Loading...
HomeMy WebLinkAboutBldsm-23-004231 RFC !LED SHEET METAL PERMIT AN 3 0 2023 Commonwealth of Massachusetts \ Town ofYarmouth BuildingDepartment +...,. *: BUILDING DEPARTMENT 1146 Route 28, South Yarmouth, MA 02664-4492 gv Date: \- C - 3 Permit#: 3L s1 l- 23-DDLt23 Estimated Job Co, I , OOO . 00 Permit Fee: $ \O Q . 0 0 Plans Submitted:0 NO Plans Reviewed: YES/ NO Business License# ) Application License# ,2 o s Business Information Property Owner/Job Location Information Name: (���— cp,-\5 — Name: Street: ��`6 N`5vv< R(*) , Street: c)., GL.c.rr�� Qom, Dr . City/Town: u . �\p � , 1'Y1A Orb City/Town: W hr•P\�at13 Telephone: Th\- 2 1 j .. )a 3 Telephone: Photo I.D. required/Copy of Photo I.D. attached: ® NO Staff Initial: 1-1/C 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 st 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:v Metal Watershed Roofing: Kitchen Exhaust System: Metal Chimney/Vents: Air Balancing: Provide detailed description of work to be done: \5-c\\\ 0 -/ \- : \ 1 V N"1) \ v ,v.,�. (0) 5 INSURANCE COVERAGE: I have a current liability insuran 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 \ther 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 /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: Master Title: Master-Restricted '1`Signature of Licensee'(` City/Town: Journeyperson Permit#: Journeyperson-Restricted License Number: Fee: $ Check at www.mass.gov/dpl '1` Inspector Signature of Permit of Permit Approval The Commonwealth of Massachusetts Emo— Department of Industrial Accidents a Office of investigations Lafayette City Center , a� m. ' "." -� ' 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): Gray Co. Address:28 Nashua Road Unit C City/State/Zip:N. Billerica MA 01862 Phone#:781-275-1233 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with Se^—3 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees -These sum=contractors have - 8.- ❑ Demolition workingfor me in anycapacity. employees and have workers' p tY f 9. ElBuilding addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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. her comp. insurance required.] *My applicant that checks box ill 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. tContractors 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:Associated Industries of Massachusetts Mutual Insurance Policy#or Self-ins. Lic. #:WMZ8008007011 Expiration Date:04/01/2023 Job Site Address: 2 Channel Point Dr. City/State/Zip:Yarmouth, MA Attach a copy of the workers' compensation policy declaration page(showingthe 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 wider the pains and penalties of peijury that the information provided above is true and correct. Signature: \J Cam- Date: \' .) - c) 3 Phone#: l 5\— 2 1 J — ) 2 33 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): 117:Board of Health 2❑Building Department 31:City/Town Clerk 4.❑Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: A'c D® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) — ‘..... 12/05/2022 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 Tracey Robicheau NAME: Brown&Brown of Massachusetts,LLC PHONE (781)455-6664 FAX (A/C,No,Eat): (A/C,No): 980 Washington Street E-MAIL Tracey.Robicheau@bbrown.com ADDRESS: Suite 325 INSURER(S)AFFORDING COVERAGE NAIC S Dedham MA 02026 INSURER A: Ohio Security Insurance Company 24082 INSURED INSURER B: Associated Industries of Massachusetts Mutual Insurance 33758 Gray Boys,Inc. INSURER C: 28 Nashua Road Unit C INSURER D: INSURER E: North Billerica MA 01862 INSURER F: COVERAGES CERTIFICATE NUMBER: 22-23 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POUCY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERALL/LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE /� OCCUR DAMAGE REN i ED 300,000 PREMISESS(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A BKS57970829 05/25/2022 05/25/2023 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY XI PRO 1-1 - _- JECT LOC PRODUCTS-COMPIOP AGG $ 2�000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 — (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED �/ SCHEDULED BAS57970829 05/25/2022 05/25/2023 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS XHIRED �/ NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY Or% AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESS UAB • CLAIMS-MADE US057970829 05/25/2022 05/25/2023 AGGREGATE $ 4,000,000 DED XI RETENTION$ 10,000 $ WORKERS COMPENSATION N,,,e( PER OTH- AND EMPLOYERS'LIABILITY Y NSTATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA WMZ8008007011 04/01/2022 04/01/2023 E.LtACHACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Rented/Leased Equipment$25,000;Umbrella follows form 30 day cancellation notice except 10 for premium nonpayment. 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 POUCY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE S Yarmouth MA 02664 frjk"',j'4' I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DIVISION OF PROFESSIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE MASTER-II N RESTRICTEO MICHAEL H SNOWDON 157 HILLTOP ROi RACUT,MA 0182 - 013 2208 0812812 23 79539 fors 4•ai' i * o w l +: t o iTTT 7.l:a"-:in '_. • • - �.... E ram"..... .. _..�