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189 LORING AVE - BUILDING INSPECTION (3) Commonwealth of Massachusetts ` � ;tlal`Permit Date: J1-a3 - !is 9 A �► 3� Permit# r-- t61b NOV 2 r dC Estimated Job Cost: $ 5-10() Permit Fee: $ J S (C1< 5 q$ , M Plans Submitted: YES ✓ NO— Plans Reviewed: YES NO — — Business License# /,S3 Applicant License# ,2 o g o Business Information: Property Owner/Job Location Information: Name: IeCN 1VE(-1/ANiC/9C Name:�,vt;BC &'itbeAS l� Street: 12o GJeST s i Street: 18 9 k,41H (5 AdE City/Town: . 4 j e s 7 City/Town:_S'F)LEP? Telephone: �09^ 5-06 - `1 9-f- Telephone: Photo I.D.required/Copy of Photo I.D.attached: YES NO_ J-1/M-1-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: 1-2family_ 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:_v 1IVAC ✓ Metal Watershed Roofing— Kitchen Exhaust System Metal Chimney/Vents_ Air Balancing Provide detailed description of work to be done: leet,)akk 1J-ci 7 0 )9 Al&ZW 2E A/r'v FL�,2 eZji / SL—r� r -Vb 4 2xn U3e5- r S-i r-,-r.-A t A— INSURANCE COVERAGE: 1 have a current liabilitV insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes 0 No❑ If you have checked Yes,indicate,the type of coverage by checking the appropriate box below: A liability insurance policy L� 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 box[],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 Progress Inspections Date Comments Final Inspection Date Comments Type of License: By g4aster Title ❑Master-Restricted /ii/kA�rc� Lrrn City/Town ell ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: aC9So Fee$ ❑ Check at www.mass.gov/dol Inspector Signature of Permit Approval - 1 ©NIMOI IIII,E/ L H1OF.MASG�;II'i.S �TrT ffi'-N 1 z l dy, � . $ r � HOLBRb0N!MA OZM37214y�i.����� �< MUDDINI AL.c R 0510312016° CERTIFICATE OF LIABILITY INSURANCE DALE/ /2016 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 policypes) must be endorsed. if SUBROGATION IS WANED, subject to the terns and conditions of the policy,certain policies may require an endorsement Astatement on this coruscate does not confer rights to the certificate holderin lieu of such endorsement(s). PROm10ER Phase:(5011)e24d051 Fax:(508)822-7664 CONTACT MARIA J R TALLMAN&CO,INC PNONE EML PA% (508)$227 654PO BOX 469112 COURT STREET 8244 TAUNTON MA 02780 mafiallman.com PAOOUCGt 13705 Agency UtlY.1780241 INSURER($ AFFORDING COVERAGE NAICN INSURED TECH MECHANICAL SYSTEMS INC.- msuRmA ,ARBELLA INSURANCE GROUP 17000 TECH 420 WEST STREET INSUMB : 17000 WEST BRIDGEWATER MA 02379 INSMUTte : 17000 INSURERo: WOOD maME1tE - IN6URERF COVERAGES CERTIFICATE NUMBER:24401 REVISION NUMBER: THIS IS TOCERTIFY THATTHE POLICIES OFINSURANCE LISTED BELOWHAVE BEENISSUED TOTHEINSURED 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 ALLTHE TERMS, IHSR TYPEOFINSURANCE ADDL man pOUCYNUMBER POUCYEFF POUCYEXP LIMifS GENERAL UAunm EACH OCCURRENCE S X COMMERCIALGENERALUABIUTY DAMAGEMRFNIEO S CLMMS4dA0E IIXAIOCCUR MEMEXP(Anyonepelsen) S PERSONAL&ADVINJURY S GENERALAGGREGATE S GENLAGGREGATE LIMITAPPLIES PER: PRODUCTS-COMPIOP AGG S POUCY X PRO- FloeI S AUTOMOMLE UAMIIIY COMBINEDSINGLEUMIT ANYAIIfD (Eaacddenq S ALLONNEOAUTOS BODILY INJURY(Perpersw) S BODILYINJURY(Perardden) S X SCHEOULEDAUfOS PROPERTY DAMAGE X HIREDAUTOS (Per2cddm0 S X NOMOWNEDAUTOS S S UMORMU UAa OCCUR EACH OCCURRENCE S EXCESS UAII CLAIMS4AADE AGGREGATE S DEDUCTIBLE S RETENTION S S A woMums colePEmenou 422005237601 04/24/16 04/24117 wcsrAru on1 AND EMPLOYEW WaW1Y •� YIN ANY PROPMETOWARTHEREIECImOE ^11 EL EACH ACCIDENT a 1,000,000 OFFICERIMDARER EXCLUDGIT J NIA phndabulaffm EL DISEASE-EA EMPLOYEE S 1,000,000 Ilymdecaheundu OE6CMPIIONOF OPETArONehdew EL DISEASE?OUGY UNIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONSIVEHICLES(Attach ACORD 101,Additional Remarks Schedule,Ifmorespace Is required) CERTIFICATE HOLDER CANCELLATION The Commonwealth of Massachusetts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Department of Industrial Accidents THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1 Congress St Suite 100 ACCORDANCE WITH THE POLICY PROVISIONS. Boston,MA 02114-2017 AVIHOPREO nEPRE6FMMIVE Attention: ACORD 25(2009109) 9)1988.2009 ACORD/CORPORATION. All rights reserved.. The ACORD name and logo are registered marks of ACORD l The Commonwealth of Massachusetts Department of lndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(BusineWOrganizadon/Individual):Tech Mechanical Systems Inc. Address:420 West Street City/State/Zip:W. Bridgewater,MA 02379 Phone#:508-588-9985 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 50 employees(full and/or part-time)! 7. ❑New construction 2.❑lam a sole proprietor orpamtership and have no employees working forme in S. ❑Remodeling any capacity.[No workers'comp.insurance required.] In I am a homeowner all work myself.[No workers'comp..insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I1.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub�contmctors listed on the attached sheet 13❑Roof repairs These subcontractors have employees and ban workers'comp.insumnoe.t . 6.Qwe are a corporation and its officers have exercised their right of exemption par MGL c. 14.❑Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy infomtation. t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such. tContmcrors 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. ifthe subcontractors have employees,they must provide their workers'comp,policy number. lam an employer tliat is providing;porkers'compensation insurance for my employees. Below is the palhcy and job site information. Insurance Company Name:Arbella Indemnity Insurance Group Policy#or Self-ins.Lie.#.0054020414 Expiration Date:04/24/16 Job Site Address: /t5 9 LV2146 /a V City/State(Zip: 5174E YI Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify tinder the at andp-ennaaalties ofperjury that the information providedabove is true and correct Sienature: <%''Y"^w Cr (✓h^"�Y Date: r Phone M 508-588-9985 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/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house - - — or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." , MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under`Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided tu the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia