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HomeMy WebLinkAboutBldsm-23-005241 Commonwealth of Massachusetts R E DE I V E D Sheet Metal Permit/ MAR 23 2023 Date: 3�( ` 136� YerZmlT# ,/ /G DEPARTMENT By Estimated Job Cost: $ p �� Permit Fee: $ Plans Submitted: YES NO Plans Reviewed: YES NO Business License# 2671 Applicant License # 360 Business Information: Property Owner/Job Location Information: Name: Thomas J. Kennedy Plumbing Name: tS,C \0 75 A 1 Street: 1635 Broadway, Suite #2 Street: J \ %- (Q � JI_ . City/Town: Raynham City/Town: 5 . yp,7MQtS�� Telephone: (508) 824-6556 Telephone: (c)11 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 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 Metal Watershed Roofing Kitchen Exhaust System Metal Chimney /Vents Air Balancing Provide detailed description of work to be60A done:L—�5 � cA-;0)n c' e� INSURANCE COVERAGE: I have a current liability,insurance 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 this box[p{,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 cz Master The ❑Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ElJourneyperson-Restricted License Number: 360 Fee$ ❑ 1 Check at www.mass.nov/dpl 3 4,34 Inspector Signature of Permit Approval The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • j) Lafayette City Center iS; 2 Avenue de Lafayette, Boston,MA 02111-1750 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Thomas J. Kennedy Plumbing, Heating & HVAC, Inc. Address: 1635 Broadway, Suite#2 City/State/Zip: Raynham, MA 02767 Phone#: (508) 824-6556 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 40 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. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P h' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 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 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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: Guardian Insurance Group Policy#or Self-ins. Lic. #: THWC379196 Expiration Date: 11/15/2023 Job Site Address: 34 Braddock St CityistateizipYarmouth, MA 02664 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 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 pen lti s of perjury that the information provided above is true and correct Signature: � Date: 3/21/23 Phone#: (508) 824-6556 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: COMMONWEALTH OF MASSACHUSETTS (Ot , #-T_ -OFESS . .._ i BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE w MASTER-UNRESTRICTED STEPHEN M KENNEDY 1635 BROADWAY SUITE 02 RAYNHAM,MA 02767 360 0612812023 69189 • 2 TkT :• .TI01N1.DATE,,_ �wSERl L NUMEEB CONTROL # JG1681350 IMPORTANT If your license is lost,damaged or destroyed; is Inaccurate;or needs to be corrected,visit our web site at mass.gov/dpi for .nstructions to ensure the proper mailing of your Renewal 4pplicaton and any other correspondence. Tnis license is subject to Massachusetts General Laws and •egulations.Your license is a privilege,and cannot be lent or assigned to any person or entity under penalty of law.Keep this icense on your person or posted as required by law anjor 'egulations. ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `...�- 11/08/2022 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 CONSTITU"E 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 MARIA J R Tallman&Co,Inc NAME: PO Box 469/12 Court Street aoNN Ext): (508)824-4051 FAX No):(508)822-7654 Taunton MA 02780 E-MAIL mariagirtallman.com ADDRESS INSURER(S)AFFORDING COVERAGE NAIC# Agency Lic#.1780241 INSURER A: ARBELLA INSURANCE GROUP INSURED INSURER B: ARBELLA PROTECTION 41360 THOMAS J.KENNEDY PLUMBING HEATING AND HVAC INC 1635 BROADWAY INSURER C: ARBELLA INSURANCE GROUP SUITE 2 INSURER D: GUARD INSURANCE GROUP 14702 RAYNHAM MA 02767 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 38744 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 SUER POLICY EFF POLICY EXP LIMITS LTR INSRD WVO POLICY NUMBER DATE(MM IY/DDY) DATE(MMIDD/YY) X COMMERCIAL GENERAL LIABILITY 8500070364 11/15/22 11/15/23 EACH OCCURRENCE $ 1,000,000 A DAMAGE TO RENTED $ 100,000 CLAIMS MADEn OCCUR PREMISES(Ea occurence) MED EXP(Any one person) $ 5,000 — PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY X PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 — JECT OTHER $ AUTOMOBILE LIABILITY 1020088059 11/15/22 11/15/23 COMBINED SINGLE LIMIT $ 1,000,000 B (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ _AUTOS ONLY —AUTOS X HIRED x NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ C UMBRELLA LIA3 OCCUR 4620090756 11/15/22 11/15/23 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 OED X RETENTIONS 10,000 $ —yWORKERSCOMPENSATION THWC379196 11/15/22 11/15/23 PER ET- D AND EMPLOYERS'LIABILITY STATUTE Eti ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A E I EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ 1,000,000 It yes,describe under E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Thomas J Kennedy Plumbing Heating and HVAC, Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1635 Broadway,Suite 2 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Raynham, MA 02767 , ACCORDANCE WITH THE POLICY PROVISIONS. Attention: Gloria A. HarnoisLic#1728ii_67, alia,2„itszAdi, ACORD 25(2016/03) Certificate# 38744 ©1988-2015 ACORD CORPORATION.All right reserved. The ACORD name and logo are registered marks of ACORD