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248 HIGHLAND AVE - BUILDING INSPECTION
� I 6[ RECEIVF��ItJ'� 4EU , R1ofHassacimsetts 2915 HAV'Fgt IiNe$atgermit 15 — Permit N. _ i Estimated Job Cost: S 9,000 — Permit Fee: S /% h Pl:ms Subn,ittad: YFS _ NO t/ Plans Reviewed: 1'ES NO 11'siness License# Oq-3l}4W-1 41 QC•' %-\5` '-% --- Applicant License tt Sr'\ a053 Business Inli,rn,ation: Property Owner/Job Location Intimation: Name: Street: Ca -------- _ Street: 24� �tGti+� N� Art City!['own: M%00�- PaoCity/Town: `�M Ci MR Telephone: 3471— S Telephone: I'huto I.D. required/Copy of Photo LD. attached: YES_ NO_ J-1 / ;�l-I-unrestricted license `1Q J-2/IN(-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. It. /2-stories or less Residential: 1-2 Family__-_ Multi-tan,il Y._ Condo/Townhouses— Other— Commercial: 0 Met!_ Retail Industrial Educational_ Institutional_ Other_ Square Footage: under 10,000 sq• tt• J over 10,000 sq. tt._ Number of Stories: _ Sheet metal work to he completed: New Work: _ Renovation: ✓ IIVAC ✓ Metal Watershed Rooting_ Kitchen Exhaust System_ Metal ('hinotey/ Vents _ Air Balancing Pro,ide detailed description of work to be done: \ fir- V�ar A6f Aft C P- Cc>,rr;,f f PIC, c un�� can r�ec C�c�u o -- ff --- - _ cxa . I i INSURANCE COVERAGE: I have a current liabilityinsurance policy or its equivalent which meets the requirements of M.G.L.Ch. i12 Yes No❑ i 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 ❑ ee does not have the insurance coverage required by Chapter 112 of the OWNER'S INSURANCE WAIVER: 1 am aware that the licens Massachusetts General Laws,and that my signature on this permit application waives this requirement Check One Only Owner ❑ Agent ❑ Signature ofOwner or Owner's Agent - By chocking this box((I,I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and Iaccurate to the best of my n compliance with all pertinent provision of the all Massachusetts Building CodInstallations and Chapter performed 112 of under he General permit issuedfor this application will be Duct inspection required prior to Insulation Installation: YES_NO Prneress [nspectinns Comments Date t Finnllusnechtil Conwrents Date Type of License: BY ❑ Master � .. rwe ❑ Master-Restricted urpro•.vn W-61urneyperson Signature of Licensee /Zr o ta5u,71 i Pemml x._. ❑Journeypersom Restricted License Number:Sn Ica S - --({-- Check at I U 2y 3l p J1_/ Inspector Signature of Permit Approval l commonwealth of Massachusetts j Department of Public Safety I Refrigeration Contractor License: RC-019547 1 1 �-Y.1 IN At i. Y nxnREw xgxax�.s 22 Cambridge Stecet tT bHddleboro MA�1.3A6 1 !i )r1. 0 Expiration: commissioner 06i22/2016 a j Employer:TOTAL TEMP INC 1t I a DPS Licensing information visit:www.Mass.Gov/DPS i k 36-004587652 a This card acknowledges that the recipient has wocessfully completed a 10-hour Occupational Safety and Health Training Course in Constnrceon Safety and Htm@h Andrew Xenalds (Peter 4 ce 66873 9/19/2013 (Rainer name-prim or type) (Course end date) _�___;__- > .� : . . . . dOMMON EWWOF, E .. . . :- » © wSOAWQF - 2 < y < + r(4 ■ � ° is 9EFtQ wOc yW AS",' u eP aUNRESTRICTED x® . : . - 2 \ . - �AN $7/NAK15 \ u o'S'T/ \ kI L+ /@ ¥ 4 --- A�Q® DAreIMMIDDlrryY) CERTIFICATE OF LIABILITY INSURANCE D3,,B,15 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(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 endorsements. PRODUCER CONTACT Add Risk Services,Inc of Florida NAME: AOn Risk Services,Inc of Florida 1001 8tickell Bay Drive,Suite#1100 PHONE I FAX Miami,FL33131-4937 Al No,Ext:800-74Ml30 NC, No:800522-7514 EMAIL ADDRESS: ADP.COI.Center Aon com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Ne Hampshire lns Co 23841 INSURED INSURER B ADP ToolSource II,Inc. 10200 Sunset Drive INSURER C M iam 1,FL 33173 ALTERNATE EMPLOYER INSURER D Total Temp Inc 22 cambridge street INSURER E Middleboro ,,MA 02346 INSURER E COVERAGES CERTIFICATE NUMBER:98236e 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. LIMITS SHOWN ARE AS REQUESTED. INSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY SEE POLICY LIMITS LTR INSR WVD MMIOONYYY MWDD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE ❑ OCCUR PREMISES Ea eccunence S NED EXP(Any oneperson) $ PERSONAL B ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANVAUTO BODILY INJURY Perperson) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Peramidem $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMB RELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMSMADE AGGREGATE $ DEC I I RETENTION$ WORKERS COMPENSATION PER OTH- A AND EMPLOYERS'LIABILITY YIN WC 094184547 MA 07/01114 07/01/15 X STATUTE Eft ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMSER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $ 2,000,000 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 200D,000 If,s.de:.wm-der DESCRIPTION OF OPERATIONS betow E.L.DISEASE-POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) All workers employees working for TOTAL TEMP INC,paid under ADP TOTALSOU RCE,INC'a payroll,are covered under the above stated policy. TOTAL TEMP INC is an alternate employer under this Policy, Project at Dunkin Donuts,248 Highurol Avenue Salem,MA 01970 CERTIFICATE HOLDER CANCELLATION City of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 93 Washington Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem,MA D1970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE prfon.&iek(Teltviaea, 4aa0 (floi ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD acoRo® CERTIFICATE OF LIABILITY INSURANCE OATS(MM DDIY 3/16/2015 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(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). PRODUCER CONTACT NAME: Trish Novak Dowling Insurance Agency, Inc PHONE ('7B1)898-7652 aC No:(]81)380-8]83 44 Adams Street E-MAIE L A DD SS,tnovak@dowlingins.com tnovak@dowlin 1ns.com R P.O. BOX 850962 INSURERS AFFORDING COVERAGE NAICS Braintree MA 02185-0962 INSURERAAL'bella Protection Insurance INSURED INSURER B: Total Temp, Inc. INSURER C: 22 Cambridge Street INSURER D: INSURER E: Middleboro 144A 02346 1 INSURER F: COVERAGES CERTIFICATE NUMBER:Salem DO 3.16.15 TN 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 ADDLSUSR POLICY EFF POLICY UP LTR TYPE OF INSURANCE POLICY NUMBER MWDDA'YYY MMIDDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 A CIAIMS-MADE FXIOCCUR 3500043737 /17/2014 /17/2015 MED UP(Any one Person) $ 5,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000;000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PIFr.TRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaaccident $ 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OS X SCHEDULED 020002289 /17/2014 /17/2015 BODILY INJURY(Per accident $ AUTOS AUTOS ) X HIREDAUTOS X AUTOS ED Pe a cideu ROPERTY DAMAGE S COMBI $ 20,00 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMSMADE AGGREGATE $ 1,000,000 DED I X I RETENTIONS 10,00C 14600043790 /17/2019 /17/2015 $ WORKERS COMPENSATION I WC STATU- I OTH- AND EMPLOYERS'LIABILITY YIN (TORY WITS ANY PROPRIETORPARTNER)EXEOUTIVE E.L.EACH ACCIDENT S OFFICERAIEMBER EXCLUDED? NIA (Mandatory in NH) E.LDISEASE-EAEMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,R more space Is required) Job: Dunkin Donuts 248 Highland Avenue Salem, MA 01970 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington Street Salem, NA 01970 AUTHORIZED REPRESENTATIVE Paul Dowling/TRISH ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 r?ntnnE,n1 The arr1GD name and Innn are ronicfemd mark.of ACnRn