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287 LAFAYETTE ST - BUILDING INSPECTION (3) L4 -7 --,t 3ro3 O Commonwealth of Massacimsetts RECEIVED r' INSPECTIONAL SERVICES Sheet Metal Permit �; 31 t 111% NOV =b P v�tA Date: . — — Permittt --- --- Estimated Jab Co t: 'S--137� Permit Fee: .5 Plans Submitted: YES t-�NO _ PIanS RCVIC1VCd: YES _— NO _ 13usinesS I-iCenSe tt /��z�/� Applicant License k Business Int6rmation: Property Owner/ Jab Location information: Name: W XIS Me c Lt Name: Sc, /�.� �fjf-7e P Oe _ Street: vc ql / `! W, Street: 2 e-7 . S 7- City/'town: _- © f P'7 City/Town: s469-1 17-4145 f Ol 270 Telephone: 97e- /— ,f,�l 7 O Telephone: Photo I.D. required/ Copy of Photo I.D. attached: YES_ NO_ J-1 / M-I-unrestricted license Staff Initial 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_ Nlulti-family_ Condo/ Townhouses Other_ Commercial: Office_ Retail _ Industrial _ Educational (� Institutional Other Square Footage: under 10,000 sq. t2. _ over 10,000 sq. ti. _ Number of Stories: Sheet metal work to be completed: New Work: _ Renovation: IIVAC i\[etal Watershed Rooting Kitchen ExhauSt System e Metal C'hinmcy/ Vents _ Air Balancing Provide detailed description of work to be done: A N S-m L�L I `4 ®_ 'iC - ISo py �' w� tc Use N�c -EXI c5(, �om� Ca I\J E't j V U1,.*� 1�.) ► � t✓2E—b _ � Gig -� 5�-- �t �o It t3 —� Lc>r0 5ipt.�or�r Syr t0 INSURANCE COVERAGE: r, „�.. I have a current Ilabilit insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes No If you have checked Yes, indicate the ty e 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 boxE1,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_ Prouress 111SI)C ions Date Comments Finul lusncction Date Comments Type of License: By ❑ Master rice_ _ ❑ Master-Restricted unyrrowo__ ❑Journeyperson Signature of Licensee pop11t z-- ❑Journeyperson-Restricted License Number: Check at w•.w.v.1i'ais.;lovl1ipl Inspector Signature of Permit Approval CITY OF &U ENf, N-LkSS:ICHL;SETI"S i BL'ILDNG DEP1RTfE1NT 120 %VASHNGTON STREET, 3"FLOOR TEL (978) 745-9595 FAx(978) 740-9845 Kj.\tB Rf RYDRISCOL T {;MAYOR t-tontAs ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/BUELDNG CO\LMISSIONBR Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anplicant Information Please Print Le ibty Valnc(nusitwscgrganiratiam'InJividual): h 7�J 1 � � � I f/C�� Address: f'o (((J�c��C Cily/State/Zip: 1)U c t ' Phone #: LS 81 76 Are you an employer?Check the•appropriate box: Type of project(required): I.L�l I am a employer with 4. O 1 am a general contractor and 1 6' employees(full and/or part-time).* have hired the sub-con ructors �0-I,�New construction 2.O I am a sole proprietor or partner- listed on the attached shear. t 7. fry tcemodeling ship and have no employees These sub-contractors have S. C] Demolition working for me in any capacity. workers'comp. insurance. 9. O Building addition [No workers'comp. insurance 5. ❑ We are a corporation and iU requited.) officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 1 I.0 Plumbing repairs or additions myself.[No workers'sump. C. 152, §1(4),and we have no 12.0 Roof repairs insurance required.) t employees.[No workers' 13.0 Other sump. insurance requin:d.J -Any applies dlul charoks box rt owl also fill uul the section below showing their woskm'eompenudon policy inbmnadon. 'I b+meuwnen who.ubntit this smrhvit indicating they me dotng ail watit and than hire ouisidecomrscton mtul nlhmit a new amldavit indiuring such. Klnnnvmn that shack this box mtal anachai an addiduml•hoe shu wing the nwna of the suba'atnracMn and III air workers'camp.put icy infumtalion. I our on employer that Is providing workers'conopersatlon/nruruuce for my employees. Belo v is the policy mrd%ab shv lofornrution. Insurance Company Name: - �/' .__�_r� \ Policy 4 or Sclf-iuv, Lie.j d: JJ � /' V }i_[ ,�b oL L Expiration Date:: (S Jub Site Address: , -� 31- /���.. tY I J City/State/Zip: , G,A4 Attach a copy of the worker'compensation pulley declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 2JA of MGL c. 152 can lead to the imposition ofcriminai penalties ofa lino up to SI.500.00 und/or one-year imprisonmcn4 as well as civil penalties in the form of it STOP WORK ORDER and aline of up to S230.00 a Jay against the violator. Ile advised that a copy of this stalement may be forwarded to the Oflice of Investigations oldie DIA for insurance coverngc verificaliun. 1 du hereby ciattitjy a der the pains andd poe/a[s,/d,(r/(�,aj�prr%ury lbu!!de injunnu!/on pr�vided�ju/r/'�uve.is True and soarer 1'I•'n II�K: i7T-AJ - '6 9't�^�✓I/" -/ — 1)a re: �i(,F � 1' 70, O%/ic'iul use only. Du nor write in lhir area,to be compleled by city or to lea n/Jieiui City Issuing,\ol parity(circle one): I. hoard of Ilealih 2. Building I)epartnlcol .1.Cilylftmii Clerk J. F.leetriul Inspector 5. Plumbing lnspeetor 6. Other C no(act Perron: Phnnc:J: I _ $&Ik6'FLLFSIzTES DiiIVERS _. LICENSE ` s iI. _20b; Hog W5322051 s _ 20f F11.� � M la xmb4l e Bd RY.MA BRUON 0 /y 7EWKBBDRY, 016'l1YI1D I (/��� SeetIQFAlt p.yNneAW — /9 Ulf Fold Multiple Tim"Along Pedomguns Beam DeWeNng r "COMMONWEALTH OF MASSACHUSETTS ~ BOARD SHEET METALWORKERS SN 'AS,A_MASTER-UNRESTRICTED ! _ ItSUE4.THE ABOVE UGENSE TO'. TYPE WILFRE1) S POWERS e N1 _;,:8:4 BRDQKFIELD-.RD TE_. : 1. RY MA 01876 2123r 302008 9606 11/28/14 302008 _ _ f" --.- -..FNe memoe nm..-nmrro ao�ewoe.e.rw.o.r;nae V - A�& CERTIFICATE OF LIABILITY INSURANCE 10n°�014MM'DD"YY" 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 endomement(s). PRODUCER CONTACT Susan McDonald.CISR Fred C.Chumh,Ina NAME 41 Wellman Street NCNIB Etl; 9763m227140 FAX No; (978)454-1855 L.R.MA 01851 s ,&m.Id@rredcc humh.mm (am)2 S-1665 ADDRESS' INSURERS AFFORDING COVERAGE NAICN INSURERA: essay insumnm 22306 INSURED INSURER B: GUARD Insurance Group 08281 WJS Mechariml Corp Heel Accident and Indemnity Company 22357 INSURER C: PO Box 241 INSURER D: Tewksbury,MA 01876 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:31201 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 TYPE OFINSURANCE AOOI SUER POLICY NUMBER MMIOOY EFF MPO�ppY EXP LIMITS LTR GENERAL UABIUTY EACH OCCURRENCE $ 1,o0g000 X COMMERCIALGENERALUABILRY PREMISES Ea ooamence $ 300.000 CLAIMS-MADE 111 OCCUR MED EXP(Any one persom $ 5,a00 A X 0ON9079662 5=2014 5222015 PERSONAL B ADV INJURY $ 1.000.000 GENERALAGGREGATE S GENL AGGREGATE LIMB APPLIES PER PRODUCTS-COMP/OP ADD $ 2.000.000 POLICY PRO- LOG I I MBINE $ AUTOMOBILE LIABILITY Es o.deDlSINGLE LIMIT S 1,000,000 ANY AUTO BODILY INJURY(Par Person) $ C ALLOOWNED X SACHOEDULED 08UECAX2471 8252014 8I2512015 BODILY INJURY(Per amdern) $ NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTO$ Per.wdant S X UMBRELLA LU121 X OCCUR EACH OCCURRENCE $ 3.000.000 A EXCESS LikeCLAIMS-MADE ODN9079662 5222014 522J2015 AGGREGATE Is 3,000,000 DED RETENTION$ S WORKERS COMPENSATION X WC STATU- OR AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER ECUrIVE YIN WJWC526932 1I12014 1112015 E.L.EACH ACCIDENT $ 1.000,000 OFFICERIMEMBER EXCLUDED? NIA 1,000,OOD (Mandatory In NH) EL DISEASE-FA EMPLOYE $ It yes,desmDe ontler 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ANacb ACORD 101.Addbional Remadra Sebedule,it more Space is required) Additional insured re9adiN general IiaWiy as required by WdOen contract mx}Caro ion Coodinsmrs(conlraclar):Charles Really A Devebpment Con,(Owned,Fellsway Plaza Junior"ohm A Project Fellsvrdy Plaza JunbrAmhOrA 686 Fells".MCMod.MA02155 CERTIFICATE HOLDER CANCELLATION Cmrstruction Coordinators.Inc 55 Kearney Road SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Needham,MA 02494 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ^ . t—__ ,., 7p"W 1rrAM 1 4 --_—�_ Creme Ma# -3TW1Cert Holder# 4tbUl ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD