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HomeMy WebLinkAboutBLDSM-23-000954 RECEIVED "� ► SHEET METAL PERMIT AUG 2 2 2022 ' Commonwealth of Massachusetts 1.--------_ - i - - . , BUILDING-O& Town of Yarmouth Building Department -- ems `' 1146 Route 28, South Yarmouth, MA 02664-4492 Date: x,71 P 7 T. ,�,)- Permit#: /3Lz.)• add 9.S Estimated Job Cost: $ 10,660 Permit Fee: $ Plans Submitted: YES/NO Plans Reviewed: YES/NO Business License# Lib Application License# f S " Business Information Property Owner/Job Location Information F � Name: 1c 11 64;- 10,ci n Name: ' r 6i Ctk 11 Street: L3j 041 Street: , )� ` ,.d.. U� -p-da j__ City/Town: i 1 City/Town: I r 6r/ Telephone: 5 6/0 2,s 81 Telephone: S -- L 0 S - 7> CS— Photo l.D. required/Copy of Photo I.D. attached: YES/NO Staff Initial: J-1.MA. 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 be done: a It f Ili/UT-et / `ill`l y 1/ rC 11JV VI c t t ir ti s Ct i' Cc) ' a -..---74, ® ,CORD CERTIFICATE OF LIABILITY INSURANCE 1 DATE(MM/DDrYYYY) ‘e..t- I 09/30/2021 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 Debi James NAME: Leonard Insurance Agency,Inc PHONE (508)428-6921 FAX (508)420-5406 (A/C,No,EM): (A/C,No): 683 Main Street E-MAIL SS: debi@leonardagency.com ADDRE Suite B INSURER(S)AFFORDING COVERAGE NAIC# Osterville MA 02655 INSURERA: Hartford Underwriters Ins Co. 30104 INSURED INSURER B: Hartford ACC&Indemnity Co. 22357 Bourque Heating&Cooling Co.,Inc.&B&L Equipment INSURER C: Hartford Insurance Group 00914 PO Box 770 INSURER D: Associated Ind.Of MA-ARWC 26158 INSURER E: Marstons Mills MA 02648-0770 INSURER F: COVERAGES CERTIFICATE NUMBER: 21-22 Master 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 AUULbUNK LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP (MMIDD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN I ED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 10,000 A 08SBAANOY24 10/01/2021 10/01/2022 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X jECT LOC 00 PRODUCTS-COMP/OP AGG $ 2,000,C) OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED 08UECBC0923 10/01/2021 10/01/2022 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS X HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY X AUTOS ONLY (Per accident) $ PIP-Basic $ 8,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 C -.XCESSLIAB CLAIMS-MADE 08 SBAANOY24 10/01/2021 10/01/2022 AGGREGATE $ 3,000,000 LIEDRETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER D ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A 173568 10/01/2021 10/01/2022 . . (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 A Data Breach-Defense&Liability Coverage 08SBAANOY24 10/01/2021 10/01/2022 Limit $50,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) HVAC Installer in MA 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 Rte 28 AUTHORIZED REPRESENTATIVE ,i S Yarmouth MA 02664 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD-25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts ..—......— IMINIEVENII VOI/1111111! Department of Industrial Accidents 1-•—zr..,—.. Office of Investigations T Lafayette City Center varlAr 7 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:Bourque Heating & Cooling Co., Inc. Address:1199 Pitchers Way City/State/Zip:Hyannis, MA 02601 Phone#:508-790-2887 Are you an employer? Check the appropriate box: Business Type(required): 1.0 I am a employer with 10 employees (full and/ 5. I- Retail or part-time).* 6. Ei Restaurant/Bar/Eating Establishment 2.n I am a sole proprietor or partnership and have no 7. Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 0 [No workers' comp. insurance required] 8. Non-profit 3.0 We are a corporation and its officers have exercised 9. Entertainment their right of exemption per c, 152, §1(4), and we have I 01 Manufacturing no employees. [No workers' comp. insurance requiredr* I I.__I Health Care 4.0 We are a non-profit organization, staffed by‘olunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other HVAC sales/service *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. "If the corporate officers have exempted themselves,hut the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:Associated Industries of MA-ARWC Insurer's Address:54 Third Ave, PO Box 4070 City/State/Zip: Burlington, MA 01803 Policy#or Self-ins. Lie. #173568 Expiration Date:10/01/2022 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under § 25A of MCI 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 o'Investigations of the DIA for insurance coverage verification. I do hereby certift, under the pains and penalties of perjury that the information provided above is true and correct. Sitmature: ") C,..7.2.4 -c-z--4---k ' - Date: 9/30/2021 Phone#: 508-790-2887 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): II:Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.1:Licensing Board 50 Selectmen's Office 6.nOther Contact Person: Phone#: wwworoass.govidia 3. 9 k' W $.:8 TA" e { \ .,?„. ,,,, - 4 -..,„„i",..:410T.;.- --.:.*-41,7*.,„I...." p - -° 5 ,�' PLC s ?>.-J 4d E b DIVISION OROFESSIONAL LIOENSURE SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE BUSINESS. ROBERT G BOURQUE '" z BOURQUE HEATI AND COOLING CO INC A PO BOX 770 i MARSTONS MILLS,MA 02$48 398 05/25/2023 28644 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER DIVISION OF OCIPATIONAL LIOENSURE BOARD SHEET METAL,WORKERS ISSUES THE FOLLOWING LICENSE MASTER-UNRESTRICTED ROBERT G BOURQUE I CROOKEDCARTWA'/ L MARSTONSMILLS MA. Q2648- SIF38 a 6435 06/28/2U24 256638 LICENSE NUMBER NUMBER 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 les, indicate the type of coverage bycheckingthe� / g appropriate box below: A liability insurance policy 'Other type of indemnity Bond OWNER'S INSURANCE WAIVER:I am aware that the licensee s not h._ avg the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application wallas,this requirement. Check One Only Owner Agent Signature of Owner or Owner's Agent By checking here-)Zi 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 V No Progress inspections Date: Comments: Final Inspections Date: Comments: Type of license: Cit /Town: Master-Restricted 1122 Journe •erson Signature of Licen -e Journe .erson-Restricted License Number: r Check at www.mass.•ov/d.f T Inspector Signature of Permit'r of Permit Approval