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7 LORING HILLS AVE - BUILDING INSPECTION (6) Commonwealth of Massachusetts c rl/ Sheet Metal Permit Date: l,2 � IJ I t � Permit# �� bn Estimated Job Cost: $ 1 'j ,df�o Permit Fee: $ Plans Submitted: YES _ NO Plans Reviewed: YES NO Business License#M-1 5MM *9 Applicant License # Business information: / Property Owner/Job Location Information: Name: UL_ (C(61e Street: ('IkoOu5 S '[ Street: o. 16 AL) G City/Town: LqA City/Town: L Q/L { AA 'relephone: I�n 6 6�272 Telephone: 9�g 'I Ll -- 706 Photo I.D. required/Copy of Photo I.D. attached: YES 11 NO Slaff lnitlaI J-1 / NI-I-unrestricted license J-2 / NI-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-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_ Nletal Watershed Roofing_ Kitchen Exhaust System Metal Chimney/ Vents Air Balancing Provide detailed description orwork to be done: OF 6 v—M,90 0 0A c "l T— INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes b6 No❑ 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 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 ❑ Master Tine ❑ Master-Restricted CityiTo.v ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee 5 ❑ Check at www.mass.govhlpl Inspector Signature of Permit Approval i COMMONWEALTH OF MASSACHUSETTS BOARD OF SHEET METAL:WORKERS AS A MASTMUNREST. ICTED ISSUES THE ABOVE LICENSE © { NICHO_LAS N P-ORTO 30 DONNA DR' °x 63 TEWKSBURYa`•::. ,�' MA 01876 3718 EXPIRATIONDATE •L PORT6J. „NtcHa4As s��pp��ppt�yA 0R d01876 III$ ka From:Kelly Grahn At:Future Comp FaxID:TD INSURANCE To:Town of Salem Date:1211MOl l 02:52 PM Page:2 of 2 „ )-> /"1 OP ID: K3 4t`oRo„ CERTIFICATE OF LIABILITY INSURANCE DA 1211311 12H 11 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(iss)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 endorsement s PRODUCER 978-688-4667 CONTACT NAME: On Insurance Inc.(MA) 978-682.9037 PNONE FAx One Griffin Brook Or Ste 100 / IL Eat: ABC No Methuen,MA01844.1865 EJAAIL Jennifer Monkiewicz AOORESS: CUSTOMER CUSTOMER MECUSTOMER,, INSURERS)MFORDING COVERAGE NAICt , INSURED Medford Wellington Service Co. INSURERA:ABC MA WC SELF-INSURED GROUP g PO Box 239 INSURER B: Medford,MA 02155 INSURER C: INSURER D: d INSURER E NSURER F: COVERAGES CERTIFICATE NUMBER: 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFF POLICY— LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYI'YY MMNOpIYn LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ee occurrence $ CLAIMS-MADE OCCUR MED EXP(My one parson) $ PERSONAL 6 ADV INXRY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (Ee acddenl) $ ALL OWNED AUTOS BODILY INJURY(Perpe,son) $ SCHEDULED AUTOS BODILY INJURY(Per ecddent) $ PROPERTY AGE HIRED AUTOS (Per accident) $ NON-OWNEDAUTOS $ $ UMSRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAS CLAIMSWADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATIIXI WC STATU- OTH- ANDEMPLOYERS'LABILITY X TORYLIMITS ER A ANY PROPRIETORIPARTNER,EXECUTIVE YIN BCMA00502911 01/01/11 01101112 EL EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? ❑ N/A (Mandeory In NH)It yes, EL.DISEASE-EA EMPLOYEE $ 1,DDD,DDD DESCRIPTION under E.L.DISEASE-POLICY LIMIT $ 1,DD0,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VE H CLES (ACach ACORD 101,Additional RemaMa Schedule,If more apace is required) Job:Grosvenor Park Nursing Center,7 Loring Hills,Salem,MA 01970 CERTIFICATE HOLDER CANCELLATION TOWNSAL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 44 Lafayette Street ACCORDANCE WITH THE POLICY PROVISIONS. Salem,MA 01970 AUTHORIZED REPRESENTATIVE Jennifer Monkiewicz O 1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD From:Kelly Grahn At:FutureComp FaXID:TD INSURANCE To:Town of Salem Date:12/1 M011 02:52 PM Page: 1 of 2 FutureComp One Griffin Brook Drive phone: 978 983-6827 Methuen,MA 01844 Fax: �9783 688-5340 Fax From: Kelly Grahn To: Town of Salem Pages: 2 Fax: (978) 740-9846 Date: 12/13/2011 02:52:11 PM Phone: ( ) - Subject: Medford Wellington Service Co. Message: Per our insured's request, here is the certificate of insurance for their workers compensation coverage. Thank you, Kelly Grahn, Underwriter 978-983-6827 direct line 978-688-5340 fax line Kelly.Grahn@TDInsure.com CC: Susan at Medford Wellington CONFIDENTIALITY NOTICE This communication is intended only for the use of the person to whom it is addressed. It may contain information that is privileged,confidential or protected from disclosure under applicable law. If you are not the intended recipient,any distribution,disclosure,copying or use of this communication or any of its contents is strictly prohibited. If you believe that you have received this communication in error,please contact us immediately by telephone so that we can arrange for itto be returned to us at no cost to you.