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Home My WebLink AboutBldsm-20-004934 t $S/U 413147) OF ^Y_ ZTNIEN i i SHEET METAL PERMIT N 1 e s Commonwealth of Massachusetts WTTACM°°°° Town of Yarmouth Building Department 1146 Route 28, South Yarmouth, MA 02664-4492 Date:2/17/20 Permit#: ;6e.1) 1-1'020 r)f1.37° Estimated Job Cost: $1 1, o a o Permit Fee: $50.00 Plans Submitted: YES/NO Plans Reviewed: YES/NO Business License#15 Application License# Business Information Property Owner/Job Location Information Name:Robies Name:Michael Fields Street:279 Yarmouth Rd Street:33 Boxberry Lane City/Town:Hyannis, Ma 02601 City/Town:West Yarmouth, Ma 02673 Telephone:508-775-3083 Telephone:781-439-3619 Photo I.D. required/Copy of Photo I.D. attached: ES/ NO Staff Initial: J-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 x Multi-family Condo/Townhouses_ Other_ Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft.x over 10,000 sq. ft._Number of stories: 1 Sheet metal work to be completed: New work x Renovation:—HVAC: X Metal Watershed Roofing:_ Kitchen Exhaust System:_Metal Chimney/Vents:_Air Balancing:_ Provide detailed description of work to be done: Furnace&install HVAC system to attic. INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes x No If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy x 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 here9 ,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 Progress Inspections Date: Comments: Final Inspections Date: Comments: Type of license: By: y Master A(A:9L1 j Title: Master-Restricted 'r Signature of Licensee City/Town: Journeyperson Permit#: Journeyperson-Restricted License Number:/3&ki Fee: $ Check at www.mass.gov/dpl 3 - '1` Inspector Signature of Permit of Permit Approval ItG I.41I1i fiUII iI/Gll6LIL U) 11114JJt11,11143Gtta Department of Industrial Accidents ' et t tRit= Office of Investigations =::Nlh 600 Washington Street -411 Boston,MA 02111 t,.,• 47 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ROBIES Address: 279 YARMOUTH D City/State/Zip: HYANNIS MA 02601 Phone#: 508-775-3083 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 43 4. I am a general contractor and I employees(full and/or part-time).* 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 8. Demolition working for me in any capacity. employees and have workers' comp.insurance.$ 9. Building addition [No workers' comp.insurance 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 insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13. Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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: FEDERATED MUTUAL INSURANCE COMPANY Policy#or Self-ins.Lic.#:6062307 Expiration Date: 12/21/2020 Job Site Address: 3c3 2o.vbe v.y Z. F City/State/Zip: H/s,,Zt Xtrrvpot 1.,. 01A a Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).O 4r3 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$250.00 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. I do hereby certify under the pains and penalties of perjury tha e information provided above is true and correct. Signature:- ----- /2-J 4- eX t Re-s, Date 02- / 7' oa 0 Phone#: 50 -775-3083 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#: '4 EP® DATE`M 'CERTIFICATE OF LIABILITY INSURANCE 12/23/2019 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 poilcy(les) 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 CONTACT FEDERATED MUTUAL INSURANCE COMPANY NAME: CLIENT CONTACT CENTER PHONE HOME OFFICE: P.O.BOX 328 (A/C,No.Est):888-333-4949 FAX No):507-446-4664 OWATONNA,MN 55060 E-MAIL CLIENTCONTACTCENTERQFEDINS.COM INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 394-850-2 INSURER B: ROBIES REFRIGERATION INC INSURER C: 279 YARMOUTH RD HYANNIS,MA 02601-2038 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:57 REVISION NUMBER:0 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DDIYYYY) (MMIDDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 AGE TO RENTED CLAIMS-MADE ❑X OCCUR PREMISES Ea occurrence) $100,000 MED EXP(Any one person) EXCLUDED A N N 6120004 12/21/2019 12/21/2020 PERSONAL&ADV INJURY $1,000,000 OEN'L AGOR ATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY I X gig111 LOC PRODUCTS-COMP/OP AOC $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) OWNED AUTOS ONLY SCHEDULED AUTOS_ _AUTOOS N N 6120003 12/21/2019 12/21/2020 BODILY INJURY(Peracdeent) HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE AUTOS ONLY (Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $3,000,000 A EXCESS LIAB CLAIMS-MADE N N 6120006 12/21/2019 12/21/2020 AGGREGATE $3,000,000 DED RETENTION WORKERS COMPENSATION X PER STATUTE ER- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Y_ E.L.EACH ACCIDENT $500,000 A OFFICERIMEMBER EXCLUDED? _NIA N 6062307 12/21/2019 12/21/2020 (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $500,000 II yes,describe under E.L DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) GENERAL LIABILITY COVERAGE CONTAINS CG 25 03 DESIGNATED CONSTRUCTION GENERAL AGGREGATE LIMIT ENDORSEMENT APPLICABLE TO EACH CONSTRUCTION PROJECT AS REQUIRED BY WRITTEN CONTRACT OR WRITTEN AGREEMENT. CERTIFICATE HOLDER CANCELLATION 394-850-2 57 0 TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 ROUTE 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SOUTH YARMOUTH,MA 02664-4463 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I/` gtA,,, O 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • • p:COMMONWEAL 'H OE MA,SSAOHUSETCS DIVISION OF PROFESSIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LI ENSE MASTER UNRESTRICTEDr MICHAEL K ROBICHAUD w t �47 MARBLE RDtO A -41 N BARNSTABLE,MA 02630 1608 ;' . i 3 � 1385 11/28/2021 746178 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER I I OMIVIONWEALTH;OF.MA.SSACHUSETT . ' DIVISIONOF PROFESSIONAL LICENSURE SHEET MET L WORKERS_ ISSUES THE FOLLOWING LICENSE Aft r BUSINESS °C JOIN.R ROBICHAyD ROEIES R RIG TION INC g '' %279 YARMb .s. HYANNIS,MA 02601 ' 15 07%2912020 500058 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER co ow,toz 1 r DD ti h 0 Lo ed Hcim0 2-1,1-1 71-,okro g PS.C!. 2vv t.,tidf 0 g,2 . _/II.] . l - ...- , I ..- 1 ,-- 1 K, ...... „., I -1 0 . , tz1,/./-- ---/-- , I , 1 , , . „o i ,---., I 0 .c 1 ._... -7 N,T1 .7.-5. . . 1 _i ..._... ., 1 ! •