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43 JEFFERSON AVE - BUILDING INSPECTION Commonwealth of ilassacImsetts Sheet A((etal Permit I)atc: /L�ZS�Z Permit !/-- ----- - Qv Emimated Job Cost: S _ Permit Fee: S ----- Plums Submitted: YES NO PlanS Rcvicwud: YES NO Business License ;t 72 O -1 MA MI Applicant� license # Business Intixmation; Property Owner/Job Location Information: Name: (Lue'l Name: Street: �(o Qu,loor�n ��fi Slrect: 143 4—� City/'I'own:��e� City/Town: S6t,e-vv-\ Telephone: S - ZZ ` -c5s 6 L Telephone: le 1-7 Z ( 2— 5 3 Photo I.D. required/ Copy of Photo I.D. attached: YES_ NO sluff touFnt J-1 / Onrestricted license J-2 / M-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-Family_ Condo/ Townhouses_ Other_ Commercial: Office_ Retail_ Industrial _ Educational_ Institutional_ Other rS(- tjui �1 Square Footage: under 10,000 sq. tt. Z— over 10,000 sq. tt. _ Number of Stories: Sheet metal work to be completed: New Work: ✓ Renovation: I IVAC Metal Watershed Rooting _ Kitchen Exhaust System_ Metal Chimney i Vents Air Balancing Provide detailed description of work to be done: __Fti4-Jv� INSURANCE COVERAGE: I have a current liability Insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes 'LJ' 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 a-/ Agent ❑ � r— Signature of Owner or Owner's Agent By chocking this h at all of the details and Information I have submitted(or entered)regarding this application are true and accurate to th- and that all shoot metalwork and installations performed under the permit Issued for this application will be In compllar rlinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. 0uct Inspection required prior to Insulation installation: YES_ NO Proflress Inspel'tI0119 Date Comments Final Inspection Date Comments Type of License: ©y taster rune ._ Xi aster-Restricted� Ttirneyperson Signature of Licensee P x --- ❑Journeyperson-Restricted mnut ? 2-0 _ License Number: I Fear_. _._- -_--..-- -_--._- -_--_ Check at :v.v:v n.c;:: uv!,ILI — � I Inp zactor Signahiro of Permit A ro al a CITY OF &UE�I, IN'L1SSikCHUSETTS BULLING DEP{RT\(ENT 120 WASHL]IGTON STREET,3aa FLOOR TEL (978)745-9595 F.kx(978) 740-9846 KIJCBHRLEY DRISCOLI MAYOR THoms ST.Ilmm DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COSMISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Amnlicant information Please Print Lee ft Natne(Ousitn'ssOrganiratiarvindividual): lz r,i._4,4 r4 I Address: A;�/�evn�e- 4-c3 n l (� �_ City/State/Zip: I�ve—r MA .--,Z r t( Phone N: '`3��— Z Z � ' O 13�0'Z Are you an employer?Check the appropriate host 'type of project(required): LSQ I. 1 am a employer with 4. 0 I am a general contractor and 1 6. 0 New construction employees(Nit and/or have hired this subK:omractors 2.0 1 am a sole proprietor or partner- listed on the attached shcet.l 7• ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'camp. insurance. 9, 0 Building addition [No workers'camp.insurance 5. 0 We are a corporation and its required,) officers have exercised their 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions myself.[No workers'comp. C. 152,$1(4),and we have no 12.0 Roof repairs / insurance required)t employees.[Noworkers, 13.9O(her �Jl+�cct_s.,5aos[I camp.insurance required.) 'Any appllc:mt th:a chuks box r I most also fill out ueliw Iwlosv showing their workers'compenudon policy into matiom '1 Nweowm"who submit this Affidavit indicating they am doing all work and than him outside contractor mul mhmil a new a(ndavil indicating such :Contractors that Oast this box most anachsd an additlunul shact showing the name of the mb coalrctors and Chair workers'comp,policy infwmadon, i urn un enrpioyer that is providing workers'comparsadon insurance for my employees Below Is the pokey and fob sits information, Insurance Company?lame: Policy A or Self•ins. Lic.a: Expiration Date- Job Site Address: If3 ?G4orso.., ,�„ City/State/Zip: 14t Prm /A(9 0/770 mlach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). Failure to sucura coverage as required under Section VA of NIG6 e. 152 can lead to the imposition of criminal penalties of s ine up to S 1,300.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to$230.00 a day against the violator. Be advlxed that a copy of this statement may be rorwarded to the Office of Investigmions of lite DIA for insurance coverage vcriticalion l do hdreby certi rpahrs-enJpe les of per/ury Jett the Lrfurmuflon provided ubuve it sue uud correc6 Taro: 2/2- r r� ,, Z Phone,rl� O/]idol use uuiy. Du nnr write in tidy uretr, to be completed by city ur Iown n/Jieiat I City ne Town: __._ _ PermitiLlcense d . Aulhorily (circle one):11.1ourdofIleahh LnuildinpDepartment .1.Citylfown Clerk 4. Electrical Ltspcetor 5. Phnnbing inspector 6.Other _ Cunlacl Person: Phanett: 1 LISTER INSURANCE Fax:781-393-9769 Dec 28 2012 10:38am P001/001 CERTIFICATE OF LIABILITY INSURANCE DATE Uomouwyy) 12/28/2012 THIS CERT1FICgTE IS ISSUED AS p, 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), AU7HORIZEO REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the eerdfleate holder is an ADO/ I NAL INSURED, the p01i0y(ios) must he endorsed. If SUBROGATION I WAIVED, suhject to the terms and conditions Of the policy, certain policies may require an endOraemers. A statement on this Certificate does not confer rights to the Certificate holder in lieu Of such endorsement(s). PRODUCER Lister Insurance Agency Inc- PO Betsy E. Lister Pa"c°."u,eM: ( tArc,NPr(781) 393 - 9769 LN7 Sox�d96 7B1) 393 - 9330 BELiater@agl.com AODRess: Medford, xda 02155 cI19TONER ID p: WSURER(a)AFFORDING COVERAGE NAIC p INSURED INSURERAWeatera Heritage Richard A- Berg INSURER B DER RE Cooling and Heating INSURER c: 16' Pembgrton Street 015URER D: Revere, Ma 02151 INSURER E: INSURER F 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, EJ ELUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURMICE INSR WVD POLICY NUMBER (NM/DDIYWY) IMNUDDr=I OMITS A GENERAL LUUNLITv 8C00907320 OS/25/12 OS/25/13 EACH OCCURRENCE s1,000,000 UAAAGETaR9iTEtt .—........ .._._. _.. gcoMMERCiAL GENERALLIA81Litt PREMISES Ea aocurrercc) a180,OD0 CUMSMPOE C OCCUR MED EXP(Amrone person) 51,000 PERSON 4AwINJURY S1,000,000 GENERALAGGREOATE $2,000,000 GBNLAGGREGhTE LIMIT APPLIE8 PER: PRODUCTS-COMPIOP AGO $2,000,000 $ :POLICf JECT LDC 3 rAUTOMO&LE Wl&LJN COMBINED SINGLE LIMIT (Ea acGOetm S ANYAtfiO hLL CAMEO AU-OS BODILY IWLIRY(PIP 1PAn) $ BODILY INIURY(PerewiI a _ SCHEOULEDP.UTOa PROPERTYOAMAGE HIRED AUTOS (Po eoGOxN) S NOIWOYMEDAUTCa f S UMBRELLA LJge OCCUR EACH OCCURRENCE 5 r EXCESS LIME CLAIMSMAII AGGREGATE a �. DsOucnaLE i $ .. RETENTION S ........- . -_......-.._ __ MORKERS COMPENSATION 3 AND EMPLOYERS'LIABILITY OTIi' PN IN Yp OVRIETOFPARTNMSXECUTIVE �YI TORYLIMITE N ER 'I OFFICERIMEMBER FXCLUDG01 NIA E.L.EACH ACCIDENT $ (Mamlafary.L NH) LJ If,e,deIoMI UP0.1 E.L DISEASE-Eq EMPLOYEE 5 DESCRIPTION OF OPERATIONS 00A. E.L.DISEASE-POLICY 41Mr $ . De5grtkITION OF OPERATIONS I LOCATIONS I VEHICLES(A hACCRD 101,AECIIIPIW Rema.Sehede ,.t I,vry c FI le rcyuheU) Heating & Cooling Job Location: U-Haul 43 Jefferson A"., Salem, Ma 01970 CERTIFICATE HOLDER CANCELLATION City Of Salem Attn: Building Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EILPIRAl1ON DATE THEREOF, NOTICE WILL aE DELIVERED IN 121 Washington Strac,t 3rd Floor ACCORDANCEVATH THE POUCYPROVISIONS. Salem, Ma 01970 AUTHORIZED REPRESENTATIVE >•ax: (97 ) 740-9846 1YSZ+•. -.�,{ � V 1983-2009 ACORD CORPORATION. All rights reServsd. ACORD 25(2009109) The ACORD narRo and logo are registered marks of ACORD