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Home My WebLink AboutBldsm-20-004746 r 2 )„1, aF y9# SHEET METAL PERMIT _ 4 +. Commonwealth of Massachusetts 4 �''' Town of Yarmouth Building Department �� 6 dO f7 "v J Date: i_ . L- . / z .' Permit#: � ., S /3( , — aO f lL'1 ,/wn Estimated Job Cost: $ / '#, 0 e Permit Fee: $ 0 •() Plans Submitted: YES/, 0 Plans Reviewed: YES/ NO Business License # t,/ 0}/ Application License # It T 2....` Business Information Property Owner/Job Location Information Name: = 12 C0'75tr'Uc1-i c ) 1 UC. Name: 5ci)c 54-eq K I�,ci, Street: 1 �3.L 6r'Sn; I'e 5f Streetl ( f )LA -e 2 City/Town: Cstiw,C. 114/) OZ/65 City/Town: Yc+r►1,;ci4-1., ) /l.�- Telephone: hi -7 - 6 26 9 ) 5 ) Telephone: Q)s7- c-sl - 66c 1 Photo I.D. required/Copy of Photo I.D. attached: YES/ NO Staff Initial: 1-1/ M-1 unrestricted license 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 Multi-family Condo/Townhouses Other Commercial: Office Retail _Industrial Educational Institutional OtherIZ-' Square Footage: under 10,000 sq. ft.✓ over 10,000 sq. ft._Number of stories: I Sheet metal wo 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: OZ) 4 c I ► j—J v 4 C -t 'Uv K 9 cam( b r c -e 5 IQ 5+-s i I Pc .1- C I,?-ey) U, oa Q 2< ,-9cy(21)- cn �/ n,yf1.e car INSURANCE COVERAGE: I have a current liability insurancc policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes \/ 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 here ,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 installation 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. Inspections shall be called for prior to insulation installation. Duct inspection required prior to insulation installation: Yes No Date: Comments: Date: Comments: Type of 'tense: By: Master Title: Master-Restricted T nature.of Lic ee T City/Town: Journeyperson Permit#: _ Journeyperson-Restricted License Number: Li 7 2iS Fee: $ Check at www.mass.gov/dpl ./ a,. �� '1` Inspector ignature of Permit of Permit Approval The Commonwealth of Massachusetts 1Department of Industrial Accidents _';j 1 Congress Street, Suite 100 _ [{= Boston,MA 02114-2017 °W� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):IDS Construction INC. Address: 382 Granite Street City/State/Zip: Quincy, MA 02169 Phone #: 617-826-9797 Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with 5 employees(full and/or part-time).* 7. ❑New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑ Building addition 4.1=1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.❑RO repairs These sub-contractors have employees and have workers'comp.insurance t e/ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. theye-A �� 152,§1(4),and we have no employees.[No workers'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 contractors must submit a new affidavit indicating such. :Contractors 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. If the sub-contractors have employees,they must provide 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. Insurance Company Name:Liberty Mutual Policy#or Self-ins.Lic.#:WC531 S337450027 Expiration Date:1/4/21 Job Site Address:521 Route 28 City/State/Zip:Yarmouth, MA 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. I do hereb certi y under the pains and penalties of perjury that the information provided above is true and correct. Signature. Date: 2/2 7/2 0 Phone#: 7-826-9797 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#: OP ID:CH ACORO` CERTIFICATE OF LIABILITY INSURANCE DATE02/25/D/YYYY) 02/25/2020 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 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 781-933-2626 CONTACT Hub International NE LLC NAME: PHONE 781-933-2626 FAX 781-932-6341 Formerly Dagger Insurance (A/C,No,Ext>: (A/C,No): 400 W Cummings Park Ste 6725 E-MAIL Woburn,MA 01801 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Evanston Insurance Company INSURED IDS Construction,InC. INSURER B:Liberty Mutual Jason Chui Athena Protection 41360 382 Granite Street INSURER C Quincy,MA 02169 INSURER D: 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYYI (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 GRENTED CLAIMS-MADE X OCCUR 3EU8238 02/25/2020 02/25/2021 PREM PREMISES(TEa occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY PEA LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ C AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO 1020016094 &18-19 03/24/2019 03/24/2020 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSE� ONLY X AUUTOpSyy BODILY INJURYp (Per accident) $ X AUTOS ONLY X AUTOS ONLY (Per accident)AMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS AND EMPLOYERS'COMPENSATION ABILIITY STATUTE EERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y/" WC531S337450027 01/04/2019 01/04/2021 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBgER EXCLUDED? N/A (Mandatory m NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth 1146 ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD L�uLN',URA • . { P1RAlia)Ni'S1T+� SF'R{pl N1iMC#�R` E+ f N�4 hdt Mf ff�