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HomeMy WebLinkAboutBLDSM-23-000760 Job# Commonwealth of Massachusetts RECEIVED Sheet Metal Permit AN 0 8 2022 Date: Permit Permit# BUILDING DEPARTMENT tsY.---- Estimated Job Cost: $201 Permit Fee: $ (' a5►441 Plans Submitted: YES X NO Plans Reviewed: YES NO Business License# 160 Applicant License# j2967 Z �jj Business Information: Property Owner/Job Locat�ion Ini"or ation: Name: W Vernon Whiteley, Inc. Name: Greg Handren PO Box 1266 9 Oak Hill Lane bG\ Street: Street: City/Town: West Chatham MA City/Town: South Yarmouth CO Telephone: 508)945-1100 Telephone: (508)432-2047 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 X 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: 2 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: New construction HVAC duct work DIVISION OF PROFESSIONAL LICENSURE SHEET`lY7AL WORKERS ISSUES THE FOLLOWING LICENCE 1 MASTER-1 Ep - ' r :MO T WHITELEY PO SOX? c WEST CHATHAM;MA ozs '" t� 2967 159981 • . LICENSE NUMBER EXPIRA UN O IL SERIAL NUMBER I i jai ', i l,.4 1 N. 4,,,4!42,„,,,1 l -,a-,.0-,.,'„,,..„,,4r„ _ N I 3 .. Y ry- ;S,, lii .X a i7- le a z m it I r I y ro'sft• -_ n'tN•. err,ry Cs• , 6 O Kai.xa'.' • t.�.s', vYs ka p a .YY V')F''sL� , „. — lia 4 _ � ;sue _' 15'1' -'1:' 1 ypma $Q77Q ) .L i i lqui .: -rarcm+r, n weary • w ss "1 p: w a k as / •_. 1' i rs �� a ^s,yq 1 v c ' roc — 9z I ;§ :;I . ,,�,4 ` I c ( r-ac _ t>_ K —... • y Iep xi ` a, L . - r$ u•oe x x S E� ,e. vf �� €' ! 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I 1 & It 9 p, : I T b � a i; a O x I Ak+AA0x1 J , IL E Mika____ W Ar 0 J g tc W a a A DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 9/17/2021 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 NAME: RogersGray, Inc. -Kingston Branch PHONE FAX 63 Smith Lane (A/C.No.Et): 508-746-3311 (A/c,No):877-816-2156 Kingston MA 02364 E-MAIL mail©rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Company,Inc. 41360 INSURED VWERNON-01 INSURERS:A.I.M.Mutual Insurance Co. 33758 W.Vernon Whiteley Plumbing&Heating P. O. Box 1266 INSURER C: West Chatham MA 02669-1266 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1593043253 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. INSRY EXP TYPE OF INSURANCE ADDL S„u D POLICY NUMBER (MMf D//YYYY) (MM/ICY EFF DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y 8500052832 10/1/2021 10/1/2022 EACH OCCURRENCE $1,000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaENTE occur ence) $100,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X PROT- LOC PRODUCTS-COMP/OP AGG $2,000,000 JEC OTHER: $ A AUTOMOBILE LIABILITY Y Y 1020006346 10 10/1/2021 10/1/2022 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED Xy NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) A X UMBRELLA LIAB OCCUR Y Y 4620086300 10/2/2021 10/2/2022 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$in pnn $ B WORKERS COMPENSATION Y WMZ-800-8007752-2021A 10/1/2021 10/1/2022 X STATUTE OTH- ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YNN N/A E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (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 04/21) 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 EDREPRESENTATIVE USA ©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 . Department of Industrial Accidents m_. = Office of Investigations t T t" Lafayette City Center , 2Avenue de Lafayette, Boston,MA 02111-1750 .w h '`Z.~ wwev.mass.gov/dra Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AQrglicaft Information Please Print Legiblh Name(Businesvarganixntion/lndividual):W Vernon Whiteley Plumbing 8 Heating, Inc Address:28 Village Landing/PO Box 1266 City/State/Zip:W��hatham, MA 02669 Phone#:508-945-1100 Are you an employer?Check the appropriate box: Type of project(required): I.® 1 am a employer with ?0 4. 0 1 am a general contractor and i 6. ❑New construction employees(full and/or put-time).• have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9, Ej Building addition (No workers' comp.insurance comp. insurance.• required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.111 Numbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.)' c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below starring their workers'compensation policy information. i Homeowners who submit this affidavit indicating they we doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box mum 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 wortters'compensation insurance for my employees_ Below is the policy and Job site information. Insurance Company Name:A.I.M Mutual Insurance co. _ _ Policy#or Self-ins.Lie.#:WMZ-.B00-8007752-2021A Expiration Date: 0/�f2022 Job Site Address: All locations in Yarmouth,MA ._ City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing ibe 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 S 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 oldie DIA for insurance coverage verification. I do hereby c the pains pan/d aides of perjury that the information provided above is true and correct Signature: '"' ._r� �✓ _— Date: r ~ Y f 2 Phone#: 508-945-1100 Official use only. Do not write in this area,to be completed by city or town official. e City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 3[jCity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.DOther , Contact Person: Phone#: It- -"L.a s � i■ .si, ,u. s • L�_ DIVISION OF PROFESSIONAL LICE:NSURE SHEETM`TAL WORM' ISS.UE&TIE FOLLO MNG LICENSE a MAST ER-Ul �TED; :I $T WHITELEY PO BOX 7AIIE t WEST�FAM;MA.ozs ,3 2967 159981 LICENSE NUMBER EXP�IRAf IUN Cit.�l•L. SERIAL NUMBER i s t i i �i gin,` INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes® No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑x Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box®I hereby certify that all of the details and information I have submitted(or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ®Master /,. Title ❑ Master-Restricted ���J_" City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: 2967 Fee$ ❑ Check at www.mass.govidpi Inspector Signature of Permit Approval