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102 LAFAYETTE ST - BUILDING INSPECTION (3) urvLrs �.� �2 I , I Z S r✓n, /T Za? .3'75 E sb(➢$ r Conuu0111vealth of Massachusetts Sheet Metal Permit —rl ,tP KA C - Date: l� ------ I'euurt # listintatrd Job Cult: S_ ��/ / Qw " r" — Permit Fee: Plans Submitted: YES '� NO_ r� - . Plans Reviewed: YFS NO ° Business L.iccnse # 3 v, 13 Applicant License # IQL/70 > 4PE; 131'siness information: Property Owner/Job Location fntimnauon N.uue' _ b Name:L0/I( r�Jl street: 3�0 -lrCi- Street: _/ �`.z_n='vLAJ;� �3$ City/Town: U` City/Town: 735 Telephone: Telephony! Photo I.D. required/Copy orphoto I.D. attached: YES_ NO N J-1 49,nrestricted license xmrn„iu:a t(3 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-tantil y Cundu/"Ibwnhouses_ Other_ C onuti'crci�l. ';Ottice_ Retail_ Industrial _ Educational Institutional Other i Square Footage: under 10,000 sq. it._ over 10,000 sq. ft.— Number of Stories: Shect'octal work to be completed: New Work: ✓ Renovation: IIVAC t/ Metal Watershed Rooting_ Kitchen Exhaust System Metal Chimney/ Vents_ Air Balancing_ 0� I'ruvide detailCd description of work to be done: cl c-�z.' cw�, e�.j�s-� PAP f -1 y3 C - �l �cv� e�/cl �Jf°7K� /o ✓- /�y Y/o� f f 7 ({ V 1) 3-'�- PeikJ,.t-1 S1� 7 '4 A f� Ste?-6 0 ./Ow "P .7 q 5 INSURANCE COVERAGE: M.G.L.Ch. 112 Yes u JFJ/No❑ I have a current liabilityInsurance policy or its equivalent which meets the requirements of 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 tthe e licensee on this permit does not have the application waives nce coverage required by Chapter 112 of the Massachusetts General Laws, that m signature Check One Only Owner Agent ❑ Signature of Owner or Owner's Agent accurate to the best of my knowledge and that all shoat metal work and Installations performed under the permit issued for thin application will be By chocking this box❑,I hereby certify that ail of the details and Information 1 have submitted(or entered)regarding this application are true an In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. to Insulation Installation: YES NO Duct Inspection required prior PrnnreSs IIISpI'L't1n nS Continents Date Final It�ction Colnluen[s Date 7Master ense: By nne -Restricted ❑Jaumeyperson Signature of Licensee i P000n s ❑Journeyperson-Restricted License Number: � r,:u i _ _.-_------- ------ ❑ _ Check at:•,•.vw.m.lssquvhlL I i , In speclor Signature of Permit Approval -- oom rue(c J 1 v 04-� O(A F CERTIFICATE OF LIABILITY INSURANCE UATE(MMDDYYYY) 8/26/2015 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. N SUBROGATION IS WANED, subject to the terns 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 Ra E: thleen Fuller NAM Sylvia 6 Company Insurance Agency, Inc. PHONE (508)995-4553 FAX No (508)995-4525 500 Faunce Corner Road EApp lL�:kfuller@ sylviagroup.coax Building 100 Butte 120 INSURE AFFORDINGCOVERAGE NAILS Dartmouth MA 02747 INSURERA:$eleCtive Insurance Co of The 39926 INSURED INSURER B:SeleCtive Insurance Co of SC 19259 ENC, LLC CBC, LLC INSURERC: 536 GRANITE ST INSURER D: Floor A3 INSU(E.R E: BRAINTREE MA 02184-3952 INSURER F: COVERAGES CERTIFICATE NUMBERA5-16 GL BAP DMB 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 AWLISUBR TYPE OF INSURANCE POLICY NUMBER MMMDDCDY M IEFF LIDYE)M LTR LIMITS R COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMA ORENTED 100,000 A CLAIMS-0MADE R OCCUR PREMISES Ea ocgarerrce $ S 2022000 7/30/2015 7/30/2016 MED EXP(AM are person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3,000,000 POLICY®Ca LOC PRODUCTS-COMPIOP AGO $ 3,000,000 OTHER: S AU LI TOMOBILE ABILITY COMBINEDSINGLE LIMIT $ 1,000,000 Ea accident B ANY AUTO B Person)BODILY INJURY(Per $ ALL OWNED R SCHEDULED A 9098720 7/30/2015 7/30/2016 BODILY INJURY(Per acadent) $ AUTOSAUTOS NON-OWNED - PROPERTY DAMAGE I HIRED AUTOS R AUTOS Per actlder4 $ Hired PD-MhirriMPremuun S R I UMBRELLA LIAR R OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS UAB CIAIMS4VIADE AGGREGATE S 5 000 000 DED RETENTIONS S 2022000 7/30/2015 7/30/2016 $ WORKERS COMPENSATION PER OTH- ANDEMPLOYEP-T=UTY YIN ATUTE ER ANY PROPMETORIPARTNEMEXECUTIVE NIA EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatary in NH) E.L.DISEASE-EA EMPLOYEE $ 6 yas descriW w,der DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Add18orml RemaHa Schedule,may he aHaaW H more space la required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE KNC I.I.C. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 536 Granite Street ACCORDANCE WITH THE POLICY PROVISIONS. Braintree, MA 02184 AUTHORED REPRESENTATIVE Maureen Armstrong/KF ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 nn14n1) I be f-onintonwetu n OJ massacnasens Department oflndustrialAccidents Office of Invesdgations I Congress Street,Suite 100 Boston,MA 02114-2017 U1V www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Ore nization/Individual): KNC, LLC Address:536 Granite Street City/State/Zip:Braintree, MA 02184 Phone#:781-843-3801 Are you an employer?Check the appropriate box:❑4. a of project I am a general contractor and I 6. (required): 1.❑■ I am a employer with 15 g 6. El New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 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.insurance. required-] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑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 comp.insurance required.] 'My applicant that checks box#l must also Ell 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. iContractors that check this box most attached an additional sheet showing the name of the sub-contractors 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'compensadan insurance for my employees. Below is the policy and job site informadon. Insurance Company Name:Berkshire Hathaway Guard Policy#or Self-ins. Lic.#: R2WC647439 Expiration Date:07/30/2016 Job Site Address: Congress St Residences-Salem City/State/Zip: Salem MA 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$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. Be advised that 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 penaties ofpedury that the informadon provided above is true and correct Simature: Ike ( Date: Phone#: 7818433801 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/TownClerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: BERKSHIRE HATHAWAY worker's Compensation and Employer's Liability Policy INSURANCE AmGUARD Insurance Company - A Stock Company RGUARDCOMPANIES Policy Number R2WC647439 Renewal of NEW NCCI No. [21873] Policy Information Page (AR) [1]Named Insured and Mailing Address Agency KNC LLC _ SYLVIA &COMPANY INSURANCE AGENCY 536 GRANITE ST 500 Faunce Corner Road/BI BRAINTREE, MA 02184 Dartmouth, MA 02747 Agency Code: MASYLV10 Federal Employer's ID 90-0872884 Insured is Limited Liability Co. (LLC) (2] Policy Period From July 30, 2015 to July 30, 2016, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Refer to Residual Market Limited Other States Insurance Endorsement-WC200306B D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ 14,153 Total Surcharges/Assessments $ 727.00 Total Estimated Cost $ 14,880.00 INTERNAL USE OH Page - 1 - Information Page MGA : R2WC647439 WC 000001A Date : 08/05/2015 MANOTE Issuing Office: P.O. Box A-H, 16 S. River Street, Wilkes-Barre, PA 18703-0020 9 www.guard.com — _— — s 3} h I , OMMOWWEAL�Tii OFOF MA"� TiUSETTS•k'I"; r • • • • f P rl s r • • • •� y I SHEET M�T�CIi WORK�RS �, , { -4" ISSUES�THEF�AtLLOWING LIG�E3E AS A �Q2 ,��s�„tc <536 GRANITF STRETf o x m ss o BRAINT�2 'MA 02i84398 � "she`- �C ''�w s�tti'•v�� ` �� • 7t2812018 '., 84756 1. � �. :.A qc) q _l L4 `1 q S G-C) G " 5 pEZML UNEEV< � (c) " -7 3 � 3 � Commonwealth of Massachusetts City of Salem Y Ta 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5041 Return card to Building Division for Certificate of Occupancy Structure CITY OF SALEM BUILDING PERMIT PERMIT TO BE POSTED IN THE WINDOW Excavation jFooting INSPECTION RECORD Foundation Framing e: Mechanical Insulation INSPECTION: BY DATE Chimney/Smoke Chamber Final ...,. Plumbing/Gas ' .Rough:Plumbing k Rough:Gas Final Electrical Service - Rough S.- Final Fire Department Preliminary .. Final Health Department Preliminary Final