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Home My WebLink AboutBldsm-23-005177 RECEIVED MAR 2 0 2023 -- 14. SHEET METAL PERMIT Buy► P T. 0)*401) Commonwealth of Massachusetts .,.„:.„ Town of Yarmouth Building Department Date: iS 9- Permit#: 73UJ.sfy1--,73-Loil� Estimated Job Cost: $ -1:7S0C v Permit Fee: $ Plans Submitted: YES/ NO Plans Reviewed: YES/ NO Business License# Application License # (,p p;,5 Business Information Property Owner/Job Location Information • Name:j b-f-�k �-� tM p vt L Name: Ce[ l'2 e St 6,(Af i --t Street: a q- r (;tl t,l b,6 i - V+ Street: tL 10}-e v-vu1 -,lz_. '1 City/Town: 1 ./II C�L1`-f100 J City/Town: -? I"-(K vWtCu tt _. • Telephone: stk. - `( if 7 • v(P'- j Telephone: 5 of, - E`lG' 9- —C1 ci ci 0 1 Photo 1.D. required/Copy of Photo I.D. attached: YES/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 J 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: I Metal Watershed Roofing:_ Kitchen Exhaust System:_ Metal Chimney/Vents:_Air Balancing:__ Provide detailed description of work to be done: ►V-i Vt cr t 9 1 1U vu ltlk �C, ' 12'6 4 s --!'mot afil,A jr,utt 1t6t\ -hicAitiLt tiIAA 1- . (SOS J a M • #1�7ttC3 1` Stt; • r ;._ 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 here4_,I hereby certify that all of the details and Informations 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 license: By: Master Title: Master-Restricted T Signature.of Licensee T City/Town: Journeyperson Permit#: Journeyperson-Restricted License Number: Fee: $ Check at www.mass.gov/dpl T Inspector Signature of Permit'l' of Permit Approval ACRL CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/15/2023 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 Marsh Affinity ty Marsh Affinity (NCO,No,Ext):NE 800-743b130 FAX No): a division of Marsh USA Inc. ADDRESS: ADPTotalSource@marsh.corn PO Box 14404 Des Moines,IA 50306-9686 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: New Hampshire Insurance Co. _ 23841 INSURED INSURER B: ADP TotalSource II,Inc. INSURER C: 5800 Windward Parkway INSURER D: Alpharetta,GA 30005 Alternate Employer: INSURER E: Total Temp Inc INSURER F: 22 CAMBRIDGE STREET Middleboro,MA 023460000 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 INSR WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTEDPREMISES(Ea occurrence) MED EXP(Any one person)• $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ POLICY PE2 LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN X STATUTE ER ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED? N/A WC 053426809 MA 07/01/2022 07/01/2023 A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) All worksite employees working for Total Temp Inc paid under ADP TOTALSOURCE,INC.'s payroll,are covered under the above stated policy.Total Temp Inc is an alternate employer under this policy.22 Cambridge St CERTIFICATE HOLDER CANCELLATION Town of Yarmouth 11146 Rt 28 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE South Yarmouth,MA 02664 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Lifo ACORD 25(2016/03) ©1988-2015 ACORD CORPO ION. All rights reserved. The ACORD name and logo are registered marks of ACORD • ,p. _GYl5T,3 'a�.n2Ffi t. .._ J j � + Please visit our web site at http://www.mass.gov/dpl/boards/SM • ANDREW XENAKIS 22 CAMBRIDGE ST (SM) STE C MIDDLEBORO,MA 02346-2090 Commonwealth of Massachusetts Division of Occupational Licensure Refriggaaret factor •r RC-019547 spires:06/22/2024 ANDREW XEIAKIS 22 CAMBRIDGE ST,UNIT.0 MIDDLEBORO,MA 02346 C C.. m i s -.. I')., r' C r;'7- ,it u.'-. vlw�wCf••, Fold,Then Detach Along All Perforations o COMMONWEALTH OF MA SACH SETTS DIVISION OF OCCUPATIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSEcc JOURNEYPERSON-UNRESTRICTED Z. ANDREW XENAKIS 22 CAMBRIDGE ST STEC MIDDLEBORO, MA 02346-2090 6053 06/28/2024 215172 tICENSE.NUMBER EXPIRATION DATE SERIAL NUMBER