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Home My WebLink AboutBLDSM-23-003295 Job# 22321 Commonwealth of Massachusetts Sheet Metal Permit Date: 12/7/22 Permit# i,6511-23, 7b32 tS' Estimated Job Cost: $ 1 0,000 Permit Fee: $50 Plans Submitted: YES NO X Plans Reviewed: YES NO Business License# 160 Applicant License# 2967 ! RECEIVED Business Information: Property Owner/Job Location Informtion: DEC 1 2 2022 W Vernon Whiteley, Inc. Lori LaBarge L Name: Name 3►q2 NT PO Box 1266 t 16 Manor Path B --� Street: Str e City/Town: West Chatham MA City/Town: W Yarmouth Telephone: 508)945-1100 Telephone: (508)432-6360 Photo I.D. required/Copy of Photo I.D. attached: YES X 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 Garage Residential: 1-2 family 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: Renovation HVAC duct work INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes® No E 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 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 Title ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: 2967 Fee$ ❑ Check at www.mass.qov/dpl Inspector Signature of Permit Approval / 1 ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/19/2022 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 CONTACT RogersGray, Inc. -Kingston Branch PHONE FAX 63 Smith Lane tA/C.No.Ex :508-746-3311 I(A/c.No):877-816-2156 Kingston MA 02364 ADOReSS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection 41360 INSURED WVERNON-01 INSURER B:A.I.M.Mutual Insurance Compan 33758 W. Vernon Whiteley Plumbing&Heating Company, Inc. Chatham Sheet Metal, Inc. INSURERC: P. 0. Box 1266 INSURERD: West Chatham MA 02669-1266 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:907742688 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 EFF POLICY EXP M/ LIMITS LTR INSD WVD POLICY NUMBER (MDDIYYYY) (MM/DD/YYYY1 A X COMMERCIAL GENERAL LIABILITY Y Y 8500052832 10/1/2022 10/1/2023 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $10,000 PERSONAL 8,ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y 1020006346 10/1/2022 10/1/2023 COMBINED t)SINGLE LIMIT $1,000,000 __.. (E ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS y HIRED y x NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) _ A X UMBRELLA LIAR OCCUR Y Y 4620086300 10/1/2022 10/1/2023 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$1n nnn $ B WORKERS COMPENSATION Y WMZ-800-8007752-2022A 10/1/2022 10/1/2023 X ;MUTE EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED? n N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) When Required by Written Contract the following Applies: General Liability—Additional Insured Ongoing,Primary and Non-Contributory Basis,Waiver of Subrogation(30AP2037 04/21)and Completed Operations (30AP2039 03/08) Automobile—Additional Insured,Primary and Non-Contributory Basis,Waiver of Subrogation(26AP1034 11/19) Workers Compensation—Waiver of Subrogation(WC000313 04/84) Excess/Umbrella—Additional Insured and Waiver of Subrogation(CU0001 04/13),Primary and Non-Contributory Basis(32AP1123 01/19) 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 ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Main Street, Route 28 South Yarmouth MA 026640000 AU ED REPRESENTATIVE USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD f` The Commonwealth of Massachusetts ►!=, t_ Department of Industrial Accidents f• _ �_ 1 Congress Street, Suite 100 Boston, MA 02114-2017 ,„' www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WiTH THE PERMITTING AUTHORITY. Applicant Information Please Print Le2iblv Name (Business/Organization/Individual): W Vernon Whiteley, Inc Address: PO Box 1266 City/State/Zip:W Chatham, MA 02669 Phone#: 508-945-1100 Are you an employer?Check the appropriate box: Type of project(required): I. 1 am a employer with 70 _employees(full and or part-time).* 7. ❑ New construction 2.0I am a sole proprietor or partnership and have no employees working for Incin 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. Demolition 10❑ Building addition 4.0 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 arc sole 1 1.0 Electrical repairs or additions proprietors with no employees. 12.®Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.ElWe arc a corporation and its officers have exercised their right of exemption per MGL_c. 14.❑Other 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 arc 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-contractor have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. A.I.M. Mutual Insurance Company Insurance Company Name: Policy#or Self-ins. Lic.#: WMZ-800-8007752-2022A Expiration Date: 10/1/2023 Job Site Address: All Locations in Yarmouth City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGI.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[MA for insurance coverage verification. I do hereby certi er the pains and penalties of perjury that the information provided above is true and correct. Signature ��-. 1 "V , �/�. Date: 9- — Z Z Phone#: s-Q e - 4 CO 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#: S. COMMONWEALTH OF A_H SRI DIVISION OF PROFESSIONAL IJCENSURE BOARD OF SHEET METAL WORKERS ISSUES.THE FOLLOWING LICENSE it MASTER-UNRESTRICTED ERIC T WHITELEY PO BOX 248 WEST CHATTH M,MA'14669424 2967 02J28/20,24 159981 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER