i City/"town: �y ()X7�� ar. 3_1�- City/Town: Telephoner 9�a0 i Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES_-_%e NO V ti1JIr I it!11:1I J-1 4Dlirestricted 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; I-2 family_ Multi-family v Condo /Townhouses Other Commercial: Office Retail Industrial Educational Institutional/ Other_ Square Footage: under 10,000 sq. ft. v over 10,000 sq. tt, _ Number of Stories: Sheet metal work to be completed: New Work:�_ Renovation: FIVAC 4e Yletal Watershed Rooting_ Kitchen Exhaust System Metal Chimney/ Vents_ Air Balancing_ Provide detailed description of work to be done: ®A1161pEfi /00k Ail 11C -d,W G We -A A-C 0C)tS PC U)o K , mw (�Al✓E 4 1e 4�C?/Q Ir / IV -- INSURANCE COVE°�RAff: ::. f A PE cV i t. I I have a current liability insurance policy orlts equivalent which meets the requirements of M.G.L. Ch. 1 El 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_ Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑ Master Title )<Master-Restricted r City./Town ❑Journeyperson Signature of Licensee Permit# *74qZ-2 ❑ r G- Journeyperson-Restricted � License Number: Fee$ ❑ Z Check at www.nr<1ss.govldpl I Inspector Signature of Permit Approval Please visit our web site at http://www•mass.gov/dpl/boards/SM BASILIO HENRIQUEZ (SM) 11A MAPLE PL FOXBORO MA 02035-2905 _ Fold,Then Detach Along All Perforations 'COMMONWEALTH OF MASSACHUSEETTSf--.,j [fig ffelmumfel • g „ SHEEIT METAL, s *. ' ISSUES THE FOLLOWING ENSE ' ,AS A MASTER UNREST CTEO/r ' Z 25 .[ AS1LI0 'HENRIQUEZ � � lfY+f1�` ,, . •' 11A MAPLE PL` .;,,,t� x o ' FOXBORO==: MA 0203$ 2905 X t24,2�'" `° ot/2811.7 FEB. 29. 2016 12: 23PM DELAND GIBSON INS NO. 8763 P. 1 UNLJrUE-01 DATTRIDGE ,d►C4JR0" CERTIFICATE OF LIABILITY INSURANCE OAT1 22912016z9nols THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERSNO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHEPOLICIES 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). CONTACT PRODUCER NAME: Deland,Gibson Insurance Associates,Inc. PWHCC0 . 781 237-1515 do r e NP 781 237-1805 36 Washington Street Wellesley ills,MA 02481 EP"A'LADDRESS:info doland ibson,com INSURERS AFFORDING COVERAGE NAICP Nsu..RA Norfolk&Dedham Insurance Company 23965 INSURED INSURER a: Unllmlted Fuel Heating Inc. INSURERC: Agustin Henriquez INSURER D: 11 Maple St.Apt,1 Foxboro,MA 02035 INSURERS: 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. NOTVd1THSTANDING 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LCYEFF P CY E%P UNITS LTR TYPE OF INSURANCE INSO POLICYNUMBER MMMON MMMVIYWY A X COMNERCIALGENERALLIABILITY EACH CCCURRENCE S 1,000,000 GLAWSWADE Q OCCUR R10460M 06/10/2015 (16/1 012 0 1 6 PREMISES&AAaerMl 100,000 MEO E%F(Any mm peMan) 6,00 AL&AOV INJURY E 1'000,000 GEN'L AGGREGATE LIMn APPLIES PER: AL AGOREGATE S 2,000,000 X POLICY�PRO-JECT � LOC CTS-COMP/OP AEG S 2,000,000 E OTHER: OSINGLELN1 $ AUTOMOBILE LIABILITY . nl A ANY AUTO 9 S661735A 0811812015 tj"INJURY(Perpemon) $ 250.00SOS IED X SCHEDULED INJURY(Per accident) S 500,000X NONLOWNED TYOAMA $ 2SO,00HIRED AUTOS X AUTOSd 1SUMBRELLA LIAB OCCUR - CCURRENCE EE7(CESS DAB OLAIMB-MAOE GATE ffi ' DEo I IRETENTION$ f� _ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LL401UTY YIN 11VE13228$A 1010312015 1010312016 E,L.EACH ACCIDENT $ 100,000 A OFCERBRLU7��TNE aNIA 100,000FINEMEEXCDED (Mandamryln Wd) E,L.DISEASE-EA EMPLOYE $ Ilyyea dadMbe wtler E.L.DISEASE-POLICY LIMIT S 500,00 DESbRIPTION OF OPERATIONS y 'M DESCRIPTION OF OPERATIONS I LOCATIONS I VENICLES (ACORD 101,Atldltlsnal Remarks SCNodule,may De klmened Irmtlm apace Is requlNtl) FAX: (978)740 9846 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL DE DELIVERED IN Town Of Salem ACCORDANCE WITH THE POLICY PROVISIONS. Salem,MA AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD \ The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 rr Boston, MA 0211 4-2 01 7 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leidbly Name (Business/Organization/Individual); r r Address: %/ l, J;L�k',ho fC0 /y�wA- (!!57 ';-a 1? � City/State/Zip: Fla X10 Wzf 0 hone#: CP /' ;7- O Are you an employer?Check the appropriate box: F� "ct(required): 1.0 I am a employer with employees(full and/or part-time).R nstruction 2.❑I am a sole proprietor or partnership and have no employees working forme in eling any capacity.[No workers'comp.insurance required.] 3.❑1 am a homeowner doing all work myself[No workers'comp.insurance required.]t tion 4.❑I am a homeowner and will be hiring contractors to conduct all work on m property. g addition Y P perty. 1 willensure that all contractors eitherhave workers'compensation insurance or are sole al repairs or additions proprietors with no employees. mbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. These -contractors have employees and have workers'comp.insurance.: of repairs 6. a are a corporation and its officers have exercised their right of exemption per MGL a er 152,§1(4),and we have no employees.[No workers'camp.insurance required.] 'Any applicant that checks box 41 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 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. //� �j fp Insurance Company Name: Oyo�d--o � >yt Policy#or Self-ins.Lic.#: /,,c Expiration Date: Job Site Address: 4R 3 61)?e5r✓!7�/r r City/State/Zip: 5��,E/?q, 7yJ`f- 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 the pains and ppenn�j/lties o per ry that the information provided above is true and correct. Suture: .(/�i> t t l Date Phone#: V Official use only. Do not write in this area,to be completed by city or town offrciaL City or Town: Permit/License# Issuing Authority(circle on 1.Board of Health 2.Building Department 3.City/Town 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 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"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-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 the appropriate line. 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 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 dog license or permit to burn 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. # 617-727-4900 ext. 7406 or 1-877-MASSAFF Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia