Loading...
HomeMy WebLinkAboutBLD-19-3443 swortlit oc ���•1' elite ammonia OLidaacituattia "✓ 013e&tinent .snyectrcanae5Estee - Owe site gal anftliddiattett 1146 goat 28, SetS 5aunoa, &02664 APPLICATION FOR FIRE PROTECTION PERMIT Date 12/4/18 PERMIT NUMBER ,l3UJ — /9" O 3 9V3 Projected Start Date: Date of issue In accordance with the provisions of 780 CMR and M.G.L. Chapter 148,as provided in Section - This application is hereby made by Legacy Fire Protection (Full name of person,Firm or Corporation) Address 592 Center Street (Contact#) 413-589-0672 Email chrism@legacyfireprotection.com Owner of property Planet Fitness Job Location 17 Long Pond Drive,South Yarmouth (Street&City or Town) For permission to(state clearly purpose for which permit is requested) Modification to existing fire sprinkler system for tenant fit out (interior remodel). Name of competent operator(if applicable) Peter Miccoli Cert. or License No. SC148712. Estimated Cost of Construction: $6,875 By (Signature of Applicant) Building Official: I./ Date: ,4.- 6'ifl FEE: $50.00 ` A592 Center Street PO Box 582 • Ludlow, MA 01056 I I GAC Y (P) 413-589-0672 (F) 413-583-6377 ®j Commonwealth of Massachusetts Department of Public Safety License: SC-148712 Sprinkler Contractor PETER E MICCOLI,tR • 160 PINEWOOD ST ,77-714,;7-71 LUDLOW MA 0105641 1t"3 = w's 111114 /427 71, `— Expiration. Commissioner 04/21/2019 QUALITY•INTEGRITY• VALUE LEGAFIR-01 KMELCHER ACORQ' CERTIFICATE OF LIABILITY INSURANCE DATE/ "YY) �� os/01/201v2ots TIPS 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 have ADDITIONAL INSURED provisions or 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 CaNTACT Christine Costa Far Mason&Mason Insurance Agency,Inc. - PHONE FAx 458 South Ave. (A/C,No,Ext):(781)447-5531 (A C,so(781)4474230 Whitman,MA 02382 Mess;ccosta@masoninsure.com INSURER(S)AFFORDING COVERAGE NAIL N INSURER A:Admiral Indemnity Company 44318 INSURED INSURER B:Safety Indemnity 33618 Legacy Fire Protection,Inc. INSURER C:State National Insurance Co 00020 592 Center Street PO Box 582 INSURER D: Ludlow,MA 01056 INSURER E: INSURER 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE WADDL SUER pDLICY NUMBER M/DPOLICY EFF POLICY EXP LIMITS I INSD VD IMM/DD/YYYYI IMD/YYYY1. A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X x CA000016543-07 06/03/2018 06/03/2019 pRFMISESffeEONNTulrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL SADV INJURY _$ 1'000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE j 2,000,000 POLICY SES, LOC PRODUCTS-COMP/OP AGG 3 2,000,000 OTHER: - $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO X X 6245112 06/03/2018 06/03/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOStFONLY X AUUTOSpBRODILY INJURY(Per accident) $ X AUITOOS ONLY X 1•15t1260 (Pereadent) $ $ A _ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5.000,000 X EXCESS UAB CLAIMS-MADE X X BEX09614125-05 06/03/2018 06/03/2019 AGGREGATE $ 5,000,000 DED RETENTION$ _ $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN X NFA0868284 06/03/2018 06/03/2019 E.L.EACH ACCIDENT $ 1,000,000 QFFICEILMEMBER EXCLUDED? N NIA - (MandatorylnNN) E.L.DISEASE-EA EMPLOYEE $ 1'000'000 If yes,describe under i oon 00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Legacy Fire Protection,Inc is recognized as Additional Insureds as respects General Liability Insurance perthe terms and conditions of forms CG2010 04/13 and CG2037 04/13 and form SCA002 12/07 for Business Auto Insurance. When required by written contract,waiver of transfer of rights of recovery in favor of additional insureds applies for General liability per the terms and conditions of form CG2404 05109. When required by written contract,waiver of transfer of rights of recovery In favor of additional insureds applies for workers compensation per the terms and . SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Legacy Fire Protection,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 592 Center Street Ludlow,MA 01056 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:LEGAFIR-01 KMELCHER LOC#: 1 ACOR EY ADDITIONAL REMARKS SCHEDULE Page -t-of 1 AGENCY _ • NAMED INSURED Mason&Mason Insurance Agency,Inc. 592 Center Street Inc. POLICY NUMBER PO Box 582 SEE PAGE 1 Ludlow,MA 01056 CARRIER NAIC COD! SEE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Description of Operations/LocationsNehicies: conditions of form WC 00 0313 04/84. When required by written contract,waiver of transfer of rights of recovery In favor of additional Insureds applies for commercial auto per the terms and conditions of form SCA005 02/14. When required by written contract,primary non-contributory for General liability applies In favor of additional insureds per the terms and conditions of form AD0657 12/03. When required by written contract,primary non-contributory for commercial auto applies in favor of additional Insureds per the terms and conditions of form SCA005 02/14. Umbrella policy Is follow form.Forms available upon request. ACORD 101(2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD