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20 LINDEN ST - BUILDING INSPECTION (2) C� Z-005 Commonwealth of Massachusetts J !t7 Z_ ' Sheet MgtWE$ermit INSPECTIONAL SERVICES I Date; Q Permit# �J 4JOI5 MAR 20 A 4- 45 Estimated Job Cost:$ a0a Permit Fee: $ I Plans Submitted: YES NO_ Plans Reviewed: YES_ NO_ f Business License# Applicant.License# 16 3 3 { Business Information: p Property Owner/Job Location Information: Name: ,�/A Q�l+`Q IwC' Name: P�h6 aQn �Q Street: if(p� 'b45�ai b ��1 Street: ) L/11��//Q//f 6-L Cityfrown: p%,��/.C/d 12A 03 city/rown:SZLiL&14., Mt,-" C3 Telephone: f 7Q� '� �� Telephone:ed/ 7'jd 70 J�J3b / 7 Photo I.D.required/Copy of Photo I.D.attached: YES_ NO Staff Initial J /M-1-unrestricted licenses 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.Y/ Multi-family Condo/Townhouses ' -Other Commercial:-' Office Retail Industrial Educational Institutional" ` Other_ Square Footage: under 10,000 sq. ft. )� over 10,000 sq. ft._ Number of Stories: Sheet metal work to be completed: New Work:_ Renovation:_ HVAC Metal Watershed Roofing_ Kitchen Exhaust System Metal Chimney/Vents_ Air Balancing_ Provide detailed description of work to be done: - i fYlr�it_�rn (a7 �'�7 < INSURANCE COVERAGE: I have a.current`Iiability insurance policy or Its equivalent which meets the requirements of M.G.L.Ch.112 Yes[YNo'❑ If you have checked Yes.indicate the type of coverage by checking the appropriate box below: A liability insurance policy 1 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 Gimeral Laws,andthat my signature on this permit,application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or OwneesAgent By checking thle bu4i hereby.cerdfythatall of the details and Information I have submitted(or entered)regarding this application are true and accurate to the beat afmy knowledge and that all shaft 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 I of the Genend Laws. Duct inspection required prior to Insulation Installation:YES NO Prouess:Insnections Date Comments Final Inspection Date Comments Type of License: By _ _ prMaster Title J� ❑Master-Restricted Cayrrown ❑Joumeyperson Signature of Licensee. PermlGa 7 ❑Joumeyperson-Restricted Li rise Number. Fee$ ❑ C eck at www.mass.aovldoi Inspector Signature of Permit Approval _ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AL4 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/ln(hviid--ual); &eAga(it /lGll 11/yci "Address: ,&/ �57 � ` 4j City/State/Zip: 5 /t' e � Phone#: Are you an employer?Cheek the appropriate box: Type of project(required): 1. I am a employer with lD 4. 1 am a general contractor and I employees(full and/or parttime): ■ have hired the sub-contractors 6. ❑New construction 2.[] I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship;and have no employees These sub-contractors have g• ❑Demolition workingfor me in an capacity. employees and have workers' any ty 9. ❑Building addition [No workers'comp,insurance comp.insurance:t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3,❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurancerequired.]t c. 152,§1(4),and we have no employees. [No workers' 13.[1 Other comp.insurance required.] *Any applicant that checks box#1 must also fill 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 wntractors.must submit a new affidavit indicating,such. Conlractars that Check this-box must attached an additional sheet showing,the name of the sub-contractors and state whether or not those entities have employees. tf the subcontractors have employees;they mustpmvide.their workers'comp.policy:number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. [� /y Insurance Company Name: 07 /ilaelIL CilIGG/e�el� Policy#orSelf-ins.Lic.#: `�Cn,�P5W�,�/ '�' Expiration Date: e8 � /1.5- Job Site Address: c2;Q Ghf 96 City/State/Zip:c e(�/�14 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 U50.00 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. 1 do hereby gerTarjyy jinder the pains andpenalties of perjury that the information provided above is true and correct. Si atur • Date: lS✓ Phone 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.CityNown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6,Other Contact Person: Phone#: PREFE-2 OP ID: KS1 CERTIFICATE OF LIABILITY INSURANCE oAElmmloorcrYr) 08/01114 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 INSURERIS), 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 endoreement(s). PRODUCER 781-914-1000 CONTACT TGA Cross Insurance,Inc. NAmE: Kelly Sturtevant 401 Edgewater Place,Suite 220 °a"(_c_°iie�g�t1:781-914-1000 FAX Nor 781.246-2601 Wakefield,MA 01880 E-MAIL Chris Hawthorne ADDRESS:ksturtevaq@tgacross.com INSURERS)AFFORDING COVERAGE NAICp INSURER A:Arbella Protection Ins.Co. 41360 INSURED Preferred Air,Inc. INSURER B: 461 Boston Street,Unit A3 -- Topsfield,MA 01983 INSURER C: INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OFINSURANCE 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. INSRR TYPE OF INSURANCE 0 L$UaR POLICY EFF POLICY EXP POLICY NUMBER JMMIDDn'YY1'l IMMIODrYYYYILIMITS GENERAL LIABILITY EACH OCCURRENCE $ 110g0,000 A X COMMERCIAL GENERAL LIABILITY 3500025668 08101114 08101/15 -DAMAGE ESO-RENTRence $ 300,000 CLAIMS-MADE OCCUR MED EXP(Am one person) $ 15,000 PERSONAL S ADV INJURY $ 110001000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGO $ 2,000,000 POLICY FX7 PRO LOC $ AUTOMOBILE LIABILITY COMBINE DSINGLE LIMIT 1,000,000 Ea accident $ _ A ANY AUTO 1020003133 08/01114 08101/16 BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) E X HIREDAUTOS X NON,OWNED PROPERTY DAMAGE $ AUTOS _(Per awdent s J( UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE 4600037647 08101114 08101115 gGGREGgrE $ 2,000,000 DELI X I RETENTIONS 10,000 1 Is WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORV LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVE ISSUED DIRECTLY FROM EL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) THE CARRIER E.L.DISEASE-EA EMPLOYE $ I(yes,descnbe under DESCRIPTION OF OPERATIONS tlelm E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more apace Is required) CERTIFICATE HOLDER CANCELLATION CITYSAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tY ACCORDANCE WITH THE POLICY PROVISIONS. Building Department Fax:978-740.9846 AUTHORIZED REPRESENTATIVE 120 Washington Street,3rd FI. Salem,MA 01970 d � ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are,registered marks of ACORD ` A6W- HUSETTS m DRIVERS - LICENSE _ 'Dcuyz"�xu�tsrs � ad xg� E S19'539 9�7' s `.) o 101959�a2 = # Bs' 5-f0 ... .`,SMITH z ROBERTV a 18 LESUE RD ROWLEY,MA.019842318 t ,k� 50�0&IbA1]Rw O]1SM09 � _ COMMONWEALTH OF MA SACHI`)SETT .xS , ja • • • • A g • Q W SHEET --'RE1'Al Y 01R�ERS , ISSUES THE , F,0LLOW1t1�Gc LIt'dNSE PYASTER UNRESTRICTED RO&ERT V SMITH exi5 LESLIE RD dE " x1y 4 t t f�4WLEYt MA 01969-2316z:w 4 ,- 09/28/15 ,l' 771r s