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16B-00-001 It __- 8 107 LOOMIS RIDGE WESTFIELD, MA 010854963 5 DO 01.17•2011 Rev 07 111P Fold, Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS - DIVISION OF PROFESSIONAL LICENSURE - BOARD OF BOARD ' " • SM ; AS AMASTER- UNRESTRICTED' ISSUES THE ABOVE LICENSE TO: I TYPE MARCI A CHEVALIER M1 197 LOOMIS RIDGE 15 1 WESTFIELD MA 01085 -3963 984144 7110 06/28/12 984144 LICENSE NO. EXPIRATION DATE SERIAL NO F Fold, Then Detach Along All Perforations * 5/4/2011 09:32 ICNE Group Marie Proulx -■SUE 2/3 DATE MINDDIYYYY) CORD CERTIFICATE OF LIABILITY INSURANCE 05/04/2011 PRODUCER P (413) 701 -2410 Foot 413731.9535 THIS CERTPICATE 1$ ISSUED AS A MATTER OF INFORMATION INSURANCE CENTER OF NEW ENGLAND ON AND CONFERS NO MONTE UPON TIM CERTIFICATE 1070 SUFFIELD STREET HOLDER. THIN CERTPICATE DOE$ NOT AMEND, EXTEND OR P 0 BOX 1230 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. AGAWAM MA 01001 INSURERS AFFORDING COVERAGE NAIC I INSURED INSURER A CNNr81 insurance Company 20230 ACTION AIR INC INSURER B: P.O. BOX 636 INSURER C: FEEDING HILLS MA 01030 INSURER D: INSURER E: COVERAGES THE POLICES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO TOE INSURED NAKED ABOVE FOR THE POUCYPERIOD MCICATED, NOTYYERLSTRDNG ANY REQUIREMENT. TERM OR CONDITION OF MN CONTRACT OR OTHER DOCUMENT WLTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAN, THE NSZRANCE AFFORDED BY THE POLICES DESCRIBED HEREIN S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDRI)NS OF SUCH POLCES. AGGREGATELNTS SHOWN MAY HAVE BEEN REDUCED BY PAD ClMAS. NSR MXNI TYPE OF INSURANCE POLICY NUMBER POLICY IIPR W OTIYE P UCY A11ON LIMITS ua ralRO GENERAL UAEIUTY CLP7978942 04/30/11 04/30/12 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL UABIUtt TO RENTED S 300,000 N ET Jbs I 1 CLAMS MADE © OCCUR MED. EXP (MN am person) $ 5,000 A PERSONAL &ADV MAY 5 1,000,000 — GENERAL AGGREGATE $ 2,000,000 GERI AGGREGATE LMTAPPLESPER PRODUCTS-CO/AMPAGG. S 2,000,000 — I POLICY n PRII ,Ecr fLOC AUTOMOBILE WWII' BAP8611192 04/30/11 04/30112 DOWNED SNOLE Lsir = 1,000,000 ANYAUTO (Esacdded) AU. OVNED AUTOS B OOLYPURY (Per parson) $ X SCOEDLLED AUTOS A — X FIRED Amos X NONLONNEDALIros t� $ PROPERTYDAMAGE S (Par amidst) - GARAGE ' AUro ONLY - EA acmes1 S ANY AUTO OTHER THAN EA ACC AUTO ONLY. AGG $ S EXCESS/ UMBRELLA LIABILITY CX37978943 04/30/11 OU30112 EACH OCCURRENCE $ 2,000,000 OCCUR n CLAMS MADE AGGREGATE S 2,000,000 A s _ DEDUCTIBLE S RETEMIIONE S 0 $ WORKERS CONNENIATION WC7978$4415 04/30/11 04/30/12 X raa�YAin a I MHIR EMPLOYERS' LIABILITY El. EACH ACCIDENT $ 500,000 A o eEUXOUM D? El. OSEASE- EAEMPLOYEE $ 500,000 asM pa. deserlbe alder M. mimeos maw E.L OISEASEPOLLCYMST $ 500,000 OTHER: DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS TO SHOW EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCROED PODS BE CANCELLED BEFORE THE DUPRATION DATE THEREOF, THE SSUWG NSIRER VALL ENDEAVOR TO MAL 20 DAYS MITTEN NOTICE TO DIE CER1FICATE HOLDER NAMED TO THE LEFT. BUT FAL RETODOSOSHALLM'OSENO FOR VERIFICATION OF INSURANCE PURPOSES ONLY OEIUGATION ORUABLIIYOF ANY STNCT UPON THE INSURER, fl'S AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE • 1511114 fin: hen 1 ACORD 25 (2001/08) Cedlfcate 1 55510 0 ACORD CORPORATION 1111111 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statue, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the forgoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees, However the owner of a dwelling house having not more that three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer". MGL chapter 152 section §25(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152 section §25(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificates(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the Members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self - insurance license number on the appropriate line. City or Towns Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 phone #: (617) 727 -4900 ext. 406 or 1- 877 - MASSAFE fax #: (617) 727 - 7749 Revised 11 -22 -06 www.mass.gov /dia The Commonwealth of Massachusetts Department of Industrial Accidents at Offic600 e of Ini W ashington vest Street Boston, Mass. 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual) : A j) k Address: 11 I i y (l tt q/ZPai f 7 Y)e. City /State /Zip: 12/0 6h( in t4 Phone #: i/ ? 6 2 iZaS Are you an employer? Check the appropriate box: Type of project (required): 1. KI am an employer with ] (0 4. ❑ I am a general contractor and I construction employees (full and/or part time). * have hired the sub - contractors ❑Remodeling 7. 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. ❑Building addition required] 5. ❑ We are a corporation and its 10. ❑ 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 perm MGL insurance required] t c. 152, § 1(4), and we have no 12. ❑ Roof repairs employees. [no workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contactors that check this box must attach 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. G � �� Insurance Company Name: / n S(i,edin& (0 , Policy # or Self -ins. Lic. #: Z,X � ci 7 R90/ /6 Expiration Date: V & 1 l 7 Job Site Address: 0?0 i j (Ise City/State /Zip: T /(Y(1.17U / 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 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby ce fy nder the p ' s ' d, i enalties of perjury that the information provided above is true and correct Signature: f ' 6224 Date: / ,1Z/ Print Name: / Nitd04i/erv #: V/5 Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license #: Issuing Authority (circle one): 1.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone #: 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 La , and that my signature on this permit application waive! this requirement. Check One Only //I Owner ❑ Agent ❑ Signature of Owner or Owner's Agent • By checking this boxO, 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 Pro¢ressInspections Date Comments • Final Inspection Date Comments Type of License. By ❑ Master Title ❑ Master - Restricted City/Town ❑Joumeyperson Signature of Licensee Permit • ❑Joumeyperson- Restricted License Number: Fee Check at www.mass.novIdpl Inspector Signature of Permit Approval RECEIVED o monwealth of Massachusetts L ( 3 MAY 620H Sheet Metal Permit 0 a L : D- • F 6U - DING NSP,= CTIONS 0 01 a' C 4 #8 4 Permit # Estimated Job Cost: $ b i C Permit Fee: $ Plans Submitted: YES k NO Plans Reviewed: YES NO Business License # Applicant License # Business Information: Property Owner / Job Location Information: Name: 476,A Name: 5 9171 L / Street: ?f) . L Y 7i 2l/) Street: eca Cit -1T (CI y9 K/-f //3 Nit- City/Town: Pie/I 22& )1 7/9 -- Telephone: ‘113-- 7FC 93? s--- Telephone: Photo I.D. required / Copy of Photo I.D. attached: YESX NO Slay Initial J -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: -V Renovation: d HVACJ( Metal Watershed Roofing Kitchen Exhaust System Metal Chimney / Vents Air Balancing Provide detailed description of work to be done: • .411 Al / )1 I _ al /1- Ci(d PnC Le lq- Vki0- Joc4 hil4ok