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219 LAFAYETTE ST - BUILDING INSPECTION (3) I Tl )- I Ll - Z-3/= Cr- 04(055.:8 $ [ 12-00 Commonwealth of Massachusetts E Sheet Metal Permit INSPECTR IOCEIVNAL SERVICES Date Map—Lot Permit# U14 HUV LOA 11: 18 Estimated Job Cost:� 0060= Permit Fee: Plans Submitted: YES NO Plans Reviewed: YES NO Business License#_5 Applicant License# Business Information: Property Owner/Job Location Information: Name- 0,V &M,6 AdA,14'1t. Narne: "/) Street://- d- )6bA, ,Aqj Street: C i tyf ro wn:<9� q11 2& City/rown i aahb Telephone: Telephone: Photo I.D. required I Copy of Photo I.D. attached: YES t,<' NO_ Building Type: Residential: 1-2 family Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. �7over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: HVAC / Metal Roofing Kitchen Exhaust System Chimney Vents Provide brief description of work to be done: -Dop Inspector Signature, b S1-Aofz--ri t-A c--, pot P c-4 12 • .5 PN�e-4`) 511 a 7 ct 7 strp V To C-/ 0 hj T. E5 CzAu&--TTj -r5f> I-QJ T-PAO—r Z 1-015 0 INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L Ch.112 Y No If you have checked Yes,Indicate the t 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 licensed 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 FM Signature of Owner or Owner's Agent By checking this bexp,I hereby cardry that all of the details and Information I have submitted for 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. Progress Inspections Date Comments T Final Inspection Date Comments Type of license: By AlMaster / Title !� -9 Master-Restricted Citytrown ❑Joumeyperson Signatur of Licensee Pennitd ❑Joumeyperson-Restricted License Number: O ) t .3(4(0 Fee$ ❑ Check at www.massmovidni Inspector 819naWre9f PermK Approval, _.--_ ... ................_..__..._.__._._..__._.. ......._ . -._-- • t • F _ t t t t 4 �.=...a:=�, a -• • •- F� ,a' 1 •sit � Lf 3< ...i-aH:' nk /1'..i '� �.+�eKn gwk� 9 � �,. ,�y u ��A�. .A..td 'I�' �fl' .y a � D;VlSiON OF PROFcS s'ON a4 'r EdCp •3e'�n�" $.` ., .' J ;StV^ 3^`� fFW� v. ° AM ff— A,o R,c_ A_ Ji&ER t uLj �.. . + � '. LICEMSc NUMBER t �. .+. 1 P1U-.It 3° h Jt�t� E�4,;°1•! ' r : � .JS-. �.f`t� r-�n'�•aYa� w s :. •�h ` �w :..¢F g.� .R'�`- ^m'�s t, � z "�`` ems• s�4 7,y m 5.e.�.' '•, +,ti {^ �'. ,�'j �' J.�� ti ) A r sft e1fA 4 y t�.,.�"5'a:�` " • - s` �-dd�'"i�4�r '�' �,a,�uy�._.�n„'rSt.`� r•�{ fR � 1 � TDA '✓_`5,.9 � .� - su �" .J:22rsnza 4..k.�fi. 'z +°a✓. xr' e2 x 51 s �...� c°4µ•�;%u�+..-•a k.- 3u�2/�:4_�...2:! a^a.c't•� 2'Yr: s+c.3i^,w T° CITY OF SALEM, NWSACHUSETI'S Buimt:IG DEPARTMFNIT 1201' ASN6NGTON STREET, 3"oFLOOR TEL (978) 745-9595 F.kx(978) 740-9846 K[NIgERLF_Y DR]SCOL `';VLIYOR TtaohtAs ST.PtERRs DIRECTOR OF PC13LIC PROPERTY/BCILDINIG CONEMISSIONiER NVorkers' Compensation Insurance Affidavit: Builders/Contractors/Electric[ans/Plumbers Anolleant )nfnrmation Please Print Leelbly Name IHminers,Organiroiorelndividual): �P�/ �{'1 /� n iCO�� Address: City/state/Zi ` 1970 Phone At: 7,,,' 7yr—sv Are you an employer?Check the appropriate box: LE34timodeling project(required): I.Q I a a employer with 4. Q I am a general contractor and 1ew co lion niplayees(full and/or part-time).* have hired the sub-contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet. fmodeling ship and have no employees These sub-contractors have molitionworking'ror me in any capacity. workers'comp. insurance. ilding addition lNoworkers'comp. insurance 5. ❑ We are a corporation and itsctrical repairs or additions required.) officers have exercised their3.Q 1 am a homeowner doing ail work right of exemption per MGL mbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no of repairsinsurance required.) t employees. [No workers' er comp. insurance required.) -Agv upplicma dux checks bur as must also rill oul dw secliu s bdowshowiny xheir worker'mmpenmfon pulisy mr madon. 'I Inmauwrw•n who wbnril this stiidavil indicating they am doing all work and than hire uutaido commctan mtul submit a na w airidavil indicating such. $.vumutun thus chwit this bus mml anachod an sddiliurul ahrzl showing the mane oftha sub•cons"ctun and their woken'comp.policy Intunraxian. f unr un etttpluyer diet is providing ivorkers'contpettsmlon blsurauce for my employers, Below is the policy and Job site infunnutian. Insurance Company .Name:it 1�C(,,//�� nn_ (��D [� Policy or ScxFio.s. Lie. it: 4)(_A � 1 (nq.. 5 f a. Expiration Dntte::/0A 0- ` ^� ��r ly—I Job Site Address:i lQ 11 _ �'Ya"` City/Starr/Zips)u't/9�l .{ 'V' l�90 Attach a copy of the trorkers'compe satloo pAc9declaration page(showing the policy number and expiration date). Failura to secure coverage as required under Section 25A of SIGL c. 152 can lead to the imposition ofcriminai penalties of a tins up to S1,500.00 undlor one-year imprismmnient,as well as civil penalties in the form of a STOP WORK ORDER and a line orup to 5250.00 a day against the violator. Ile advised that a copy of this statement maybe furwardcd to the 011icc or Investigations orihc DIA fur insurance coverage verification. /du her c• r y under rite pubis and penoBlec ufperjury that floe bi/bratatlon provided above is true coirdd orrecL S ,•n t c' - pate' �_� �// r P r ,Y: � — 2 4 FC.t'y ul use only. Ou n✓r rvrire in r/iir area, ro be cuurpletad by city car rurvn o/PubuL r l'nwn: _-- -- Permit/Lleensc q—_..-.---. Issuing Aulh°rily (circle one): 1. Board of Ilcahh 2. Building Deparinxcut .).caya,mi,C'ierk J. Electrical luspcctur S. Plumbing Inspeclor I 6. Other i I Contact Perron: ___ Phone:J_______ i s COMMONIiUEAL7li:'OF MAtgi' -i 1S S F:ilmff!MMLSI OM 0 .pp w^ .p SHEEIM T = ETAl WORKERS s , ISSUES:TNE FOLLOWIJGgL1'CENSEg AS--A MASTER-UNRESTRICTED DAVt�? A GARO'INE R a.: 457 .WikwiCUNDETT_'RD . ' 2 APT .3}0 HAMPTON NH 03842 281° ° 'O, 28,1 zt81Gt , --o'll, DRYAI.1 OP ID: OUJA ;d►lklw " CERTIFICATE OF LIABILITY INSURANCE 1 DATE11/2 D/YYYY) 1/24/14 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 poliey(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 Phone: 978-688-6921 CONTACT Macdonald&Pangione Insurance PHONE FAX P.O.Box 428 Fax: 978-688-6350 A/c o Exth INC.No 104 Main Street E-MAIL North Andover,MA 01845 ADDRESS: Michael Pangione INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Libedy Mutual Insurance Co INSURED Dry Air Systems Inc INSURER B:Commerce Ins Co 34754 18 Graf RDod, Unit 10 Newburypr;rt, MA 01950 INSURER C INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY TH r THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVVITHS:ANDING 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 CON:-LIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYnE OF DDL UBR POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD/YYYY MMIDD/ffYYI LIMITS GENERALLIARILI'IY EACH OCCURRENCE $ 1,000,000 A X GGMMERCIAL GENT" 11-LIABILITY BKS56168953 07/11/14 07/11/15 PREMISES Ea occurrence $ 1,000,000 CLAIiA$-MADE XI OCCUR MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMI I 'JPLIES PER PRODUCTS-COMPIOP AGO $ 2,000,000 POLICY FX PRO- Loc EPLI 1 $ 10,000 AUTOMOBILE UARILITY COMBINED SINGLE LIMIT 1,000,00 Ea accident 8 B ANY AUTO BDJNWZ 07/11/14 07111/15 BODILY INJURY(Per person) $ ALL O=PIM ' SCHEDULED - AUTOS AUTOS BODILY INJURY(Per accident) $ I HIRED Alli05 }: NON-OWNED PROPERTY DAMAGE $ AUTOS Paraccident $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESS LIAD CLAIMS-MADE 0001556210624 07N1/'14 07/11/15 AGGREGATE $ 4,000,000 DED X RETEN I"1N$ 10000 $ WORKERS COrnPENSALK"I WC STATU- MR EMPLOYI-RS'LIADII.I'Y YIN T MIT R ANY PROPRIMOR/PARII. uEXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICERIMEXIIiEIt EXCEL Id)P NIA (Mandatory in Nil) E.L.DISEASE-EA EMPLOYE $ If yes,dasmbe,:ndor DESCRIPTION OF OPER/SONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATION'S ,.9CATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more spew Is required) CERTIFICATE HOLDER CANCELLATION - - - SHOULD ANY OF THE ABOVE DESCRIBED-POLICIES BE CANCELLED BEFORE City Of Salom THE EXPIRATION DATE THEREOF,.NOTICE .WILL .BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washlr.gton Street -- Salem, MA J1970 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. 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